bluuebunny/crossref_metadata_2025 huggingface dataset:
710. In Vitro Activity and Performance of Available Susceptibility Testing Methods for Eravacycline Against Carbapenem-Resistant Enterobacteriaceae (CRE)
Authors: Jones Chelsea E , Kline Ellen G , Nguyen Minh-Hong , Clancy Cornelius J , Shields Ryan K
Published: October 2019

Background

Eravacycline (ERV) is a recently-approved, fully synthetic fluorocycline agent that demonstrates broad in vitro activity against multidrug-resistant pathogens. We sought to compare the activity of ERV with minocycline (MIN) and tigecycline (TGC) against diverse CRE clinical isolates, and to evaluate the performance of commercially-available susceptibility testing methods.

Methods

ERV, MIN, and TGC minimum inhibitory concentrations (MICs) were determined in triplicate by broth microdilution against previously characterized CRE isolates. ERV susceptibility was also measured by disk diffusion (20 µg disk; Mast Group) and MIC test strips (MTS; Liofilchem) according to manufacturer instructions.

Results

148 CRE were tested, including 92 K. pneumoniae, 32 Enterobacter spp, 11 E. coli, 5 C. freundii, 4 K. oxytoca, and 4 S. marcescens. 72% of isolates harbored blaKPC, which encoded KPC-2 (n = 33), KPC-3 (n = 48), and other KPC variants (n = 22). 77% and 19% of isolates were resistant to meropenem and ceftazidime–avibactam, respectively. By BMD, the ERV, MIN, and TGC MIC range, MIC50 and MIC90 for shown in the Table. ERV MICs were ≥2-fold lower than MIN and TGC against 99% and 43% of isolates, respectively. ERV MICs did not vary by species or KPC-subtype. ERV MICs determined by BMD and MTS were well-correlated showing 89% essential agreement (MIC within one 2-fold dilution; Figure). The rate of categorical agreement (CA) was 73%. By comparison, the CA rate between BMD and disk diffusion was 78%. By both MTS and disk diffusion methods, susceptibility results clustered on either side of the susceptibility breakpoint. 50% of disk diffusion zones clustered between 14 and 16 millimeters (mm), which is 1 mm on either side of the susceptibility breakpoint (≥15 mm).

Conclusion

This study confirms the in vitro activity of ERV against CRE clinical isolates, which is comparable to TGC. ERV MTS demonstrated high rates of EA, but lower rates of CA. Clinicians should be aware of the nuances of ERV susceptibility testing and recognize that the modal distribution of ERV MICs against CRE lies on either side of the susceptibility breakpoint.

Disclosures

All authors: No reported disclosures.
714. Analysis of the Effect of Urine on the In Vitro Activity of Gepotidacin and Levofloxacin Against Escherichia coli, Staphylococcus epidermidis, and Staphylococcus saprophyticus
Authors: Koeth Laura M , DiFranco-Fisher Jeanna M , Scangarella-Oman Nicole
Published: October 2019

Background

Gepotidacin (GSK2140944) is a first in class novel triazaacenaphthylene bacterial type II topoisomerase inhibitor in clinical development for the treatment of gonorrhea and uncomplicated UTI (acute cystitis). Gepotidacin selectively inhibits bacterial DNA gyrase and topoisomerase IV by a unique mechanism not utilized by any currently approved therapeutic agent and demonstrates in vitro activity against most target pathogens resistant to established antibacterials, including fluoroquinolones. This study was undertaken to determine the effect of various urine parameters on the in vitro activity of gepotidacin and a comparative agent, levofloxacin, against a variety of bacteria.

Methods

Study strains were tested according to the reference CLSI broth microdilution method using cation-adjusted Mueller–Hinton broth (CAMHB) and the following method variations: CAMHB with 25%, 50%, and 100% urine (not pH adjusted) and 100% urine (pH adjusted to 7.2–7.4, and 8). Quality control strains were concurrently tested each day.

Results

MIC endpoints in the reference method and in 100% urine were easily determined (i.e., clear buttons of growth up to the first well of no growth). Gepotidacin MIC results are summarized in the table. For E. coli and S. saprophyticus, there was a trend for higher gepotidacin MIC results with the addition of increasing amounts of urine. However, the increase was minimal such that mean dilution differences were ≤ 1.54. Against S. epidermidis, gepotidacin MICs were not significantly impacted by the addition of urine as 100% of urine condition MICs were within ±1 doubling dilution of the reference method MIC. The gepotidacin results for E. coli indicate that the average 1–2 dilution MIC increase observed in the unadjusted 100% pooled urine MIC may be associated with lower pH. A similar increase in levofloxacin MIC results for E. coli were also associated with pH, but at the higher pH of 8.0. In contrast, the increase in MIC observed in both the gepotidacin and levofloxacin S. saprophyticus results in 100% pooled urine do not appear to be a function of pH.

Conclusion

Overall, the effect of urine on the gepotidacin and levofloxacin MICs was minimal and not inclusive of all strains tested.

Disclosures

All authors: No reported disclosures.
715. Bulgecin A lowers Imipenem MICs in Clinical MDR Acinetobacter baumannii (ACB) Strains
Authors: Skalweit Marion J , Rojas Laura J , Bonomo Robert A , Dik David A , Tomoshige Shusuke , Mobashery Shahriar
Published: October 2019

Background

Genetic screening of ACB has revealed genes that confer increased susceptibility to β-lactams when these genes are disrupted suggesting novel drug targets. One such target is lytic transglycosylase, LT. Bulgecin A (BlgA) is a natural product of Paraburkholderia acidophila and an LT inhibitor that potentiates the activity of β-lactams.

Methods

Broth microdilution MICs were performed using carbapenem-resistant (CR)-colisitin susceptible (ColS) and CR-ColR clinical ACB strains, with a variety of resistance mechanisms, previously studied via whole-genome sequencing. A fixed concentration of pure BlgA at 100 μg/mL was combined with varying concentrations of imipenem. Sequences of the putative LTs in ACB strains were analyzed to look for amino-acid substitutions and correlated with the MIC lowering effect of BlgA. Homology models of the LTs of AB0057 ACB strain were generated.

Results

ACB MltE most resembles soluble LTs of other species with 22.39% sequence identity and 92% query coverage to Slt70 of E. coli. MIC results and amino-acid sequence variations in MltE LT of ACB are shown. There were no clear amino-acid substitution patterns to account for differences in BlgA effect. The mutations are distal to the BlgA binding site at residue E506.

Conclusion

These are the first MICs reported for BlgA in combination with a carbapenem demonstrating reduction in the MIC by four-fold for several MDR ACB clinical strains. Mutations in MltE Lt do not account for variations in the MICs observed. Changes in the MICs may be related to other factors such as drug penetration and alterations in PBP expression. Additional studies are underway to examine these factors.

Disclosures

All authors: No reported disclosures.
730. Cefiderocol for the Treatment of Achromobacter xylosoxidans Infections in Two Lung Transplant Patients with Cystic Fibrosis
Authors: Warner Nathaniel C , Bartelt Luther , Lachiewicz Anne , Lachiewicz Anne , Tompkins Kathleen Marie , Miller Melissa B , van Duin David
Published: October 2019

Background

Achromobacter xylosoxidansis a highly resistant Gram-negative bacterium that causes chronic infections in patients with cystic fibrosis (CF). Treatment options for A. xylosoxidans are limited. In the peri-lung transplant setting, the treatment of A. xylosoxidans infections is especially challenging. Cefiderocol is a novel siderophore cephalosporin antibiotic with broad anti-Gram-negative activity, including against A. xylosoxidans. We report here two cases of compassionate use of cefiderocol in CF lung transplant recipients with A. xylosoxidans infection.

Methods

Cefiderocol was obtained through compassionate use from its manufacturer, with approval from the local Institutional Review Board. In the first case, it was used as salvage treatment, and in the second case as a planned part of the peri-transplant regimen.

Results

A male in his 20s with CF and a trimethoprim-sulfamethoxazole (TMP-SMX) allergy was chronically colonized by A. xylosoxidans, which was sensitive only to piperacillin–tazobactam (PIP-TAZ), and TMP-SMX. After lung transplant, he developed A. xylosoxidansbacteremia, and extended-infusion PIP-TAZ was started. Repeat bronchoscopy grew A. xylosoxidans. Due to lack of improvement, cefiderocol was added to PIP-TAZ with rapid clinical improvement. However, after completing his course, he was readmitted with A. xylosoxidans pneumonia. He was treated with 6 weeks of cefiderocol and imipenem and has been well since with an 8-month follow-up. In the second case, cefiderocol was used as part of the planned peri-transplant regimen for a female with CF in her late teens, with chronic A. xylosoxidans colonization, which was intermediate to PIP-TAZ, and resistant to all other drugs tested. Her native lungs grew 4+ A. xylosoxidans at the time of explant. Post-transplant, she was treated with 5 weeks of meropenem and 6 weeks of cefiderocol. At four-month follow-up, she is doing well. However, she is asymptomatically colonized with A. xylosoxidanspost-transplant. Isolates from both cases were susceptible to cefiderocol (case #1 MIC = 0.12; case #2 pretreatment MIC = 1, post-treatment MIC.

Conclusion

Cefiderocol may be a useful option for lung transplant recipients with A. xylosoxidans infections.

Disclosures

Anne Lachiewicz, MD, MPH, MicroGenDx: Consultant; Shionogi: Consultant.
734. Modeling the Pharmacokinetics and Pharmacodynamics of Intravenous and Oral Omadacycline with and without a Loading Dose
Authors: Friedrich Lawrence , Curran Marla , Chitra Surya , Manley Amy , Bai Stephen , Noble Bob , Steenbergen Judith N , Garrity-Ryan Lynne , Tzanis Evan
Published: October 2019

Background

Omadacycline (OMC) is an intravenous (IV) and oral aminomethylcycline antibiotic in the tetracycline class approved in the United States to treat acute bacterial skin and skin structure infections (ABSSSI) and community-acquired bacterial pneumonia (CABP) in adults. The approved dosing regimens of OMC include a loading dose designed to achieve steady-state exposures early in the course of therapy. We assessed the impact on OMC exposure and subsequent pharmacodynamics (PD) on Day 2 and at steady state (Day 5) in the situation where a loading dose may not be given.

Methods

Phase 1 pharmacokinetic (PK) data were used to determine OMC exposure on Day 2 and at steady state (Day 5) for the following: IV regimens 100 mg IV q12h on Day 1 then 100 mg IV QD (load), 100 mg IV QD (no load); and oral regimens 450 mg oral QD on Days 1 and 2 then 300 mg QD (load) and 300 mg oral QD (no load). AUCs on Day 2 and Day 5 for no-load regimens were compared with the regimens with loading doses. Additionally, AUC:MIC ratios were calculated using OMC MIC90 for two main pathogens of interest in ABSSSI and CABP, respectively, Staphylococcus aureus (0.25 mg/L) and Streptococcus pneumoniae (0.12 mg/L). In vivo AUC:MIC targets for stasis and 1-log kill used were 21.9 and 57.7 (S. aureus) and 31.2 and 65.8 (S. pneumoniae).

Results

Day 2 and 5 AUCs are shown in the Figure. AUCs on Day 2 were lower for the two regimens without loading doses and were 72% (IV) and 73% (oral) of those with a loading dose. However, at steady state on Day 5, no-load regimen AUCs were essentially the same at 98% for both the IV and oral regimens. Despite lower AUCs on Day 2 for the no-load regimens, the AUC:MIC ratio would still be expected to exceed the stasis threshold for both pathogens and the 1-log kill threshold for S. pneumoniae (figure). This same pattern was also noted on Day 5.

Conclusion

Exposure as assessed using AUC was lower early on in therapy on Day 2 for both IV and oral regimens. However, exposures were not different on Day 5 at steady state. Despite lower exposure on Day 2, OMC would still be expected to meet or exceed PK/PD thresholds associated with stasis for S. aureus and S. pneumoniae. The 1-log kill threshold was exceeded for S. pneumoniae. Further studies are needed to confirm any clinical impact of the omission of OMC loading doses.

Disclosures

All authors: No reported disclosures.
748. Does Improving Discharge Documentation Improve Post-Discharge Care for Patients on Outpatient Parenteral Antimicrobial Therapy (OPAT)?
Authors: Certain Laura , Benefield Russell J , Thomas Frank O
Published: October 2019

Background

Patients discharged on intravenous antibiotics require regular monitoring by an infectious disease (ID) specialist or other provider familiar with outpatient parenteral antibiotic therapy (OPAT). However, the lab monitoring and outpatient follow-up plan outlined prior to discharge is not always realized. We are working to understand what steps the discharging hospital can take to improve the outpatient monitoring and follow-up for patients on OPAT, who are discharged to a wide variety of institutions. We studied whether documenting the OPAT plan in a standardized note led to increased inclusion of that plan in the discharge documentation and thus to improved lab monitoring and outpatient follow-up for our patients.

Methods

We compared the pre- and post-intervention frequency of seven key OPAT elements (antibiotic, duration, end date, indication, follow-up appointment, recommend labs, fax number for labs) in the discharge documentation. Pre-intervention, this information was documented by the inpatient ID service in the Problem List (overview) section of the electronic health record. Post-intervention, OPAT plans were documented within standardized OPAT Progress Notes. Efficiency and clinical outcomes were: proportion of OPAT treatment weeks with laboratory monitoring; number of weeks the outpatient ID team had to track down missing laboratory results; number of “No Show” ID clinic visits; number of OPAT-related telephone encounters.

Results

There were 73 patients in the pre- and 68 in the post-intervention cohort. Having a formal OPAT Progress Note was associated with a significant increase in the number of OPAT elements included in the discharge documentation (7 vs. 5, P = 0.002). In addition, the entire OPAT note was included in the discharge documentation more frequently in the post-intervention cohort (3/73 vs.. 14/68, P = 0.007). However, except for reduced telephone encounters related to OPAT (2 vs. 1 per patient, P = 0.0001), there were no significant improvements in post-discharge clinical or efficiency outcomes.

Conclusion

Creating an OPAT Progress Note improves the capture of OPAT elements into discharge documentation. Except for reducing telephone encounters, no other benefits occurred. Future interventions will focus on improving the other measured outcomes.

Disclosures

All authors: No reported disclosures.
756. Impact of Infectious Diseases Pharmacists as Part of an Interdisciplinary OPAT Team Managing Vancomycin
Authors: Adamsick Meagan L , Gandhi Ronak G , Steiger Samantha N , Bidell Monique R , Nelson Sandra B , Ard Kevin L , Elshaboury Ramy H
Published: October 2019

Background

Outpatient Parenteral Antimicrobial Therapy (OPAT) is a growing area of Infectious Diseases (ID) that allows for the treatment of severe infections in the ambulatory setting. Massachusetts General Hospital (MGH) incorporated inpatient ID pharmacists into the OPAT team in June 2017 to assist with vancomycin monitoring and dosing. Laboratory results were received and documented by the OPAT nurse and forwarded to the pharmacists for assessment via the electronic medical record (EMR). Pharmacists then sent clinical recommendations to the physician. This study aimed to determine the impact of pharmacists’ involvement in OPAT vancomycin management.

Methods

An EMR-generated report identified patients in the OPAT program from June 2016 through May 2017 as the control group and June 2017 through May 2018 as the intervention group. One hundred patients were randomly selected during each period. Patients were excluded from the intervention group if no pharmacist documentation was present. The primary outcome was to evaluate the proportion of vancomycin levels within the patient-specific goal range and secondary outcomes included the proportion of (1) pharmacists’ recommendations accepted by the ID physician and (2) patients who experienced adverse drug events.

Results

A total of 200 patients were evaluated. The most common indication for enrollment was osteomyelitis (46%). No differences in baseline characteristics were noted, and the median age was 67 years. The percentage of vancomycin levels within goal was significantly higher in the pharmacist-managed group compared with the control group (66.8% vs. 54.2%; P < 0.0001). The number of patients who experienced adverse drug events was similar between the two groups (39% vs. 43%; P = 0.66); however, fewer patients in the pharmacist group experienced acute kidney injury (5% vs. 13%; P = 0.08). Finally, 100% of pharmacist recommendations were accepted by ID physicians.

Conclusion

Leveraging inpatient ID pharmacists at MGH in the management of OPAT vancomycin provided improved percentage of vancomycin in therapeutic range and high acceptance rate of interventions. Further evaluation is necessary to assess the inpatient ID pharmacists’ workflow for implementation into other OPAT programs.

Disclosures

All authors: No reported disclosures.
765. Pyomyositis in the United States: Trends and Associations From the Healthcare Utilization Project Nationwide Inpatient Sample Database
Authors: Maravelas Rheanne K , Melgar Thomas , Sadarangani Sapna , Lima Neiberg , Rich Zachary , Vos Duncan
Published: October 2019

Background

Pyomyositis is a spontaneous infection of skeletal muscle that can lead to abscess formation and sepsis. The purpose of our study was to better describe the characteristics, risk factors, and trends of primary pyomyositis in the United States.

Methods

This study is a retrospective review of data from the Healthcare Utilization Project Nationwide Inpatient Sample Database from 2002 to 2014. We systematically searched ICD-9 codes and included diagnoses of infective myositis and/or tropical pyomyositis and excluded progressive myositis ossificans and/or traumatic myositis ossificans. We compiled lists of codes for co-occurring infections, candidate risk factors, and microbiological data. Each group of related ICD-9 codes was combined into a single composite indicator. SAS studio was utilized for analysis.

Results

The database included a total of 100,790,900 discharges accounting for 482,872,274 weighted discharges with 13,011 pyomyositis cases accounting for 62,657 weighted cases. The patients with pyomyositis were significantly more likely to be younger, male, and have a longer duration of hospitalization. The proportion of discharges with pyomyositis has steadily risen more than 3-fold from 0.0054% to 0.0209%. Of the cases of pyomyositis, a minority had co-occurring deep tissue infections: 16.9% had osteomyelitis and 8.8% had septic arthritis. We found significantly higher rates of co-occurrence with HIV, diabetes mellitus, organ transplant, alcohol abuse, and chronic kidney disease compared with the general hospitalized population, suggesting these as relevant risk factors. When microorganisms were diagnosed, Staphylococus aureus was most common, followed by Streptococcus spp.

Conclusion

Our study identified a rapid increase in pyomyositis cases in the United States over our 12-year study period. Our results substantiate risk factors for pyomyositis related to immunosuppression and suggest that diabetes mellitus may be an important risk factor in the United States. Identifying causative organisms is helpful for empiric treatment. It is important that clinicians be aware of this emerging diagnosis relevant in both temperate and tropical areas of the globe.

Disclosures

All authors: No reported disclosures.
766. Telehealth Practices, Barriers, and Future Interest among Pediatric Infectious Disease Clinicians in the United States: Results from the 2019 Pediatric Infectious Diseases Society (PIDS) Telehealth Working Group Survey
Authors: Olson Daniel , Hakim Amin , Gaviria-Agudelo Claudia , Sabella Camille , Fanella Sergio , Arun Aparna , Russo Michael E , Kronman Matthew , Adler-Shohet Felice , Holzmann-Pazgal Galit , Sanderson Susan , Phillips Terri Christene , Edwards Kathryn , Siddiqui Javeed , Bryant Kristina
Published: October 2019

Background

There is a paucity of access to pediatric infectious diseases (PID) physicians in the United States. To improve access, PID clinicians spend significant time providing nonreimbursed curbside consultations (CCs) to community providers. While there is increasing utilization of telehealth technologies to increase access to PID physicians, there is limited knowledge regarding adoption of these technologies and how they may be used to improve care and reimbursement.

Methods

The PIDS Telehealth Working Group developed a 33-question online survey to collect individual- and practice-level data on the burden of CCs, current telehealth practices and barriers, and interest in providing future telehealth services. It was emailed to the PIDS Listserv (n = 1,213) in April 2019.

Results

A total of 161 (13%) providers completed the survey (100% MD/DO), representing 37 states; most are university- (n = 100, 62%) and/or hospital- (n = 74, 46%) employed. Respondents’ practices provide a mean of 1–10 CCs/week to outside institutions (median 3–5 hours/week), with a median of 6–10% resulting in referrals. Outside nonreimbursed CCs are performed by phone/paging systems (n = 156, 98%), secure email (n = 66, 42%), text messaging (n = 46, 29%), and EMR-messaging (n = 38, 24%); they include a variety of services (Figure 1). Only 46 (29%) of individual respondents provide any type of reimbursed telehealth at their practices (Figure 2). Reimbursement mechanisms include fee-for-service (31%), Medicaid/Medicare (25%), private insurance (24%), and internal institutional (i.e., internal RVU) payments (16%). The majority of respondents were unaware of credentialing (n = 90, 64%) and liability coverage needs for telehealth (n = 68, 47%). Though most respondents (n = 81, 57%) were not satisfied with their current telehealth program and barriers were significant (Figure 3), the majority (n = 144, 95%) were interested in implementing a variety of reimbursable telehealth services and modalities (Figure 4).

Conclusion

PID survey respondents indicated a lack of knowledge on key aspects of telehealth and perceive significant barriers to implementing telehealth at their institutions. Nonetheless, there is a strong interest in participating in a variety of telehealth services to increase access to care, with appropriate institutional support.

Disclosures

All authors: No reported disclosures.
769. Comparison of Vancomycin Continuous and Intermittent Infusion Dosing Strategies Among Patients in an Outpatient Antimicrobial Therapy Program
Authors: Shakeraneh Pegah , Gilotra Tarvinder S , Wang Dongliang , Fazili Tasaduq , Steele Jeffrey , Seabury Robert , Miller Christopher , Kufel Wesley D
Published: October 2019

Background

Vancomycin may be administered via intermittent infusion (I-I) or continuous infusion (C-I). C-I vancomycin has advantages including the potential for less nephrotoxicity; however, available data are inconsistent and varies based on inpatient and outpatient settings. Thus, the primary objective of this study was to compare rates of nephrotoxicity in patients who received C-I or I-I vancomycin in an outpatient parenteral antimicrobial therapy (OPAT) program. Secondary objectives included time to onset of nephrotoxicity and clinical failure.

Methods

This was a single-center, propensity score-matched, retrospective cohort study of patients who received C-I or I-I vancomycin for at least one week in the OPAT program between October 1, 2017 and March 31, 2019. Exclusion criteria included patients lost to follow-up, age less than 18 years old, and those requiring renal replacement therapy. Nephrotoxicity was defined as a serum creatinine (Scr) increase of >0.5 mg/dL or >50% from baseline for two consecutive measurements. Clinical failure was defined as unplanned readmission, extension of planned therapy, or change in antibiotic therapy.

Results

Three hundred patients were identified who received C-I or I-I vancomycin. After propensity score matching and exclusion criteria were applied, 74 patients were included in each cohort. Demographic information was similar between cohorts including baseline Scr, age, gender, comorbidities, concurrent nephrotoxins, indication, and vancomycin duration. C-I was associated with a 3.22-fold decrease in nephrotoxicity risk when compared with I-I [C-I: 6.8% vs. I-I 18.9%; OR (95% CI): 3.22 (1.10–9.46), P =0.027]. C-I was associated with a significantly slower onset to nephrotoxicity compared with I-I (P = 0.035; Figure 1). A significant difference in clinical failure was not observed between C-I and I-I (10/74, 13.7% vs. 17/74, 23.0%; P = 0.147).

Conclusion

C-I vancomycin was associated with a lower nephrotoxicity risk and slower onset to nephrotoxicity, but no difference in clinical failure rates when compared with I-I.

Disclosures

All authors: No reported disclosures.
772. Access Denied: Impact of Insurance Denials for High-Cost Outpatient Parenteral Antimicrobial Therapy
Authors: Bianchini Monica L , Kenney Rachel , Lentz Robyn , Zervos Marcus , Malhotra Manu , Davis Susan L
Published: October 2019

Background

Outpatient parenteral antimicrobial therapy (OPAT) allows patients to receive prolonged antimicrobial therapy while reducing the length of hospitalization and healthcare costs. In the United States, most public and private insurance companies require prior authorization (PA) for OPAT. The impact of OPAT PA delays is not known. This study aimed to characterize discharge barriers and authorization delays associated with high-cost OPAT antibiotics.

Methods

IRB-approved study of adult patients discharged with high-cost OPAT antibiotics from January to December 2017. Antibiotics were included based on the frequency of OPAT use and average sales price (ASP) greater than $100 per day, including: daptomycin, ceftaroline, ertapenem, and the novel β-lactam β-lactam inhibitor combinations. Patients with an OPAT authorization delay >24 hours were compared with patients without an OPAT authorization delay. Primary endpoint: total direct hospital costs, starting from the start of treatment with the OPAT antibiotic, from the institutional perspective using Healthcare Cost and Utilization Project and Center for Medicare and Medicaid Services 2019 ASP Drug Pricing data. Secondary outcomes: discharge delay and 30-day readmission or mortality.

Results

Two-hundred patients included: 151 (76%) no OPAT delay vs. 49 (25%) OPAT delay. The use of antibiotics was similar between groups, except ertapenem was more common in the no OPAT delay group: 60 (43%) vs. 15 (25%), P = 0.022. Patients with no OPAT delay were more commonly discharged with home infusion and less commonly to a facility: 75 (53%) vs. 19 (32%), P = 0.007, and 52 (37%) vs. 37 (63%), P = 0.001, respectively. Discharge delays were more common in patients with OPAT delays: 21 (15%) vs. 31 (53%), P < 0.001. The median total direct hospital costs were higher in patients with OPAT delays: $7,770 (3,031–13,974) vs. $19,576 vs. (10,056–37,038), P < 0.001. Table 1 compares the total direct hospital costs of patients with and without an authorization delay.

Conclusion

OPAT with high-cost antibiotics requires significant care coordination. Authorization delays for these antibiotics are common and may contribute to a delay in discharge. OPAT transitions of care represent an important opportunity for Infectious Diseases providers to improve care and address access barriers.

Disclosures

All authors: No reported disclosures.
786. Improving Access by Prescreening Self-Referred Patients to an Infectious Disease Clinic
Authors: Saldana Carlos S , Olender Jeff , Gordon Steven M , Holman Katherine
Published: October 2019

Background

Studies show that 35% of patients obtaining care in a specialty clinic are self-referred, of these, 60% do not have a PCP. Frequent changing of physicians without provider referral contributes to high costs and healthcare inefficiencies. Many subspecialty clinics do not require provider referral for access, so-called: ‘self-referral’; becoming an issue when patients discern a need for a subspecialty that does not align with their disease process. The Infectious Disease (ID) Department of the Cleveland Clinic Main Campus began prescreening all self-referred patients in July 2016. (Figure 1) We reviewed this process after sustained implementation.

Methods

Retrospective cohort study examining “self-referred” patients (lacking an internal referral order) to the ID Clinic from December 2016–October 2018. Grouped patients by chief complaint using system-based categories, subsequently reviewed records received for prior workup and identified if they had been seen by a specialist or received antibiotics in the past 6 months prior to visit. Those seen in our department were evaluated for: (1) additional workup ordered (2) if antibiotics were prescribed, and (3) referral to another specialty.

Results

1449 patients self-referred. By prescreening them, waiting time for appointment fell from >40 to 13 days, no-shows steadily drop from 11% to 8%. We audit 105 (40%) of patients seen, most common reasons for referral: Skin 19 (18%), Bone/Joint 18 (17%), Concern for Lyme Disease 16 (15%). 73% had been previously seen by a subspecialty; majority by ID. 75% received antibiotics in the past 6 months. After the visit, 53% had new work up ordered, 21% were prescribed antibiotics and 26% patients were referred to another specialty.

Conclusion

Prescreening self-referred patients contributed to improved access to subspecialty care and decreased”no-show’ appointments. The majority of self-referred patients had previous evaluation, frequently by the specialty being requested.

Disclosures

All authors: No reported disclosures.
999. Examining the Impact of a Penicillin Allergy Skin Testing Brochure on Inpatient Perceptions: a Pre-Post Intervention Study
Authors: Brown Mikaela , Uzoma Joy , VanSice Ryan P , Conn Kelly M , Ramsey Allison , Staicu Mary L
Published: October 2019

Background

Despite the negative implications associated with a penicillin (PCN) allergy label, less than 0.1% of ~25 million subjects with PCN allergy undergo a PCN skin testing (PST). There is a lack of data assessing patient knowledge and attitude about PCN allergy and PST. The purpose of this study was to evaluate the impact of an educational brochure on knowledge and perception of PST in adult inpatients with a PCN allergy label.

Methods

This was a pre-post intervention study conducted at a 528-bed community teaching hospital between June 2016 and March 2019. An electronic medical record was used to identify adult inpatients with an active PCN allergy. Participants completed a pre-brochure survey to assess demographic characteristics and baseline knowledge of PCN allergy and PST. Individuals then read an educational brochure, returned it to study personnel and were provided a post-brochure survey to complete. The primary and secondary outcomes of knowledge and perception were measured based on the level of agreement with statements about PCN allergies and PST using a 5-point Likert scale. McNemar’s test was used to compare responses for those who agreed vs. did not agree to knowledge statements.

Results

Among 125 patients approached, 101 completed the survey (80.8%). Patients were predominantly female (66.3%), >65 years of age (42.6%), Caucasian (78.2%) and completed high school or beyond (81.2%). The minority of patients (40.6%) previously heard about PST while 25.7% agreed they had previous discussions about PST with a healthcare provider. Only 24.8% agreed that people can outgrow a PCN allergy at baseline; however, after reading the brochure, this percent tripled (77.2%) (P < 0.01). Among 56 participants who disagreed that PST would be helpful for them at baseline, 30 subsequently agreed with this statement on the post-brochure survey (P < 0.001). Post-brochure, 86.1% indicated they felt better informed about PST. Despite this, 34.7% indicated they would be scared to use PCN again if future PST results were negative.

Conclusion

An educational brochure improved general knowledge of PCN allergy and PST, including subject report of feeling more informed. Although the brochure successfully educated patients, gaps remain regarding how individuals will personally apply this new information.

Disclosures

All authors: No reported disclosures.
1014. Decreasing Antimicrobial Use by 25% via Submission to NHSN-AUR Module
Authors: Kassamali Zahra , Kilcup Meg J , Werth Brian J
Published: October 2019

Background

Tracking antimicrobial data are a core element of antimicrobial stewardship programs. Since 2014, the Washington State Health Association (WSHA) has tracked antimicrobial use (AU) to address and reduce C. difficile infections statewide. In 2016, WA state began promoting the National Healthcare Safety Network (NHSN) tool to upload hospital AU. Both track days of antimicrobial therapy (DOT) but WSHA uses patient-days as the denominator while NHSN uses days-present. Each measure accounts for hospital length of stay but the latter is affected by unit transfers and the former is not.

Methods

Observational review of AU data submitted to NHSN and to WSHA in a 2-year period. Sixteen antibiotics selected by WSHA were reviewed and organized into 5 groups: broad-spectrum penicillins, cephalosporins, carbapenems, fluoroquinolones, and clindamycin. Data from a single center were used to compare results between each AU tracker. AU and days-present were obtained from the electronic medical record. Patient-days were obtained from the hospital quality department. The primary outcome was a difference in AU per WSHA vs. NHSN.

Results

Between January 2017 to December 2018, the median rate of antimicrobial use was 279 days per 1000 patient-days and 201 days per 1000 days-present. The median difference in total AU reported was 25% less using NHSN vs. WSHA and ranged from 18% - 31%.

Conclusion

Switching from patient-days to days-present decreased the reported rate of AU by 25%. In WA state, hospitals have nonuniformly adopted submitting antimicrobial use data to the NHSN. Until all hospitals submit their data via NHSN, both individual institutions and the state will have to contend with mismatched data. An interim solution may be to collect monthly patient-days and days-present from all hospitals and adjust the data before comparing AU among institutions. For institutions with a long history of tracking antimicrobial use, this change in denominator and resulting impact on AU represents a barrier to using the NHSN AU module.

Disclosures

All authors: No reported disclosures.
1026. Ertapenem Use During Antibiotic Stewardship Interventions in Community Hospitals
Authors: Peterson Nathan , Castro Sarah , Barbosa Felipe , Yoon Jungwon
Published: October 2019

Background

Antimicrobial stewardship programs (ASP) promote the judicious use of antimicrobials to reduce antimicrobial resistance and improve patient outcomes. In our institution, we identified the overutilization of ertapenem and implemented several interventions to decrease its usage. The objective of this study was to assess the impact of these interventions on ertapenem use, rates of surgical site infection (SSI), carbapenem-resistant Enterobacteriaceae (CRE), and hospital-onset Clostridioides difficile infection.

Methods

This was a retrospective study conducted in 3 community hospitals in Iowa and Illinois using surveillance of anonymized antibiotic and infection control data from 2015 to 2018. Target ASP interventions included a daily retrospective review of ertapenem use, alternative alerts to providers through electronic health records (EHR), carbapenem restriction to infectious disease (ID) providers, and educational meetings with high-use provider groups. The primary outcome was the usage trend of ertapenem, and secondary outcomes were rates of SSI, CRE, and hospital-onset C. difficile infection. Interrupted time series analysis was performed to assess changes in the rates over the study period.

Results

An overall significant reduction in ertapenem use was observed in all 3-community hospitals from 2015 to 2018. Ertapenem days of therapy adjusted for case-mix index per 1000 patient-days was 11.2 in 2015 and 2.05 in 2018. Two breakpoints were identified; the addition of an ID trained pharmacist to the ASP (10/2016) and educational meetings with colorectal surgeons (5/2017). No significant difference was seen for hospital-onset C. difficile infection, SSI, or CRE. Purchase costs decreased for ertapenem by 81% in 2018 compared with 2015(P < 0.001).

Conclusion

Adding an ID trained pharmacist to an ASP decreased usage of ertapenem. The majority of ertapenem use was for surgical prophylaxis, and our data suggested that educational meetings with a high-usage group were effective. Surgical site infection rates did not increase when narrower spectrum surgical prophylaxis was used. Overall hospital-acquired C. difficile rate was unchanged, possibly due to alternative antibiotic use. Our study suggests ASP interventions can be cost saving.

Disclosures

All authors: No reported disclosures.
1031. Effect of On-Site ID Specialist Led, Antimicrobial Stewardship Pharmacist Driven Program on Provider Acceptance, Antimicrobial Utilization and Clostridoides Infection Rates In a Community Hospital / Rural Regional Referral Center
Authors: Brailita Daniel , Lane Justin
Published: October 2019

Background

Antibiotic Stewardship (ASP) standards for hospitals became effective January 1, 2017. Core Elements implementation guidelines have been challenging for rural hospitals usually lacking on-site expertise. Our 170-bed Community Hospital / rural referral center has dedicated resources for on-site ASP. Our team includes on-site Infectious Disease (ID) Specialist and dedicated ASP pharmacist. Over first 2 years, our model shows very high provider acceptance, improvement in antimicrobial use pattern and reduction in the number of Clostridioides difficile infections (CDI).

Methods

The ASP Pharmacist conducted a daily review of ASP targets. He met with on-site ID Physician 3 days weekly to discuss interventions and review complex cases. The ASP team - ID Medical Director, ASP Pharmacist, Microbiologist, Invention Preventionist and Hospitalist met monthly to discuss outcomes and facility-wide interventions.

ASP audit included: positive cultures, patients on multiple or broad-spectrum antimicrobials, patients receiving dual nephrotoxic drugs, carbapenems, fluoroquinolones, candidates for IV to PO conversion

The audit results were communicated in-person to attending physician and documented in electronic medical record.

Results

ASP team recommendations were accepted in 94% of cases

ID consult was recommended in 4.69% and was accepted 100%.

Top 20 IV antimicrobial use decreased by 10%. Fluoroquinolones (29%) and carbapenems (28%) showed highest decrease. Cephalosporins showed small increase.

Hospital-acquired CDI rate decreased from 0.83 cases/ 1000 patient-days (PD) pre-ASP to 0.53 cases/ 1000 PD post-ASP. General CDI diagnosis decreased from 3.21 cases/1000 PD pre-ASAP to 2.23 cases/ 1000 PD post-ASP

Conclusion

An on-site, ID Specialist reviewed and dedicated ASP Pharmacist driven program at a rural referral center/ Community Hospital significantly improved antibiotic use and decreased Clostridium Difficile Infections in the first 2 years. Direct feedback of ASP review to providers resulted in an excellent acceptance rate. On-site ID and ASP Pharmacist collaboration is logistically difficult to achieve but expanding our model to rural referral centers should be considered. More research is needed to determine the cost-effectiveness of onsite, dual led programs.

Disclosures

All authors: No reported disclosures.
1043. Love Thy Steward – Who Does Not Love Antimicrobial Stewardship?
Authors: Kazi Aamir S , Sansom Sarah , Varughese Christy , Hodgson Hayley A , Won Sarah Y
Published: October 2019

Background

The impact of antimicrobial stewardship programs (ASPs) depends on physician perception of antimicrobial stewardship and institutional antibiotic prescribing culture. At Rush University Medical Center (RUMC), we conducted an antimicrobial stewardship study targeting inpatient levofloxacin (FQ) use and assessed rates of implementation of recommendations (IORs) by general medicine (GM), vs. surgical services (SS) (general surgery, urology, orthopedics and neurosurgery), vs. transplant surgery-immunocompromised host (T-ICH) teams when made by either infectious disease pharmacists (IDPharmD) or infectious disease fellows (IDMDF).

Methods

Between August 13, 2018 and January 15, 2019 at RUMC, IDPharmDs reviewed 251 inpatients on FQ, and made ASP recommendations on 36 (14%) that were communicated via telephone. No scripted discussion or note was utilized. From January 15, 2019 to April 19, 2019, an IDMDF reviewed 207 inpatients on FQ, and made ASP recommendations on 47 (22%). IDMDF’s recommendations were communicated via a scripted discussion describing the role of ASP, highlighting the importance of optimizing FQ use due to toxicity, low rates of RUMC’s FQ susceptibilities and to decrease rates of resistance. Telephone recommendations were made to the primary team house staff or attending followed by a templated electronic note left in the medical chart. Rates of IORs were assessed during each period and by each group.

Results

In 20 out of 83 recommendations (24%), no antibiotic was indicated (Figure 1). GM teams had the highest overall (IDPharmD + IDMDF) IOR (76%), compared with 40% IOR for both SS and T-ICH groups. For all groups, the scripted IDMDF recommendations had higher IOR compared with the nonscripted IDPharmD recommendations (GM 89% vs. 61%; SS 50% vs. 29%; T-ICH 50% vs. 0%).

Conclusion

ASP interventions using scripted discussions and notes by an IDMDF were more effective than nonscripted IDPharmD interventions across all service lines. Both interventions were less successful with SS or T-ICH compared with GM services. These findings demonstrate the need for further research to understand the importance of scripted vs. nonscripted communication methods by pharmacists and ID physicians, and to develop alternative communication models for nongeneral medicine service providers.

Disclosures

All authors: No reported disclosures.
1044. Impact of Interdisciplinary Rounds on Antimicrobial Use at a Community Hospital
Authors: Castillo Emma , Heuts Luke , Dodds Ashley Elizabeth , Moehring Rebekah W , Yarrington Michael E , Johnson Melissa D
Published: October 2019

Background

Antimicrobial stewardship (AS) implementation is challenging in resource-limited settings such as smaller community hospitals that may lack dedicated personnel resources or have limited access to infectious diseases experts with dedicated time for AS. Few studies have evaluated the impact of interdisciplinary rounds as a strategy to optimize antimicrobial use (AU) in the community hospital setting.

Methods

We evaluated the impact of interdisciplinary rounds in a 280-bed acute care nonteaching, community hospital with an established ASP. The primary outcome was facility-wide antibiotic utilization pre- and post-implementation. Rounds included key healthcare personnel (hospitalists, clinical pharmacists, case managers, nurses) reviewing all patients on inpatient wards Monday through Friday, with a discussion of diagnosis, antibiotic selection, dosing, duration, and anticipated discharge plans. AU was compared for a 7-month post-intervention period (June 1, 2018–December 31, 2018) vs. similar months in 2017 based on days of therapy (DOT)/1,000 patient-days and length of therapy (LOT) per antimicrobial use admission. In addition, trends in AU for the post-intervention period were compared with the previous 17 months (January 1, 2017–May 31, 2018) using segmented binomial regression.

Results

Interdisciplinary rounds incorporating AS principles was associated with a decrease in overall AU in this facility, with a significant decrease of 16.33% (P < 0.0001) in DOT/1,000 pd in the first month and was stable (decrease of 1.1% per month, P = 0.15) thereafter (Figure 1). There was no significant change in LOT/admission after the first month of the intervention, but the trend demonstrated a 2% per month decrease (P < 0.03) thereafter (Figure 2). Comparing 2018 intervention months with similar months of 2017, the use of antibacterial agents decreased on average by 191.3 (95% CI −128.2 to −254.4) DOT/1,000 patient-days (Figure 3) and 0.546 (95% CI: −0.28 to −0.81) days per admission (Figure 4).

Conclusion

In this community hospital with an existing antimicrobial stewardship program, implementation of interdisciplinary rounds was associated with a substantial decrease in antimicrobial use. This was sustained for at least a 7-month period.

Disclosures

All authors: No reported disclosures.
1049. Using Alternative Alerts in the Electronic Health Record to Guide Antimicrobial Selection Decisionmaking at the Point of Order Entry
Authors: Ebert Steven C
Published: October 2019

Background

In a White Paper published in 2019, SHEA describes “The role of electronic health record and ‘add-on’ clinical decision support systems to enhance antimicrobial stewardship programs.” Modifications of the electronic health record and add-on clinical decision support systems are compared and contrasted. Some disadvantages of modification of the EHR include the need to include all end-user affiliates in modifications, lack of order set utilization, and heavy demands of IT staff to modify the EHR. We have utilized alternative alerts which may be customized to individual affiliates and are relatively easy to build which fire when specific medications are ordered (whether within order sets or not) and guide clinicians to more appropriate antibiotic choices.

Methods

From an antimicrobial stewardship perspective, alternative alerts are activated during the ordering of antibiotics for which routine use is discouraged (e.g., carbapenems, fluoroquinolones). When a provider enters an order, the alternative alert will pop up. The alert consists of two sections: an alert section describing the reason for the alert and a list of therapeutic options for the targeted drug; and links to orders for alternative antibiotics/combinations. The alerts may be configured to allow or not allow the orderer to continue with the original order. Different alternative alerts can be created and used at different facilities using the same EHR platform. We designed alternative alerts for fluoroquinolones, carbapenems, and fifth-generation cephalosporins that allowed providers to continue with the original order. We tested their impact on antimicrobial prescribing for 18 months after implementation, measured as quarterly days of therapy (DOT)/1000 pt-days.

Results

We noted marked reductions in quarterly DOT/1000 pt-days for fluoroquinolones (-70%) and fifth-generation cephalosporins (-90%). The impact on carbapenem prescribing was more variable.

Conclusion

Alternative alerts represent an easily created, customizable means to guide providers’ antimicrobial selections. We plan to incorporate more alternative alerts into our antimicrobial ordering process and strengthen the alert for carbapenems.

Disclosures

All authors: No reported disclosures.