bluuebunny/crossref_metadata_2025 huggingface dataset:
1691. Cryptococcus Species Other than C. neoformans and C. gattii: Are They Clinically Significant?
Authors: Cano Cevallos Edison J , Yetmar Zachary A , Razonable Raymund R
Published: October 2019

Background

Cryptococcus sp. is a major cause of opportunistic infections in immunocompromised patients, with nearly all cases due to C. neoformans or C. gattii. There are occasional reports of other Cryptococcus species causing invasive human disease. However, their epidemiology and clinical significance are not fully defined. We sought to describe the patients with cultures positive for Cryptococcus species other than neoformans and gattii.

Methods

A retrospective descriptive review of patients with cultures growing Cryptococcus species other than neoformans and gattii from November 2011 to February 2019. Clinical and laboratory data were analyzed.

Results

Out of 177 cases with a culture positive for Cryptococcus sp., 54 patients (mean age, 53.3 years; 61% men) had a culture for Cryptococcus other than neoformans and gattii. The most common species were unspecified non-neoformans/gattii (10), magnus (9), laurentii (8), and ater (7). Three patients had active malignancies and 15 were on immunosuppressive drugs, 6 due to transplant. The most common sites or specimens were skin (16), respiratory (16), urine (7), joint (3), intravascular catheter (2), cerebrospinal fluid (2), oral (2), peritoneal fluid, donor liver transplant, bone marrow, sinus, nail, and cornea. Whereas 21 (38.9%) cultures were obtained due to local symptoms, there was only one case of invasive disease, affecting the peritoneum, while the majority was either unaddressed (25) or considered contaminants (17). Only 12 patients received antifungal treatment, where sources were skin (4), oral (2), peritoneum, donor liver, respiratory, vascular catheter, urine, and nail. Antifungal drugs were fluconazole, itraconazole, clotrimazole, caspofungin, and griseofulvin, for a mean duration of 37.6 days. Among patients who were not treated, four died within 6 months but mostly of unrelated causes (3) or not known (1).

Conclusion

This large series of patients with Cryptococcus sp. other than neoformans and gattii suggests that these species rarely cause clinically significant infection in humans. Only one case of invasive disease was found.

Disclosures

All authors: No reported disclosures.
1707. Invasive Pulmonary Aspergillosis in Patients with Severe Fever with Thrombocytopenia Syndrome
Authors: Bae Seongman , Jung Jiwon , Jae Kim Min , Cho Eunbeen , Young Kim Mi , Yun Sung-Cheol , Hwa Lee Keun , Pil Chong Yong , Lee Sang-Oh , Choi Sang-Ho , Soo Kim Yang , Hee Woo Jun , Kim Sung-Han
Published: October 2019

Background

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging tick-borne disease often accompanied by immune catastrophic course and subsequent fatal outcome. More than 90% of patients with SFTS had leukopenia and about one-third of those need the admission of intensive care unit (ICU) during the hospital course. So, there has been growing concern about the complications such as invasive pulmonary aspergillosis (IPA) in critical SFTS patients. We thus investigate the incidence and clinical characteristics of IPA in patients with SFTS.

Methods

All patients who were confirmed as SFTS in a tertiary care hospital, Seoul, South Korea, between January 2013 and October 2018 were enrolled. The modified AspICU algorithm was used to identify cases of putative invasive pulmonary aspergillosis (PIPA) and discriminate these invasive diseases from colonization.

Results

Of the 45 PCR-confirmed SFTS patients, 16 (36%) received ICU care. Of these 16 patients, 9 (56%) developed PIPA during hospitalization. The median duration from admission to the first evidence of PIPA was 8 days (range, 2–11 days). None of the PIPA cases met the revised EORTC/MSG criterion. Septic shock and corticosteroid administration preceded more frequently in PIPA group than non-PIPA group (100% vs. 19%, P < 0.0001 and 67% vs. 14%, P = 0.003, respectively). Patients complicated by PIPA showed significantly higher mortality than non-PIPA patients (44% vs. 8%, P = 0.048 by log-rank test). Mortality was lower in patients with PIPA who received antifungal treatment (17% [1/6]) than in those with PIPA who did not (100% [3/3]) (log-rank test, P = 0.002).

Conclusion

More than half of patients with SFTS in ICU were complicated by IPA during early hospital course. Cautious scrutiny for IPA in patients with SFTS followed by early appropriate antifungal therapy for IPA is needed.

Disclosures

All authors: No reported disclosures.
1709. Epidemiology of Invasive Fungal Infection (IFI) after Severe Influenza Requiring Intensive Care Unit (ICU) Admission: 10-Year Experience at a Tertiary Care Center in the United States
Authors: Viehman J Alex , Sappington Penny , McCreary Erin K , Marini Rachel V , Shields Ryan K , Rivosecchi Ryan , Clarke Lloyd , Clancy Cornelius J , Nguyen Minh-Hong
Published: October 2019

Background

Despite increasing recognition of aspergillosis complicating severe influenza and its associated high fatality in Europe, incidence and features of the disease in the United States are unknown.

Methods

We reviewed all influenza cases requiring ICU admission from 2009 to 2019 at our center.

Results

262 patients with influenza required ICU admission. 4% (10) developed IFI at median 2d after influenza diagnosis. 80% (8/10) of patients with IFI were infected with influenza A vs. 88% (221/252) without IFI. 20% were on steroids at the time of IFI diagnosis. 70% of IFI required mechanical ventilation. Types of IFI were pneumonia (70%, 6 Aspergillus and 1 Wangiella), endobronchial IFI (20%, 1 each with Aspergillus and Lictheimia), and Coccidioides fungemia (10%). 4% (10) of patients were fungal colonized, but did not have IFI (5 A. fumigatus, 1 A. terreus, 4 Penicillium). CT findings of IFI included nodules (4), cavitation (3), and ground-glass opacities (2). Serum galactomannan (GM) was positive in 3 (43%). Median time to antifungal therapy (AF) was 2 days. Triazoles were prescribed to all 7 patients with aspergillosis. Posaconazole and amphotericin B were AF for patients with Wangiellaand Lichteimia, respectively. Patients with C. immitis fungemia died before AF. Median duration of AF was 60 days among survivors. Patients with IFI required acute hemodialysis more frequently than colonized patients (60% vs. 0%, P = 0.01). 30-day mortality was 60% (6/10) and 20% 92/10) in patients with IFI and colonization, respectively (P = 0.2). Patients with IFI had significantly higher in-hospital and 60-day mortality than those without IFI (Fig 1, P = 0.009).

Conclusion

Our rate of post-influenza IFI (4%) was lower than reported in Europe (~15%), which might stem from a lack of systematic BAL GM testing at our center, over-reliance on GM to make diagnoses in Europe, and/or differences in pt populations and clinical practices in treating severe influenza. IFI and fungal colonization rates were similar at our center, highlighting the importance of using well-defined criteria to define disease. Given the high mortality of post-influenza IFI, priority should be given to defining risk factors that might identify patients for targeted AF prophylaxis. In using AF, it is important to recognize that Aspergillus is not the only cause of IFI.

Disclosures

All authors: No reported disclosures.
1745. Retrospective Cohort Analysis to Determine the Incidence of CMV Infection and Disease in Allogeneic Hematopoietic Cell Transplant Recipients at an Academic Children’s Hospital
Authors: Galetaki Despoina M , Hayes Molly , Newman Alexander , Boge Craig L K , Elgarten Caitlin W , Freedman Jason L , Olson Timothy S , Fisher Brian T
Published: October 2019

Background

Data on cytomegalovirus (CMV) infection and disease by donor (D)/recipient (R) status or prophylaxis regimen in pediatric hematopoietic cell transplant (HCT) recipients are limited. There is an absence of data on adverse events (AE) attributable to prophylaxis.

Methods

A single-center cohort (N = 352) of allogeneic HCT episodes between January 2004 and June 2017 was assembled. Exclusion criteria were CMV PCR positivity 30 days before HCT, lack of CMV surveillance (<2 blood PCRs in the 30 days post HCT), or unknown D/R CMV status. CMV prophylaxis was recommended for CMV D+ or R+ patients with ≥1 of the following factors: T-cell depletion, cord blood product, or exposure to distal alemtuzumab. The CMV prophylaxis regimen was standard-dose acyclovir from day −7 to +7, then foscarnet to engraftment, and then valganciclovir to day +100 (acyc → fos → valgan). If a patient did not meet criteria for CMV prophylaxis but was HSV IgG positive then standard-dose acyclovir was given from day −7 to the end of study follow-up (SD-acyc). All remaining patients did not receive antiviral prophylaxis. Outcomes of CMV infection and CMV disease by day +180 were captured. AEs attributable to antiviral prophylaxis were also identified. An AE was attributed to an antiviral prophylaxis medication if the dose was reduced or stopped. AEs were only reported in HCT episodes with complete medical records (n = 221).

Results

The CMV infection rate was 26.7%, with a median time to detection of 23.5 days (range: 4–146). CMV infection was common in D+/R+ (58.9%) and D−/R+ (34.6%) patients. Just under 11% of CMV infections progressed to disease (Figures 1 and 2). Breakthrough CMV infection occurred in 49.1% of patients despite acyc → fos → valgan (Figure 3) at a median of 11 days from HCT (range: 4–132). The attributable AE rate was 13.4% and 36.8% for SD-acyc and acyc → fos → valgan, respectively (Figure 4).

Conclusion

CMV infection was common in D+/R+ and D−/R+ patients, and a substantial proportion progressed to disease. Breakthrough infection persisted despite acyc → fos → valgan prophylaxis and AEs attributable to this regimen were common. CMV infection in R+ patients was frequent even in the absence of additional risk factors. Studies of novel prophylaxis approaches are needed and should include R+ patients regardless of other factors.

Disclosures

All authors: No reported disclosures.
1753. Adherence and Immunogenicity of Early Vaccination in Pediatric Allogeneic Hematopoietic Cell Transplantation (allo-HCT) Recipients
Authors: Danino Dana , Stanek Joseph , Skeens Micah , Rangarajan Hemalatha , Ardura Monica I
Published: October 2019

Background

Allo-HCT recipients are at increased risk for vaccine-preventable infections. Early vaccination (EV) beginning at 3–6 months (mo) post-HCT has been shown to be safe, immunogenic, and is recommended. We assessed adherence and immunogenicity to EV in children post-allo-HCT.

Methods

Retrospective analysis of allo-HCT performed 1/1/10–6/30/18 at NCH. Children who died, relapsed, or received anti-CD20 biologics in the 6 mo preceding intended vaccination were excluded. Institutional guidelines recommend EV starting at 6 (+1) mo post-HCT with: 3 PCV13 + 1 PPSV23, IPV, HBV, DTaP and HIB. Vaccination rates were analyzed at 6(+1), 8(+1) and 10(+1) mo post-HCT and serologies were obtained pre- and ≥ 4 weeks post vaccination. Immunogenicity was defined as antibody (Ab) concentrations ≥ 1.3 µg/mL or a 4 fold rise ≥ 70% of 10 PCV13 serotypes, tetanus (T) and diphtheria (D) Ab ≥ 0.1 IU/mL, and HBs Ab ≥ 10 IU/mL. Non-parametric statistics were applied; correlations between T&B cell subsets and IgG pre-vaccination and specific Ab post-vaccination were performed.

Results

During the 8-year study period, 171 allo-HCT were performed: 131 children were eligible for EV (Table 1); however, EV occurred in only 49.6% (65/131) and was completed in 37.5% (45/120) of children at 10(+1) mo post-HCT. Vaccine immunogenicity of PCV13, HBV, T and D was achieved in 40/45, 34/36, 63/64, and 18/18 of evaluable children, respectively. Protective Ab response after EV for PCV13, HBV, T and D was found in 21/24 (87.5%), 14/16 (87.5%), 35/36 (97.2%), and 8/8 (100%) children, respectively. Specific IgG geometric mean concentration pre- and post-vaccination was similar in children whether they received early or delayed vaccination (median 9.8 mo post-HCT, IQR 8–14) (Figures 1 and 2). No correlations were found between absolute CD4, CD8, CD19 and IgG pre-vaccination and vaccines specific Abs post-vaccination (Figure 3).

Conclusion

Despite recommendations, adherence to EV was low among our cohort of allo-HCT recipients and identified opportunities for improvement. Overall, vaccines were immunogenic with no significant differences in Ab concentrations among patients receiving early vs. delayed vaccination. No robust correlations were found between number of T&B cells or total IgG and Ab titers.

Disclosures

All authors: No reported disclosures.
1783. More than Which Molecular Test: Following the Directions in How and Who to Test in the Diagnosis of Influenza
Authors: Mayer Jeanmarie , Spangler Kathryn , Hanson Kimberly , Hanson Kimberly , Fendler Jamie , Pearson Lauren , Couturier Marc Roger
Published: October 2019

Background

The CDC and IDSA recommend testing hospitalized patients with suspected influenza using molecular assays, in part to implement precautions to prevent transmission. Both PCR and a rapid isothermal nucleic acid amplification test (NAAT) for influenza detection are available at the University of Utah Health (UU). The UU has required the more-sensitive PCR to discontinue isolation for suspect in patients, but we hypothesized the NAAT could be sufficient in most patients.

Methods

A retrospective review of influenza diagnostics pre- and post-reinforcement of proper test procedures was performed across a university healthcare system, including a 650-bed tertiary care and 100-bed cancer hospital. During August 2018, providers and staff involved in testing were interviewed to describe their practices. Gaps were addressed in September 2018 with flyers outlining procedures, providing optimal sampling supplies, and EHR prompts for appropriate specimen type. A subset of UU patients tested by both NAAT and PCR within a 48 hour period were identified from the corporate data warehouse as Pre (September 2016 through March 2018) or Post reinforcement (October 2018 through March 2019). Agreement within PCR/NAAT test pairs was determined, with chart reviews of patients with discrepant results. Time of testing from the onset of symptoms was noted, and flu-like symptoms were defined as fever (>38°C) and cough or sore throat.

Results

Prior to reinforcement, most hospital staff were unaware of the optimal specimen type and collection swab for NAAT vs. PCR. Units initially lacked appropriate sampling supplies for NAAT. Providers complained of needing to confirm negative NAAT for inpatients with questionable symptoms, and supported the reinforcement to target follow-up PCR in those clearly symptomatic or immunocompromised. Concordance with NAAT and PCR pre- and post-reinforcement of proper test procedures when both methods were done is shown in the Figure.

Conclusion

Diagnosis of influenza is important in hospitalized patients. In addition to selecting a sensitive assay, attention to optimize test performance is critical. Our results suggest there is a need to train and monitor clinicians in identifying who to test and when, what specimen to collect and how, and in interpreting results.

Disclosures

Kimberly Hanson, MD, MHS, BioFire: Consultant, Grant/Research Support; T2 Biosystems: Consultant.
1793. Clinical Outcomes among Febrile Infants Before and After Implementation of BioFire® FilmArray® Panels
Authors: Crook Jennifer , Xu Meng , Slaughter Chris , Browning Whitney , Estrada Cristina , Gay James , Thomas Gale , Quinn Criziel , Benton Alison , Schmitz Jonathan , Banerjee Ritu , Banerjee Ritu
Published: October 2019

Background

The clinical benefits of multiplex polymerase chain reaction panels are not well defined. We evaluated outcomes among infants before and after implementation of the BioFire® FilmArray® Respiratory Panel 2 (RP2) and Meningitis Encephalitis Panel (MEP).

Methods

This single-center study compared outcomes among infants ≤ 90 days presenting to the Emergency Department with fever (T ≥ 38.0°C) or hypothermia (T < 35.8°C) during 3 time periods. P1 (January 1, 2011–December 31, 2014) had batch testing using a Genmark Dx® respiratory viral panel (RVP) and no standardized clinical practice guideline (CPG); P2 (January 1, 2015–April 30, 2018) had the RVP and a CPG; and P3 (May 1, 2018–March 31, 2019) had on-demand RP2 and MEP testing and a CPG. Clinical data were collected from medical records. Statistical analyses were performed using Kruskal–Wallis and Pearson tests.

Results

There were 5195 total patients: 2514 in P1, 2082 in P2, 599 in P3. Groups did not differ in pathogens or antimicrobials used. Testing was faster and performed more commonly in P3 than P1 or P2 (P1, 10%; P2, 6.9%; P3, 71%; Table 1). From P1 to P3 there were significant decreases in length of stay (LOS), % receiving antimicrobials, antibiotic durations, ancillary test use, lumbar punctures (LPs), and chest X-rays (Table 1). In P3 compared with P2, infants more commonly received no antimicrobials (43.1% vs. 32.4%, P < 0.001; Figure 1), had fewer median (IQR) number of ancillary tests (5 (5–8) vs. 7 (3–10); P < 0.001), and shorter median (IQR) days of antibiotics (2.0 (1.0–2.7) vs. 2.4 (1.1–3.4); P < 0.001; Table 1). Among P3 infants, those with positive RP2 and/or MEP results were less likely to receive antimicrobials, be hospitalized or readmitted, had fewer ancillary tests and LPs, and shorter LOS and antibiotic durations than those with negative tests (Table 2).

Conclusion

In this large pre-post intervention study among infants ≤ 90 days with fever or hypothermia, a clinical guideline plus rapid testing with RP2 and MEP was associated with less antimicrobial use and ancillary testing than a clinical guideline alone. Infants with positive RP2 and/or MEP results had fewer admissions, shorter LOS, and less antimicrobial and ancillary test use than those with negative tests. Rapid pathogen testing has benefit for infants.

Disclosures

Ritu Banerjee, MD, PhD, Accelerate Diagnostics: Grant/Research Support; BioFire: Research Grant; Biomerieux: Research Grant; Roche: Research Grant.
1977. Comparing Acute Kidney Injury Risk among Antibiotic Classes: A Study of the FDA Adverse Event Reporting System (FAERS)
Authors: Patek Taylor M , Teng Chengwen , Kennedy Kaitlin E , Frei Christopher R
Published: October 2019

Background

A recent article published in 2018 studied the FDA Adverse Event Reporting System (FAERS) and listed the most common medications associated with acute kidney injury (AKI) based on number of AKI reports. In regards to antibiotics, the study only ranked vancomycin, fluoroquinolones, penicillin combinations, and trimethoprim–sulfamethoxazole as having a significant association with AKI. The objective of this study was to evaluate those and additional antibiotic classes using FAERS, and to compare their risk associated with this adverse drug event.

Methods

FAERS reports from January 1, 2015 to December 31, 2017 were included in the study. The Medical Dictionary for Regulatory Activities (MedDRA) was used to identify AKI cases. Reporting Odds Ratios (RORs) and corresponding 95% confidence intervals (95% CI) for the association between antibiotics and AKI were calculated. An association was considered statistically significant when the lower limit of the 95% CI was greater than 1.0.

Results

A total of 2,042,801 reports (including 20,138 acute kidney injury reports) were considered, after inclusion criteria were applied. Colistin had the greatest proportion of AKI reports, representing 25% of all colistin reports. Acute kidney injury RORs (95% CI) for antibiotics were (in descending order): colistin 33.10 (21.24–51.56), aminoglycosides 17.41 (14.49–20.90), vancomycin 15.28 (13.82–16.90), trimethoprim-sulfamethoxazole 13.72 (11.94–15.76), penicillin combinations 7.95 (7.09–8.91), clindamycin 6.46 (5.18–8.04), cephalosporins 6.07 (5.23–7.05), daptomycin 6.07 (4.61–7.99), macrolides 3.60 (3.04–4.26), linezolid 3.48 (2.54–4.77), carbapenems 3.31 (2.58–4.25), metronidazole 2.55 (1.94–3.36), tetracyclines 1.73 (1.26–2.36), and fluoroquinolones 1.71 (1.49–1.97).

Conclusion

This study found 17 classes of antibiotics and combinations that were significantly associated with AKI compared with four antibiotics that were mentioned in a recently published article looking at drug-associated AKI. While this study confirmed previous literature of certain antibiotics associated with increased risk of AKI, it also compared antibiotics within classes and provided additional insight regarding which antibiotics had the highest associated risk of an AKI.

Disclosures

All authors: No reported disclosures.
1993. Impact of Pharmacist Intervention in Response to Rapid Molecular Testing Results of Blood Cultures
Authors: Baskett Lauren , Colley Peter , Nguyen Hoa L , Berhe Mezgebe
Published: October 2019

Background

Rapid diagnostic testing can identify bacterial pathogens and genetic markers of resistance. This information can aid in deescalating antimicrobial therapy based on local patterns prior to the return of final culture and susceptibility reports. In August of 2017 at our institution, pharmacists were incorporated in the review of these rapid diagnostic tests in real time with recommendations for changes to therapy paged to providers. The purpose of this study was to determine whether the inclusion of a pharmacist in this workflow reduces time to change in antimicrobial therapy.

Methods

This retrospective study over two periods in 2016 and 2018 analyzed the pre- and post-implementation of a workflow incorporating pharmacist review of positive blood cultures analyzed by rapid molecular assay. Patients were included if they were at least 18 years of age and were initiated on empiric antibiotics prior to test results. Patients were excluded if transitioned to hospice within 24 hours of test results, discharged prior to test results, if more than one infectious process or organism was identified, or if test results were positive for coagulase-negative staphylococci. The primary outcome of the study was the time to change to targeted antimicrobials. Secondary outcomes were rates of Clostridium difficile infection within 3 months and inpatient mortality. Categorical variables were evaluated using chi-squared or Fisher exact tests, and continuous variables were evaluated using Wilcoxon rank-sum tests.

Results

A total of 199 patients were included, with 98 and 101 patients in the pre- and post-implementation groups, respectively. The median time to change to targeted antimicrobials was significantly reduced with pharmacist intervention from 18.35 to 8.43 hours (P = 0.042). The groups had similar rates of C. difficile infection (1% vs. 0%, P = 0.492) and mortality (7.1% vs. 5%, P = 0.564). The post-group also had significant reductions in antibiotic days of therapy (10.5 vs. 9 days, P = 0.014) and intensive-care unit length of stay (3.04 vs. 1.44 days, P = 0.046).

Conclusion

Incorporating pharmacist review of rapid molecular results of blood cultures decreased time to change in antimicrobial regimen and reduced antibiotic days of therapy.

Disclosures

All authors: No reported disclosures.
2014. Assessment of Cost, Morbidity, and Mortality Associated with Blood Culture Contamination
Authors: Davis Kevin A , Painter Jacob , Lakkad Mrinmayee , Dare Ryan K
Published: October 2019

Background

Blood cultures are the primary diagnostic tool for bloodstream infections, but accuracy of results is dependent on collection technique. Decreasing blood culture contaminations is a priority for antimicrobial stewardship programs as false positives can expose patients to adverse effects of unnecessary antibiotics. In this study, we present an analysis comparing clinical outcomes and cost associated with false-positive and true negative blood cultures at our institution.

Methods

We conducted a single-center, retrospective, case–control study in patients admitted following blood culture collection in the emergency department from 2014 to 2018. Demographic and clinical characteristics were evaluated in patients with false-positive blood cultures (cases) and negative blood cultures (controls). Contaminants were identified per American Society of Microbiology recommendations. Clinical outcomes were compared between cases and controls, and adjusted analyses were performed with logistic regression, linear regression, and generalized linear models controlling for age, race, body mass index, and sepsis. Statistical analysis was performed using SAS 9.4.

Results

A total of 1,102 cases and 11,266 controls were included in analysis. All clinical outcome measures were significantly higher in patients with contaminated blood cultures (see table). Select clinical outcomes remained significant when controlling for potential confounders.

Conclusion

To the best of our knowledge, this is the largest study evaluating the clinical and financial impact of blood culture contamination with inclusion of >1,000 cases during a 5-year period. Our study shows that blood culture contamination is associated with increased length of stay, unnecessary exposure to antibiotics and procedures, development of antibiotic-associated adverse events, and higher hospital charges as reported in smaller studies. However, this study is the first to the best of our knowledge reporting increased mortality associated with blood culture contamination. Implementation of innovative strategies to reduce contamination should be pursued. Antimicrobial stewardship programs should prioritize identification of contaminants and rapid de-escalation of inappropriate antibiotics in these patients to improve patient care.

Disclosures

All authors: No reported disclosures.
2034. Standardized Point Prevalence Survey on Antibiotic Use to Inform Antimicrobial Stewardship Strategies in the Caribbean
Authors: Hsieh Jenny , Sati Hatim , Ramon-Pardo Pilar , Bruinsma Nienke , F. Galas Marcelo , Marie Rwangabwoba Jean , Irene. Fletcher Payton Zoila , Bonet Mariano , Forde Corey A , Alladin-Karan Bibi A , Mohamed-Rambaran Pheona , Chery Gemma , Singh Nalini
Published: October 2019

Background

Inappropriate use of antimicrobials is one of the core contributors to antimicrobial resistance. While hospitals create high selection pressures on bacteria due to the high quantity and broader spectrum of antibiotics used, information on antimicrobial use at the patient level in the Caribbean is sparse. In response, PAHO implemented a standardized WHO methodology to engage national leaderships, build local capacity, and facilitate the use of data to inform antimicrobial stewardship programs (ASP) in the Caribbean.

Methods

Point prevalence surveys (PPS) were performed in four acute care hospitals in Barbados, Guyana and Saint Lucia between June and July 2018. Medical records of all inpatients were reviewed to collect information on antibiotic use, indications and use of laboratory services (Figure 1). A hospital questionnaire was used to assess hospital infrastructure, policy and practices, and monitoring and feedback systems (Figure 2). Training on PPS methods and electronic data collection tool in REDCap™ were provided to build local capacity and identify potential ASP leaderships. A standardized data validation, analysis and reporting system was built in R to streamline the process. Results and recommendations were disseminated to national authorities and stakeholders to support hospital and national decision-making and training for healthcare providers (Figure 3).

Results

A total of 60 physicians, nurses, pharmacists, laboratory technicians, and infection control specialists were trained and participated in the PPS. The survey collected records of 816 patients in which 442 (54%) were females and 374 (46%) were males. In total, 356 (44%) patients received 551 antibiotics. Overall, 300 (75%) of 398 indications for antibiotic use were treatment and 72 (18%) were prophylaxis. A higher use of parenteral antibiotics (79%) was observed compared with oral antibiotics (21%). Antibiotic prescribing patterns differed across hospitals. The most commonly used antibiotics were metronidazole (12%) and amoxicillin/clavulanate (11%).

Conclusion

The PPS method provided a feasible and effective way to collect baseline data and identify target areas for interventions. Engaging national leaderships and building local capacity offered a sustainable way in optimizing antimicrobial use in resource-limited settings.

Disclosures

All authors: No reported disclosures.
2049. Trends in Antibiotic Use and Antibiotic Resistance among Veterans Affairs Community Living Centers from 2011 to 2017
Authors: Appaneal Haley , Caffrey Aisling , Hughes Stephanie , Lopes Vrishali , Jump Robin L , Dosa David , LaPlante Kerry
Published: October 2019

Background

Antibiotic resistance is a global public health crisis, with antibiotic overuse contributing to selection pressure, and thus driving antibiotic resistance. Strategies to reduce antibiotic overuse may slow the development of resistance, but large-scale studies assessing trends in antibiotic use and resistance among nursing homes at the national level are limited. We describe trends in antibiotic use and resistance nationally among Veterans Affairs (VA) Community Living Centers (CLCs).

Methods

We assessed antibiotic use and microbiological cultures among VA CLC residents from 2011 to 2017. Antibiotics were grouped into eight drug classes and annual days of antibiotic therapy per 1,000 bed-days were calculated. Facility-weighted annual antibiotic resistance rates were calculated. Joinpoint Software was used for regression analyses of trends over time and to estimate annual average percent changes (AAPC) with 95% confidence intervals (CI).

Results

Over 7 years and among 146 CLCs, several significant trends in decreasing antibiotic use and corresponding reductions in resistance were identified. Fluoroquinolone use decreased by 9.9% annually (95% CI −11.6 to −8.2%) and fluoroquinolone resistance decreased by 2.3% per year for Escherichia coli, 5.1% for Klebsiella spp., 1.8% for Proteus mirabilis, 4.9% for Pseudomonas aeruginosa, 12.6% for Enterobacter spp., and 3.2% for Enterococcus spp. Anti-pseudomonal penicillin use decreased by 6.6% annually (95% CI −10.6 to −2.4%) and anti-pseudomonal penicillin resistance rates decreased each year by 7.9% for Escherichia coli, 8.9% for Klebsiella spp., 15.2% for Proteus mirabilis and 4.2% for Pseudomonas aeruginosa. Anti-staphylococcal penicillin use decreased by 5.4% annually (95% CI −10.0 to −0.5%) and resistance in Staphylococcus aureus decreased 1.7% per year.

Conclusion

Nationally among VA CLCs, we observed significant reductions in the use of several classes of antibiotics with corresponding reductions in antibiotic resistance, including an impressive decline in fluoroquinolone use and corresponding decreases in fluoroquinolone resistance among six organisms. Future research should assess whether reductions in antibiotic use predict later reductions in antibiotic resistance and improvements in resident outcomes.

Disclosures

All authors: No reported disclosures.
2052. Characterizing Nursing and Provider Social Networks to Develop an Instrument to Improve Antibiotic Stewardship Efforts in Nursing Homes
Authors: Ewers Tola , Mundt Marlon P , Crnich Christopher
Published: October 2019

Background

Inappropriate antibiotic use is a common problem in nursing homes (NHs). Antibiotic decision-making in NHs is complex. Characterizing the patterns and nature of social interactions between providers and nursing staff may offer insights into the factors influencing antibiotic decisions and opportunities to improve their quality in NHs.

Methods

Chart reviews and interviews with key informants were used to identify social interactions between nursing staff and providers associated with antibiotic prescribing decisions in three NHs. Data collection was restricted to provider-nurse exchanges following a resident change in condition recognition up to receipt of an order for an antibiotic. A survey administered to nursing staff was used to collect information on employment tenure and their perceptions about facility team climate. UCINET software was used to describe network characteristics, including density and centrality.

Results

Urinary tract infections (UTIs) accounted for nearly 40% of antibiotic events across all sites. The number of contacts between nursing staff and providers was approximately two-times greater for treated UTI events when compared with treated soft-tissue infections and were four-times as great as for treated pneumonia events. Network structures were different at each study NH with varying numbers of core team members and network density (Figure 1). Team climate survey responses across SNFs demonstrate generally positive climates (4.1 on a scale of 1 to 5, 5 reflects positive).

Conclusion

NHs have unique network structures; however, more complex social interactions associated with UTI events were common across all sites. Future studies should examine influences of different social network structures on antibiotic decision-making in NHs and whether modification of network structures or their characteristics is amenable to change.

Disclosures

All authors: No reported disclosures.
2053. Information Gaps Among Patients Prescribed Antibiotics on Discharge to Nursing Homes
Authors: Furuno Jon P , Noble Brie N , Weber Bo , Nordby Vicki , McGregor Jessina C , Bearden David T , Chan Dominic , Tjia Jennifer , Crnich Christopher
Published: October 2019

Background

Antibiotic use in nursing homes (NHs) is frequently initiated in acute care hospitals. Comprehensive antibiotic administration instructions are critical to inform antimicrobial stewardship efforts in NHs. However; little is known about the quality of discharge communication for residents transitioning from hospitals to NHs with an antibiotic prescription.

Methods

We reviewed hospital discharge summaries from a 10% random sample of hospital-initiated antibiotic prescriptions among residents of 17 for-profit NHs in Oregon, California, and Nevada admitted between January 1 and December 31, 2017. Data elements of interest were documentation of antibiotic choice, indication, instructions, and pending microbiology tests.

Results

Among 217 hospital-initiated antibiotic prescriptions, mean (standard deviation) age was 64 (29) years and 57% were female. The most frequently prescribed hospital-initiated antibiotics were cephalosporins (36%), fluoroquinolones (16%), and penicillins (14%). Hospital discharge summaries were missing from 19% (42/217) of the resident medical records. Core antibiotic prescribing information was missing from 38% (67/175) of the medical records with a discharge summary: 11% (20/175) were missing all core elements, 23% (41/175) were missing the antibiotic indication, 27% (48/175) were missing antibiotic dose, 27% (48/175) were missing antibiotic frequency, and 32% (56/175) were missing antibiotic duration. Parental antibiotics were more frequently missing information compared with oral antibiotic prescriptions (45% vs. 37%, P = 0.32).

Conclusion

Information gaps around antibiotic prescriptions are prevalent in transfer documentation for NH residents admitted from acute care hospitals. Interventions are needed to improve the quality of information transferred from acute care hospitals to NHs.

Disclosures

All authors: No reported disclosures.
2056. Retrospective Analysis of Intravenous Vancomycin Outcomes in Patients Discharged to Skilled Nursing Facilities
Authors: Gibson Heather D , Arnoczy Gretchen S , Kessell Andrew , Jawanda Jaspaul S
Published: October 2019

Background

Patients treated with intravenous (IV) vancomycin at skilled nursing facilities (SNFs) are at increased risk for adverse events.

Methods

Single-center, retrospective chart review to assess specific outcomes of patients receiving IV vancomycin discharged to an SNF from a single institution under the care of infectious diseases (ID) physicians. Population included all patients under the care of an ID provider between November 1, 2017 and October 31, 2018 with GFR > 30 who were discharged to an SNF on IV vancomycin for a minimum of 2 weeks. Patients with chronic kidney disease and patients younger than 18 years old were excluded. It was intended that all patients have weekly labs, including vancomycin troughs, communicated to the ID provider. Outcomes evaluated included complications related to vancomycin therapy, assessment of appropriate trough timing and sub-therapeutic troughs (defined as a trough less than 10), and assessment of communication to the prescribing physician. Complications were defined as vancomycin trough greater than 30, increase in serum creatinine greater than 0.5 above baseline, documented adverse events related to vancomycin, or hospital readmission during antibiotic therapy.

Results

25 patients who met inclusion criteria were admitted to 14 different SNFs. Osteomyelitis was the most common indication and MRSA was the most commonly isolated organism. 13 of 25 patients experienced the predefined complications; 5 of 25 patients had at least one trough value greater than 30. 13 of 25 patients had troughs drawn at inappropriate times in relation to doses and 15 of 25 patients had either absent or incomplete labs communicated to the prescriber. 4 of 25 patients had at least one trough value less than 10. Only 2 of 25 patients assessed had no complications, troughs appropriately drawn, and lab values communicated to the prescriber.

Conclusion

Patients discharged to SNFs on vancomycin had high rates of complications, low rates of appropriate laboratory monitoring, and poor communication between SNFs and the prescribing ID physician. Vancomycin administration at an SNF warrants careful monitoring for patient safety and demonstrates an area with significant opportunity for improvement.

Disclosures

All authors: No reported disclosures.
2058. Patient Satisfaction Not Impacted by Antibiotic Prescribing for Viral Upper Respiratory Infections
Authors: Ray Michael J , Tallman Gregory B , McCracken Caitlin M , Elman Miriam R , McGregor Jessina C
Published: October 2019

Background

Treating viral upper respiratory infections (URI) with antibiotics is a major contributor to the rise of antimicrobial resistance. Major drivers of unnecessary prescribing are a patient’s expectation to receive an antibiotic for acute illness and the physician’s desire to provide satisfactory care. Our objective was to determine whether receiving an antibiotic prescription for a URI is associated with increased patient satisfaction.

Methods

We identified emergency department (ED) and ambulatory visit (AC) visits with an acute URI diagnosis code between September 2015 and May 2016 that had an associated patient satisfaction survey. The survey queried patients’ overall satisfaction (“Overall rating of care received during your visit”) using a Likert-type scale ranging from 1 (Very Poor) to 5 (Very Good). We assessed survey responses among patients receiving and not receiving antibiotics using the Wilcoxon rank-sum test. Results from ED and AC visits were compared separately.

Results

We collected survey responses from 282 ED patients and 1306 AC patients with acute URI. Compared with non-recipients, ED respondents receiving an antibiotic were more likely to be female (67% vs. 55%) and on Medicare (28% vs. 21%); AC respondents receiving a prescription were more likely to be female (68% vs. 61%) and have private insurance (63% vs. 53%). Overall satisfaction was very high (Median = 5, IQR 4–5 for both groups). Median responses did not differ by antibiotic prescription status in either group (rank-sum P = 0.4 and 0.8 for ED and AC respectively). When dichotomizing the overall satisfaction score, more patients receiving an antibiotic reported satisfaction of good to very good than those not receiving an antibiotic (84% vs. 76%; Pearson’s Χ2P = 0.1) among ED patients, but not AC patients (95% vs. 94%; P = 0.5).

Conclusion

Patient satisfaction with their visit was not strongly associated with antibiotic receipt among ED and AC patients with URI in our study. This finding suggests that providers may limit the spread of antibiotic resistance by ceasing to unnecessarily prescribe antibiotics without jeopardizing patient satisfaction. Given low response rates to visit satisfaction surveys, further work is needed to verify the validity of this study and evaluate its generalizability.

Disclosures

All authors: No reported disclosures.
2085. Bedside Nurses Improve Antimicrobial Stewardship and Infection Prevention Outcomes: Results of a 3.5-Year Study in Three Hospital Telemetry Units
Authors: Ha David , Bette Forte Mary , Broberg Victoria , Olans Rita , Olans Richard , OYong Kelsey , Kullar Ravina , Catipon Nora , Ancheta Vickie , Desai Mamta , Khattak Yesenia , Okamoto Donna , Lira Donna , Chan Sarah , Mourani John , Gluckstein Daniel , McKinnell James
Published: October 2019

Background

Minimal literature exists to demonstrate the quantitative impact of bedside nurses in antimicrobial stewardship (AMS). We initiated bedside nurse-driven AMS and infection prevention (AMS/IP) rounds on three inpatient telemetry units of a community regional medical center. Rounds were nurse-driven, involved an infectious diseases (ID) pharmacist and infection preventionist, and were designed to complement traditional ID pharmacist and ID physician AMS rounds. Rounds were focused on use of antibiotics, urinary catheters (UCs), and central venous catheters (CVCs). Recommendations from rounds were communicated by the bedside nurse either directly to providers or to the ID pharmacist and ID physician for intervention.

Methods

This was an observational, multiple-group, quasi-experimental study conducted over 3.5 years (July 2015 to December 2018) to characterize the impact of bedside nurse-driven AMS/IP rounds on antibiotic, urinary catheter and CVC use, hospital-onset C. difficile infection (CDI), catheter-associated urinary tract infections (CAUTI), and central line-associated bloodstream infections (CLABSI). Outcomes were assessed in two cohorts based on time of AMS/IP rounds implementation (Cohort 1 implemented on one telemetry unit in July 2016, Cohort 2 implemented in two telemetry units in January 2018).

Results

A total of 2,273 patient therapy reviews occurred (Cohort 1: 1,736; Cohort 2: 537). Of these reviews, 1,209 (53%) were antibiotics, 879 (39%) were urinary catheters, and 185 (8%) were CVCs. Pre- vs. post-intervention, significant reductions were observed in both cohorts for mean monthly antibiotic days of therapy per 1,000 patient-days (Cohort 1: 791 vs. 688, P < 0.001; Cohort 2: 615 vs. 492, P < 0.001), UC days per patient day (Cohort 1: 0.25 vs. 0.16, P < 0.001; Cohort 2: 0.19 vs. 0.14, P < 0.001), CVC days per patient day (Cohort 1: 0.15 vs. 0.11, = 0.002; Cohort 2: 0.09 vs. 0.07, p = 0.005), and CDI per 10,000 patient-days (Cohort 1: 17.8 vs. 7.1, p = 0.035; Cohort 2: 19.1 vs. 5.4, p = 0.003). Numerical reductions were observed in CAUTI and CLABSI per 10,000 patient-days.

Conclusion

Bedside nurses can improve AMS and IP outcomes in a scalable fashion when supported by an interdisciplinary AMS/IP team and are complimentary to traditional AMS and IP practices.

Disclosures

All authors: No reported disclosures.
2091. Use of Telehealth to Expand Antimicrobial Stewardship Capacity Among Critical Access Hospitals in Washington State
Authors: Kvak Staci , Bryson-Cahn Chloe , D’Angeli Marisa A , Kassamali Zahra , Jain Rupali , Chan Jeannie D , Martinez-Paz Natalia , Pottinger Paul , Lynch John B , Lynch John B
Published: October 2019

Background

Critical access hospitals (CAH), defined as those with 25 or fewer beds and/or located in rural settings, may have difficulty implementing core elements of antimicrobial stewardship (CES) due to limited human resources, expertise, and funding. A 2015 National Healthcare Safety Network (NHSN) hospital survey found only 26% of CAH reported implementing all 7 CES compared with 50% of larger hospitals across the United States. The University of Washington Tele-Antimicrobial Stewardship Program (UW TASP) was developed through partnership with the University of Washington for hospitals lacking stewardship resources. The state department of health (DOH) provided funding to allow CAH to participate.

Methods

In January 2017, CAH were recruited to join UW TASP and participate in weekly 60 minute audiovisual conference calls led by an interdisciplinary team of infectious diseases physicians, pharmacists and microbiologists. Each session included a 15-minute didactic on stewardship topics followed by a discussion of case studies presented by participating hospitals. UW TASP faculty visited CAH to foster a collegial relationship between teams. Using hospital-reported metrics from the NHSN hospital survey reported in year 2016–2018 for years 2015–2017, we compared CES implementation by CAH participating in UW TASP (TASP CAH) in 2017 (n = 17) to those not participating (non-TASP CAH) (n = 22).

Results

TASP CAH reported increased implementation of all 7 CES from 29% (2015) to 59% (2016) before joining TASP to 76% (2017) after joining TASP (Figure 1). Non-TASP CAH reported implementation increased from 32% (2015) to 45% (2016) to 59% (2017). By the end of 2017, TASP CAH also succeeded in implementing individual CES to a greater degree than did non-TASP CAH (Table 1).

Conclusion

TASP CAH reported more successful implementation of CES than did non-TASP CAH. Improved CES implementation in TASP CAH may in part be due to differences in baseline hospital characteristics; however, expertise and support provided by UW TASP likely contributed. The use of telehealth mentoring increased antimicrobial stewardship in this resource-limited setting.

Disclosures

All authors: No reported disclosures.
2100. A Retrospective Chart Review of Emergent Antibiotic Use
Authors: Blyth Michelle , McNary James , Decano Arnold , Renson Audrey , Carey Jeanne
Published: October 2019

Background

The need for responsible antibiotic stewardship can be difficult to reconcile with the clinician’s task of quickly recognizing and treating sepsis. Empiric antibiotics are often given in patients with any suspicion of infection, yet antibiotics carry non-trivial risks including antibiotic resistance and susceptibility to other infections, such as Clostridium difficile.

Methods

This retrospective chart review includes 200 patients who were admitted to the hospital and administered antibiotics while in the Emergency Department (ED). From clinical documentation several clinical data points were gathered such as: changes to (including discontinuation of) antibiotics by the admitting team, final culture data, discharge diagnosis, vital signs and routine laboratory values.

Results

Our study finds that the majority of patients administered antibiotics in the ED of our academic community hospital were not diagnosed with sepsis (67%) and did not meet SIRS (62.5%) nor qSOFA (88%) criteria prior to administration of antibiotics. Vancomycin (39.7%) and piperacillin–tazobactam (22.2%) were the most frequent empiric antibiotics started. Antibiotics were stopped completely on admission by the admitting team in 22.2% of included patients. A wide variety of sources of infection were suspected, pneumonia (33%), cellulitis (15%), and cystitis (18%) being the most common. The overall mortality rate for this group during the admission was 4.5%, which was comparable to all-cause hospital mortality during the same time period. Infection was ruled out by discharge in 91 of the included 200 patients (45.5%). At least 37.5% of all included patients had received antibiotics within the last 3 months. Intriguingly, recent exposure was nearly twice as common (47.8%) among infected patients than in those without infections (24.7%), with a relative risk of 1.48 (CI 1.0993–2.0014).

Conclusion

These findings suggest that an opportunity exists for increased antibiotic stewardship in the emergency department in the management of suspected sepsis and/or infection. Stable patients in whom infection cannot be definitively ruled out may benefit more from prompt, thorough evaluation by an admitting team prior to the initiation of empiric antibiotics.

Disclosures

All authors: No reported disclosures.