bluuebunny/crossref_metadata_2025 huggingface dataset:
743. Evaluation of Adverse Drug Reactions due to Common β-Lactam Therapies Among Patients Enrolled in an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program
Authors: Mays Erin , Kinlaw Alan C , Swartwood Michael J , Boerneke Renae A , Farel Claire E , Marx Ashley
Published: October 2019

Background

The UNC Medical Center Outpatient Parenteral Antimicrobial Therapy (OPAT) program was started in 2015 to provide multidisciplinary monitoring and management of patients discharged on parenteral antimicrobials. Laboratory abnormalities and adverse drug reactions (ADRs) are potential complications of OPAT that may result in readmission and treatment changes. The purpose of this study was to evaluate the time to first ADR for OPAT patients treated with BL therapies for diabetic foot infections (DFI) and osteomyelitis (OM).

Methods

This was a retrospective cohort study of patients enrolled in the UNC OPAT program between January 2015 and September 2018 for treatment of DFI or OM. Included patients received one of the following BL: cefepime, ceftriaxone, ertapenem, meropenem, and piperacillin/tazobactam. The primary outcome was time to first ADR during OPAT. Secondary outcomes were estimation of risk of ADR during OPAT for each medication; and ADR types and frequencies observed among patients treated with BL alone or with concomitant vancomycin or daptomycin.

Results

In this cohort, 178 OPAT patients received 193 OPAT courses, for a median duration of 42 days (IQR 38–50). The average patient age was 55 years, and 68% were male. Ertapenem was the most commonly prescribed BL (76 courses, 39%), followed by ceftriaxone (29, 15%), cefepime, (41, 21%), piperacillin/tazobactam (30, 16%) and meropenem (17, 9%). Approximately 40% (76) patients received concomitant vancomycin. ADR was documented in 48 patients (27%) and 56 courses of therapy (29%). Kaplan–Meier-estimated risk of at least one ADR in the first 8 weeks of therapy was 38.7% (95% CI 29.1% to 48.2%). ADR resulted in 32 therapy changes and 8 readmissions.

Conclusion

More than one-third of patients treated with BL for treatment of DFI and/or OM are at risk of ADR within 8 weeks. ADR commonly resulted in treatment changes, and possible hospital readmission. BL therapy is associated with significant ADR risk, and careful selection and monitoring is essential for optimal patient safety during OPAT.

Disclosures

All authors: No reported disclosures.
759. High-Dose Daptomycin Is Well Tolerated via 2-Minute Infusion
Authors: Gill Christian Mark , Kenney Rachel , Makowski Charles , Davis Susan L
Published: October 2019

Background

Intravenous (IV) base solution shortages pose issues in the administration of IV antimicrobials and necessitate alternative administration strategies. Safety data supports 2-minute infusions of IV daptomycin up to the labeled dose of 6 mg/kg. The purpose of this study was to evaluate the safety of administering high-dose daptomycin (HDD) (>6 mg/kg) as a 2 minute IV infusion compared with traditional 30-minute infusion.

Methods

IRB-approved, retrospective cohort in a five-hospital health system admitted 9/1/17–9/1/18. Inclusion criteria: Patients receiving HDD as either a rapid 2 minute IV push (IVP) or a traditional 30-minute infusion (IVI) while inpatient. Exclusion criteria: <2 doses of HDD, pregnant, age <18, concomitant medication associated with infusion reactions (e.g., amphotericin B or monoclonal antibody). Primary outcome: proportion of patients with infusion-related reactions (IRR) after daptomycin administration. Infusion-related reactions were assessed using the Naranjo algorithm and adjudicated by 2 reviewers blinded to administration strategy. Bivariate statistical tests were used to compare patient characteristics and outcomes between groups. Data were reported using descriptive statistics and measures of central tendency.

Results

300 patients included: IVP n = 200, IVI n = 100, representing a total of 1697 administrations. Median age IVP 61 (49, 71), IVI 63 (52, 74). Median BMI IVP 28 (23, 35), IVI 27 (23, 32). Median daptomycin dose IVP 700 (550, 900), IVI 700 (600, 900) with mg/kg doses of 8.2 (7.9, 10) and 8.3 (8, 10), respectively. Administration site was similar in both groups with the most common central venous catheters. Potential IRR occurred in 4% of the IVP arm and 1% of IVI arm, P = 0.28. After adjudication, IRR occurred in 1% of both treatment groups. Descriptions of IRR are in Table 1 and only 1 patient in the IVI arm required discontinuation. CPK elevations: 3% of entire cohort.

Conclusion

Administering HDD as an IVP was not associated with increased risk of IRR compared with IVI. This administration may be advantageous during fluid shortages and in outpatient administration.

Disclosures

All authors: No reported disclosures.
767. Can Integration of Addiction Treatment Facilitate Safe Discharge on OPAT for Patients with Infectious Complications of Injection Drug Use?
Authors: Solomon Daniel A , Price Christin , Johnson Jennifer A A , Montgomery Mary W , Martin Bianca , Suzuki Joji
Published: October 2019

Background

While there is a growing body of evidence that suggests outpatient parental antibiotic treatment (OPAT) for people who inject drugs (PWID) may be safe, research on integrating OPAT with addiction treatment for PWID has been limited.

Methods

Adults hospitalized for infectious complications of injection drug use (IDU) requiring prolonged IV antibiotics were included in this study. The suitability for OPAT was determined by the infectious disease and addiction consultation services. Eligibility criteria included safe housing, attendance at infectious disease (ID) clinic visits, and engagement with addiction treatment. Demographic and clinical outcomes were summarized, and compared with patients without any IDU history enrolled in OPAT during the same time at the same institution.

Results

Eighteen OPAT episodes among 17 individuals were included, with 9 (50.0%) males. Mean age was 38.4 (SD 9.5). Types of infection included endocarditis (38.9%), epidural abscess (38.9%), and bone/joint infections (33.3%). Opioid use disorders (OUD) were most common (94.4%), followed by cocaine (33.3%) and benzodiazepines (16.7%). All individuals completed the recommended course of IV antibiotics. All OUD patients received buprenorphine (52.9%) or methadone (47.1%). Two (11.1%) relapsed to drug use during OPAT, but no instances of line tampering, thrombosis, line infection or line dislodgement were identified. No deaths or overdoses were reported. Collectively, 504 inpatient days were avoided. Compared with 390 individuals without any history of IDU, those with IDU history were significantly younger (38.4 vs. 59.0, P < 0.0001), had fewer episodes of endocarditis (38.9% vs. 43.6%) and bone/joint infections (33.3% vs. 41.8%), but more epidural abscesses (38.9% vs. 3.1%). There were no statistical differences in rates of readmission (22.2% vs. 11.3%), line complications (0% vs. 3.5%), mortality (0% vs. 1.0%), ID clinic visit attendance (100.0% vs. 82.0%), or number of days on OPAT (28.0 vs. 30.1).

Conclusion

Results add further evidence of OPAT’s safety among PWID and that integration of addiction treatment may be feasible. OPAT outcomes were similar to those without any IDU history. More research is needed to study the impact of integrating addiction treatment with OPAT for PWID.

Disclosures

All authors: No reported disclosures.
1008. The Reduction of Fluoroquinolone Prescribing in Rural Vermont Hospitals
Authors: Smith Lindsay , Ahern John W
Published: October 2019

Background

In 2017 The Joint Commission required all hospitals irrespective of size to implement antimicrobial stewardship programs (ASPs) using the CDC core elements (CE) for antimicrobial stewardship (AS). Critical access and rural community hospitals have struggled with developing effective ASPs. Many ASPs seek to reduce fluoroquinolone (FQ) prescribing due to its high risk for drug-drug interactions, risk of Clostridioides difficile infection, and numerous side effects, including five black box warnings from the FDA.

Methods

We contracted with the Vermont Department of Health to help rural VT hospitals develop ASPs that are compliant with the CDC CE for AS. Six of Vermont’s 13 hospitals were recruited between June – December 2017 (Table 1). Each hospital obtained antibiotic usage (AU) data in grams (g)/1000 (1k) patient-days (PD) from their electronic medical record (EMR), starting from January 2017. All identified FQ as frequently prescribed antimicrobials. Each hospital had unique interventions to decrease FQ prescribing (Table 1), including orderset changes and pharmacist intervention. Monthly combined FQ (ciprofloxacin + levofloxacin) administration data were collected in g/1K PD. AU data from each hospital were summed and expressed as total FQ g/1000 patient-days. The FQ prescribing trend was analyzed by linear regression.

Results

Prior to implementing ASP, there was a combined FQ rate of 69 g/1K PD. After 20 months of ASP interventions, combined FQ prescribing decreased to 26 g/1K PD (Figure 1, R= 0.9797, P < 0.001). This trend is also significant for each individual FQ: ciprofloxacin (R=0.8364, P < 0.05) and levofloxacin (R= 0.9801, P < 0.01).

Conclusion

Rural and critical access hospitals can have successful antimicrobial stewardship programs. We have shown that rural hospitals in Vermont (1) can extract AU data from their EMR, (2) develop interventions to decrease high use antimicrobial agents, and (3) be successful in decreasing FQ prescribing in less than 2 years.

Disclosures

All authors: No reported disclosures.
1016. Standardized Antimicrobial Administration Ratio (SAAR) and Clostridioides difficile Infection Standardized Infection Ratio (SIR): Are they connected? An Evaluation of 28 Hospitals
Authors: Sebastian Danielle , Daragjati Florian , Saake Karl , Sturm Lisa K , Fakih Mohamad G
Published: October 2019

Background

Clostridioides difficile infections (CDIs) are the most prevalent healthcare-associated infection in the U.S. Of all CDIs, most are related to healthcare exposures and are potentially preventable by reducing unnecessary antibiotic use and interrupting patient-to-patient transmission of CDI.

Methods

The adult SAARs for 4 antimicrobial agent categories were compared with the CDI SIR at 28 facilities with greater than 100 beds across the health system for the calendar year of 2018. The 4 adult antimicrobial agent categories chosen for comparison were: antibacterial agents posing the highest risk for CDI, broad-spectrum antibacterial agents predominantly used for hospital-onset infections (BSHO), broad-spectrum antibacterial agents predominantly used for community-acquired infections (BSCA) and all antibacterial agents.

Results

The 2018 aggregate CDI SIR for the 28 facilities was 0.609. The aggregate SAAR for the adult antimicrobial agent categories were 1.05 for the antibacterial agents posing the highest risk for CDI, 1.05 for BSHO, 0.88 for BSCA, and 1.03 for all antibacterial agents. No correlation was seen between any of the 4 adult SAAR antimicrobial agent categories and the facility CDI SIR (Figure 1–4).

Conclusion

While reducing unnecessary antibiotics is an important strategy in preventing CDIs, having a higher observed vs. predicted administration ratio in the four antimicrobial agent categories studied was not correlated with a higher CDI SIR, including the CDI SAAR category. Reduction of CDI is challenging requiring a multipronged approach to include infection control strategies, appropriate testing, and antimicrobial stewardship.

Disclosures

All authors: No reported disclosures.
1021. Accuracy of Provider-Selected Antibiotic Indications at Point of Order Entry Compared with Electronic Health Record Documentation
Authors: Mary Bradley , Huang Joanna , Neville Nichole , Schwarz Kerry , Barber Gerard , Huang Misha , Miller Matthew A
Published: October 2019

Background

The Centers for Medicaid and Medicare Services (CMS) state that hospital antimicrobial stewardship (AMS) policies require indications be documented for all orders. This may be included in the electronic medical record (EMR) or during order entry per CMS. Reliance solely on EMR documentation may be inconsistent or absent at times. In an effort to optimize compliance to this new measure and improve antibiotic use tracking, the University of Colorado AMS committee implemented required indications for all systemic antimicrobial orders. To follow up on this intervention we sought to determine the accuracy of ordered indication based on EMR documentation.

Methods

Retrospective review of antibiotics ordered between May 2, 2017 and December 1, 2017 among hospitalized patients aged 18–89 years. The primary objective was the accuracy of provider-selected indications (PSI) compared with EMR documented-clinical indication (DCI). Secondary objectives included accuracy comparison between check-box and free-text PSI format, and adherence to institutional antibiotic use guidelines. Differences between proportions of antibiotic orders with certain variables were assessed with Pearson’s chi-square and Fisher’s exact as appropriate.

Results

A total of 304 patients were evaluated with a median age of 56 years, 49% male, and 31% identified as immunocompromised. Check-box was most utilized in 81%, with 93% having a single indication selected. Most orders were classified as empiric (63%), followed by prophylaxis (23%) and definitive (15%). Frequent indications chosen were pneumonia (17%), bacteremia (13%), skin and soft tissue (10%), urinary tract infection (9%), and intra-abdominal infections (5%). Accuracy by PSI/DCI match was 78%, which was not different by a method of indication entry. Only indication type (P = 0.023) and care team specialty (P = 0.009) were shown to significantly impact accuracy. Nonadherence to institutional guidelines was 19%.

Conclusion

Antibiotic indications on order entry are an effective strategy to improve documentation and meet compliance around new CMS standards. Ordering by surgical services and prophylactic indications had lower PSI/DCI match, mostly resulting from absent EMR indication documentation.

Disclosures

All authors: No reported disclosures.
1029. Clinical and economic outcomes of a newly implemented daptomycin dosing policy in a four-hospital health system
Authors: Todd Meredith , Jones Kelci , Hill Sharon
Published: October 2019

Background

In light of recently published clinical and pharmacokinetic data regarding the use of daptomycin in obese patients, the Charleston Area Medical Center (CAMC) Antimicrobial Stewardship Program implemented an adjusted body weight dosing strategy for obese patients. Along with this new dosing strategy, an effort to reduce drug waste was also implemented by restricting the timing of routinely scheduled daptomycin doses for inpatients. This study aims to determine the clinical outcomes for patients receiving daptomycin both before and after this policy change. Secondary objectives include assessing creatinine phosphokinase (CK) levels in the study participants, defining the risk of CK elevation with the coadministration of HMG Co-A reductase inhibitors and daptomycin, and assessing any reduction in drug waste for the pharmacy department.

Methods

This study is a single-center, one-group pretest-posttest, quasi-experimental study evaluating the implementation of a two-part daptomycin dosing policy. The pretest group included all patients meeting inclusion and exclusion criteria that received daptomycin at CAMC from September 1 - November 30, 2017. The new daptomycin dosing policy was implemented on September 1, 2018. The posttest group included all patients meeting the stated criteria that received daptomycin from September 1 - November 30, 2018.

Results

A total of 118 patients were included in this study. There were 5 (7.7%) treatment failures in the pretest group and 3 (5.7%) in the posttest group (P = 0.7). Of the patients with CK levels monitored, 6 (33%) were found to have significant elevations in the pretest group and 4 (40%) were found in the posttest group (P = 0.6). There was no difference observed in the risk of CK elevation with daptomycin administration in the presence of an HMG-CoA reductase inhibitor. For the two time periods reviewed, the pharmacy department purchased fewer vials of daptomycin in the posttest group.

Conclusion

Patients at CAMC receiving daptomycin after implementation of a new dosing policy did not experience an increased risk of treatment failure. The Antimicrobial Stewardship Program will continue to monitor patients receiving daptomycin therapy at CAMC.

Disclosures

All authors: No reported disclosures.
1040. Effects of An Antimicrobial Stewardship Team-led Staphylococcus aureus Bacteremia Management Bundle: A Quasi-Experimental Study
Authors: Marx Ashley H , Chundi Vahini , Zaccardelli Jill , Angle Timothy , Oriet Jonathan , Swartwood Michael J , Boyce Ross , Daniels Lindsay M , Juliano Jonathan J
Published: October 2019

Background

Mortality associated with Staphylococcus aureus bacteremia (SAB) has prompted the development of “bundle”-based approaches to improve outcomes. Components of bundled strategies include appropriate antibiotic selection, early source control, documenting negative cultures, echocardiogram, and adequate treatment duration. In 7/2016, the UNC Antimicrobial Stewardship Program (ASP) began prospective monitoring of SAB patients. Here we describe the impact of these ASP efforts.

Methods

Quasi-experimental study of patients ≥16 years with SAB 9/2015-3/2016 (pre-intervention) and 9/201/2017 (post-intervention). Patients were excluded if the bloodstream infection was polymicrobial, therapy began at an outside hospital, or the patient was discharged or died within 72 hours of positive blood culture. Minimum adequate treatment duration was defined as 14 days for uncomplicated SAB; 28 days for complicated SAB; 42 days if endovascular disease or osteomyelitis present. Categorical variables were compared using the chi-squared test, significance level of P < 0.05. The study was approved by the UNC IRB.

Results

217 treatment courses were included; 114 pre- and 103 post-intervention. Rates of adequate empirical antibiotics were consistently high throughout the study (Table 1). Pre-intervention, individual bundle components occurred frequently: negative culture documented (95%), echocardiogram (80%), and adequate duration of an appropriate antibiotic (71%; Table 2). After ASP intervention, echocardiography and adequate treatment duration rates increased to 92% (P < 0.05, both outcomes), as did ID consultation rates (59% to 67%; P = 0.04). Overall bundle achievement increased from 54% to 82%. ASP interventions were documented for 11 (10%) and 32 (31%) of patients during the periods. Mortality and readmission within 6 months of discharge were unchanged (12% and 11%; 41% and 42%, respectively).

Conclusion

ASP intervention was associated with increased rates of bundle achievement but did not impact mortality or 6-month readmission. Despite adequate empiric therapy and relatively high rates of adherence to best-evidenced practices, SAB continues to be associated with significant mortality and high rates of 6-month readmission.

Disclosures

All authors: No reported disclosures.
1045. Impact of an Antimicrobial Stewardship Pharmacist on Microbiology Rounds
Authors: Sapozhnikov Julia , Huang Angela , Revolinski Sara , Ledeboer Nathan A , Buchan Blake W
Published: October 2019

Background

Microbiology rounds is an area for antimicrobial stewardship programs (ASP) to potentially intervene on antimicrobial prescribing in both the inpatient and outpatient settings. The purpose of this study was to describe and evaluate the impact of ASP pharmacist participation in microbiology rounds.

Methods

This was a single-center retrospective descriptive study including inpatient and ambulatory adults ( ≥18 years) with a susceptibility request requiring review during microbiology rounds between October 2018 and 3/2019. During daily microbiology rounds, susceptibility or workup requests were reviewed with the multidisciplinary microbiology team. The ASP pharmacist was called for their clinical expertise in assessing complicated or nonstandard susceptibility requests. Number and types of interventions made by ASP pharmacist were recorded (e.g., approval rate, education, ASP referral, ID consult referral). Additionally, number and types of intervention outcomes (unnecessary susceptibility prevented, optimized susceptibility request, treatment recommendation, improved clinician understanding, etc.) were analyzed.

Results

There were 66 susceptibility requests reviewed by an ASP pharmacist from October 2018 to 3/2019, of which 84.8% were inpatient. An ID provider was the requestor for 35% of requests. ASP pharmacists completed chart reviews for 92.4% of patients and contacted the requester/primary team 72.7% of the time. Thirty-three (50%) susceptibility requests were approved and, notably, 65.2% of requests from an ID provider were approved. Intervention rates for education provided, ASP referral, and ID consult referral were 50%, 1%, and 7%, respectively. ASP pharmacists were able to impact multiple intervention outcomes, including preventing unnecessary susceptibility requests (45.5%) and improving clinician understanding (39.4%) (Table 1).

Conclusion

ASP pharmacists are an important part of the microbiology team and are able to use their clinical expertise to help approve or deny susceptibility requests, make potential recommendations to optimize antimicrobial therapy, and provide education to other healthcare professionals.

Disclosures

All authors: No reported disclosures.
1059. Impact of a Syndrome-Based Antimicrobial Stewardship Intervention on Anti-Pseudomonal β-Lactam Use, C. difficile Rates and Cost in an Urban Community Hospital
Authors: Mena Lora Alfredo J , Cortez Martin , Li Ella , Sanchez Lawrence , Bello Rochelle , Krill Candice , Coleman Yolanda , Takhsh Eden , Bleasdale Susan C
Published: October 2019

Background

The use of anti-Pseudomonal β-lactam (APBL) agents has significantly increased in the past decade, carrying higher costs and contributing to antimicrobial pressure. Antimicrobial stewardship (ASP) can promote evidence-based antimicrobial selection and mitigate excess APBL use. We implemented a comprehensive ASP with syndrome-based prospective audit and feedback (PAF) at an urban community hospital. The goal of this study is to assess the impact of syndrome-based PAF on APBL use, C. difficile rates and cost.

Methods

ASP with all CDC core elements was implemented at a 151-bed community hospital in October 2017. Syndrome-based guidelines and PAF was established and overseen via direct communication with an ID physician. Days of therapy (DOT), cost and C. difficile rates were assessed 12 months before and after ASP. DOT for APBL and non-APBL utilization was tabulated by unit and paired t-test performed.

Results

Most cases reviewed by PAF (51%) were represented in our syndrome-based treatment guidelines (Figure 1). Soft tissue (33%) and intra-abdominal (24%) infections were the most common syndromes. Change to guideline was the most common PAF intervention (62%) followed by de-escalation (30%). At 12 months, total DOT/1,000 increased (392.5 vs. 404) while the proportion of parenteral antimicrobials used decreased (71% vs. 65%). Antibiotic expenditures decreased by 23%, with a reduction in APBL of 20% and non-APBL of 10% (Table 1). Statistically significant reductions APBL use in non-ICU settings (P = 0.0139) and statistically significant increases in non-APBL in ICU settings occurred (P = 0.0001) (Figure 2 and 3). C difficile rates decreased from 21% (3.27 vs. 2.56).

Conclusion

Syndrome-based PAF was successfully implemented. A reduction in APBL use was seen in non-ICU settings, where evidence-based de-escalation may be more feasible. APBL use remained high in the ICU but was guideline consistent. A rise in non-APBL use also occurred. Certain critical illness syndromes warrant APBLs, but PAF may promote culture-directed and syndrome-specific treatments. ASP increased guideline-based therapy and contributed to decreased broad-spectrum antimicrobial use, antimicrobial expenditures and C difficile rates. Syndrome based PAF can be successfully implemented in community settings.

Disclosures

All authors: No reported disclosures.
1072. The Role of an On-site Infectious Disease Specialist in Hospital-Based Antimicrobial Stewardship Programs
Authors: Livorsi Daniel J , Nair Rajeshwari , Lund Brian , Alexander Bruce , Beck Brice , Goto Michihiko , Ohl Michael , Perencevich Eli N
Published: October 2019

Background

Antimicrobial stewardship programs (ASPs) are now a requirement for many hospitals, but a large proportion of US hospitals lack an on-site Infectious Disease (ID) specialist. We sought to compare the processes and outcomes of ASPs at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist.

Methods

This retrospective cohort included all acute-care patients in VHA hospitals admitted during 2016, or 2 years after a VHA mandate for hospital-based ASPs. Data from a mandatory nationwide survey were used to identify hospitals that self-reported the absence of an on-site ID specialist, including an ID physician or ID pharmacist, in 2016. Antimicrobial use was quantified at the hospital-level as days-of-therapy (DOTs) per 1,000 days present and categorized based on National Healthcare Safety Network definitions. A facility-level negative binomial regression model with risk adjustments made for aggregated case-mix and facility-level factors was used to determine the association between the presence of an on-site ID specialist and antimicrobial use.

Results

Eighteen of 122 (14.8%) hospitals lacked an on-site ID specialist. Non-ID hospitals had fewer admissions per month than ID sites (mean 107.3 vs. 425.4, P < 0.01). An ASP policy and an ASP pharmacy champion were present at ≥90% of hospitals with and without an ID specialist. Core ASP strategies were frequently used in both ID and non-ID sites, including prior authorization (90.4% vs. 83.3%, P = 0.41) and prospective audit-and-feedback (76.9% vs. 66.7%, P = 0.38). Broad-spectrum antibacterial use (263.9 vs. 317.6 DOTs per 1,000 days-present, P = 0.01) but not total antimicrobial use (600.8 vs. 634.3 DOTs per 1,000 days-present, P = 0.34) was lower at ID vs. non-ID hospitals. After facility-level risk-adjustment, broad-spectrum antibacterial use (OR = 0.81, 95% CI 0.69–0.94) but not total antimicrobial use (OR = 0.92, 95% CI 0.70–1.21) was lower at ID hospitals.

Conclusion

An on-site ID specialist was not associated with greater use of core ASP strategies, but the presence of an on-site ID specialist was associated with less frequent prescribing of broad-spectrum antibacterial agents. An on-site ID specialist may be an important part of an effective hospital-based ASP.

Disclosures

All authors: No reported disclosures.
1073. Analysis of the Antimicrobial Stewardship Program Recommendation Process in the Intensive Care Units at a Large Tertiary Community Hospital
Authors: Song Youchan , Holt Jessica , Gens Krista
Published: October 2019

Background

Studies suggest up to 60% of antibiotics prescribed in the intensive care units (ICUs) may not be optimized. The antimicrobial stewardship team (AST) at Abbott Northwestern consists of infectious diseases trained pharmacists, pharmacy residents, and/or advanced pharmacy practice experience (APPE) pharmacy students and provides prospective audits and feedback on all inpatients not being seen by infectious diseases specialists and currently receiving any anti-infectives. Comprehensive daily profile reviews are performed and recommendations are communicated via a physician sticky note in the electronic medical record (EMR) and/or via a direct page. Beginning January 2018, the AST started reviewing patients in the two ICU units earlier to ensure recommendations were completed prior to multidisciplinary rounds. The AST also initiated sending a message within the EMR alerting the decentral pharmacists prior to rounds.

Methods

A retrospective chart review was conducted on recommendations made by the AST between February and April 2017 (control group) and February and April 2018 (intervention group) for patients on two ICU units (ICU 1 and ICU 2). Time to acceptance and acceptance rates were calculated for the control and intervention period. A one-tailed t-test was performed for the time to acceptance analysis and a Chi-squared test was performed to compare acceptance rates. Results were deemed statistically significant when P < 0.05.

Results

Time to acceptance for the recommendations showed a significant decrease from 25.9 to 13.7 hours with the new process in ICU 1 (P = 0.038). Provider acceptance rate increased significantly from 77.8% to 88.4% in ICU 2 (P = 0.037).

Conclusion

Changing the workflow of the prospective audit and feedback process by the AST had a meaningful impact by decreasing the response time (time to acceptance) and increasing acceptance rates of the recommendations in the ICUs. The revised process improved communication between the AST, decentral pharmacist, and attending provider, which in turn may have contributed to the positive outcomes.

Disclosures

All authors: No reported disclosures.
1100. Facility Factors Are a Stronger Driver of Peri-Operative Vancomycin Use Than Patient Risk Factors
Authors: Branch-Elliman Westyn , O’Brien William , Strymish Judith , Itani Kamal , Gupta Kalpana
Published: October 2019

Background

Prior reports suggest that the use of vancomycin for surgical prophylaxis is common and increasing. However, rates of administration and reasons for choosing vancomycin are unknown. Thus, we sought to quantify the frequency of vancomycin as a surgical prophylaxis agent and to determine drivers of use.

Methods

All Veteran patients undergoing major cardiac, orthopedic total joint, vascular, or colorectal procedures and entered into the VA External Peer Review Program (EPRP) database during the period from October 1, 2008 to September 30, 2013 were included. EPRP includes a manual review of surgical cases to measure type of prophylaxis, and, in the case of vancomycin, clinician-documented reasons for vancomycin use (β-lactam allergy, patient at high risk of methicillin-resistant Staphylococcus aureus (MRSA), facility high rate of MRSA). Descriptive statistics were used to evaluate findings.

Results

Among 79, 058 surgical procedures at 109 different medical centers, 20,349 (25.7%) received vancomycin either alone or in combination with another agent for prophylaxis. Rates of vancomycin use were the highest for cardiac surgeries (10,455/21,396, 48.9%), followed by orthopedic total joint replacement surgeries (8,044/38,675, 20.8%), vascular surgeries (1,504/8,177, 18.4%) and colorectal surgeries (346/10,810, 3.2%). The most common reason for vancomycin use was a perceived high facility rate of MRSA (7,367, 36.2%) followed by β-lactam allergy (4,855, 23.9%) and high-risk patient (1,420/20,349, 7.0%). There was no reason documented in 5,194 (25.5%). The most common reason for vancomycin use differed by surgical type. Among cardiac and orthopedic cases, high facility rate was the most commonly reported reason, but β-lactam allergy was the most common driver among vascular and colorectal procedures.

Conclusion

Facility factors are a major driver of peri-operative vancomycin use, more so than β-lactam allergy or patient-level factors, particularly in cardiac and orthopedic surgery. These data suggest that facility-level interventions, such as implementation of specific guidelines, may be helpful for limiting vancomycin use in this population.

Disclosures

All authors: No reported disclosures.
1102. Ertapenem vs. Nonertapenem Antibiotics in Colorectal Surgery: A Stewardship Opportunity
Authors: LaDow Tiffany , Brust Karen B , Zolfaghari Kiumars , Midturi John
Published: October 2019

Background

The optimal regimen for antibiotic prophylaxis in colorectal surgery is not well defined. The aim of this study was to determine whether nonertapenem antibiotic prophylaxis in colorectal surgery is associated with increased rates of surgical site infections (SSI), defined by both deep and incisional infections, compared with ertapenem prophylaxis. Secondary aims were to identify differences in C. difficile infection rates at 60 days between the two groups.

Methods

This was a single-center retrospective study from November 2016 to December 2018 at a 600-bed teaching hospital equipped with a Level I Trauma Center in Central Texas. National Healthcare Safety Network (NHSN) criteria for colorectal surgical site infection (SSI) were used to identify eligible patients. Patients under 18 years or lacking pre-operative antibiotic documentation were excluded. SSI and C. difficile rates between the two prophylactic strategies were compared using Chi-squared and Fisher’s exact tests as appropriate.

Results

A total of 761 patients were included in the analysis. There were 87 patients in the ertapenem group and 674 patients in the nonertapenem group. Antibiotics included in the nonertapenem group were cefazolin (32%), ceftriaxone (22%), or ciprofloxacin (15%) plus metronidazole, and other antibiotics (31%). Baseline characteristics including age, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and number of surgical procedures were similar for both groups. The overall SSI rate was 4.7% and the 60-day C. difficile rate was 3.9%. No significant differences were found between ertapenem and nonertapenem groups in SSI rates (5.8% vs. 4.6%, P = 0.6) or 60-day incidence of C. difficile (6.9% vs. 3.6%, P = 0.1).

Conclusion

Our study, with a large sample size and a low overall incidence of SSI, did not find a significant difference in either SSI rates or 60-day C. difficile rates between ertapenem and nonertapenem prophylaxis in colorectal surgery. Given the rise of Gram-negative resistance, this study highlights an important opportunity for carbapenem stewardship.

Disclosures

All authors: No reported disclosures.
1106. Assessment of Fluoroquinolone Appropriateness for Hospitalized Patients with Asymptomatic Bacteriuria and Cystitis: A Multi-Hospital Cohort Study
Authors: Gandhi Tejal N , Petty Lindsay A , Vaughn Valerie M , Patel Twisha S , Ratz David , McLaughlin Elizabeth , Malani Anurag N , Dumkow Lisa , Pogue Jason M , Thyagarajan Rama , Hsaiky Lama , Bernstein Steven J , Flanders Scott A
Published: October 2019

Background

Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance, but are frequently used for hospitalized patients with bacteriuria. We assessed patterns and predictors of inappropriate fluoroquinolone (FQ) use among hospitalized patients with asymptomatic bacteriuria (ASB) and cystitis.

Methods

This is a retrospective cohort study of non-ICU medicine patients with ASB or cystitis (complicated or uncomplicated) from January 2018 to March 2019 at 43 Michigan hospitals. Patients with concomitant infections, bacteremia, or pyelonephritis were excluded. Each day of FQ (ciprofloxacin, levofloxacin) use (inpatient and post discharge) was assessed for appropriateness. FQ use was inappropriate if: (A) ASB, (B) urine culture with an FQ-resistant bacteria, (C) a safer alternative empiric or definitive antibiotic (treatment ≥2 days after urine culture collection) based on disease severity, cultures, allergies, and renal function, or (D) excess duration (>7 days complicated cystitis; >3 days uncomplicated cystitis). Hospitals were also surveyed on existing stewardship (ASP) practices targeting FQ use. ASP practices associated with inappropriate FQ use were evaluated using logistic generalized estimated equation models adjusting for patient factors and hospital clustering.

Results

Of 4849 included patients with ASB (39.7%) or cystitis (60.3%), 21.9% (n = 1,061) received an FQ and 92.7% (n = 984) received a, FQ inappropriately (Figure 1). Of 5,465 FQ days of therapy (DOT), 90.7% (n = 4,959) were inappropriate. Definitive treatment of complicated cystitis led to the greatest proportion of inappropriate FQ DOTs (50.6%), followed by ASB (36.4%) (Table 1). Hospitals varied (Figure 2), but those with cascade reporting of antibiotic susceptibilities, urinary tract infection (UTI) treatment guideline or an ASP performing prospective audit and feedback on FQ use had lower inappropriate FQ treatment rates (Table 2).

Conclusion

Hospitalized patients with ASB and cystitis often receive an FQ. Most FQ use is inappropriate due to ASB treatment or FQ use for complicated cystitis despite the option of an alternative antibiotic. Prospective audit and feedback, UTI guidelines, and cascade reporting of antibiotic susceptibilities can be used by ASP to reduce inappropriate FQ use.

Disclosures

All authors: No reported disclosures.
1120. Reliability of Parent-Reported Pediatric Antibiotic Use in a Longitudinal Birth Cohort
Authors: D’Arinzo Lauren , Patel Krisha , Carrington Tevin , Goba Miatta , Gerber Jeffrey
Published: October 2019

Background

Depending on the population of interest, it is not always feasible to acquire electronic health record (EHR) data for antibiotic prescribing in longitudinal outpatient studies. Even when available, EHR algorithms are limited to only capturing in-network prescriptions. Thus, there is value in learning more about the reliability of parent-reported data to see whether this approach can be validated for epidemiologic research.

Methods

We examined antibiotic prescribing in the MAGIC (Microbiome, Antibiotics, and Growth Infant Cohort) Study, a longitudinal birth cohort of healthy newborns followed through 2 years of life. An informatics algorithm within an EHR platform was developed such that the study team received a text message alert every time a study participant who sought care in the Children’s Hospital of Philadelphia (CHOP) Care Network was prescribed an antibiotic. Families were also asked every 3 months whether their child had been prescribed an antibiotic in the past 3 months. We compared parent-reported antibiotic use with antibiotic use that generated an alert in the EHR.

Results

Among the 104 EHR-documented antibiotic exposures in 3-month spans, 52 (50%) were reported by parents at the relevant time point. Of the 52 nonreported antibiotic prescriptions that generated alerts, 4 (4%) were explicitly not reported by families and the remaining 48 exposures (46%) were not reported because the family did not answer the question at the relevant time point. There were 11 total exposures that were patient-reported without documented EHR alerts.

Conclusion

In this longitudinal birth cohort, only half of in-network, EHR-generated alerts for antibiotic prescriptions were reported by parents, and parent-reported antibiotic exposures occurred outside of the pediatric network that, by definition, could not generate EHR-based alerts. These results suggest that the most effective method for quantifying antibiotic use may be using EHR data supplemented with parent-reported data.

Disclosures

All authors: No reported disclosures.
1125. In with the Out-patient Antimicrobial Stewardship Initiative: A Collaboration between a Children’s Hospital Antimicrobial Stewardship Program and a Nonaffiliated Pediatric Private Practice
Authors: Namtu Katie , Berman David M , Hough-Telford Catherine
Published: October 2019

Background

While antibiotic stewardship programs have been well described in the inpatient setting, data on effectiveness and guidance on implementing outpatient stewardship in pediatric patients is scarce. To the best of our knowledge, this is the first study describing the impact that an established inpatient pediatric antimicrobial stewardship program (ASP) has had on antimicrobial prescribing practices in a multi-site (14 locations) nonacademic, nonaffiliated pediatric outpatient practice. This study’s main objective was to compare the prescribing patterns for urinary tract infections (UTIs) at baseline (before education was provided on local uropathogen resistance patterns, implications of broad-spectrum antibiotic usage, national practice guidelines, cost, etc.) and after antimicrobial stewardship education and interventions.

Methods

Prescribing patterns for UTIs at baseline were reviewed and assessed for appropriateness by the inpatient ASP the summer of 2018. Following this review, education was provided to the outpatient prescribers that included discussion on local uropathogen resistance patterns, UTI guidelines, antimicrobial properties, risk for adverse effects, appropriate antimicrobial selections and dosing for UTIs. After education was provided prescribing patterns from the various sites and prescribers was reviewed on a quarterly basis. Email reminders were also sent out to providers reminding them to use cephalexin as first-line treatment. Unblinded peer comparison was utilized as a behavioral intervention in which all prescribers received reports comparing their antibiotic prescribing rates for UTIs to their peers.

Results

The rate by which cephalexin was prescribed for UTIs has steadily improved from 4.02% of all prescriptions for UTIs during the reporting period of December 2017 - February 28, 2018 to 67.55% during the reporting period January 1 - March 31, 2019.

Conclusion

Collaboration between an established inpatient pediatric ASP and a nonaffiliate, multi-site private pediatric outpatient practice resulted in decreased utilization of broad-spectrum antibiotics and optimization of empiric treatment of urinary tract infections based on local resistance patterns.

Disclosures

All authors: No reported disclosures
1126. Variability in Antibiotic Use in Children’s Hospitals in the United States
Authors: Griffith Hannah , Dantuluri Keerti , Thurm Cary , Williams Derek , Banerjee Ritu , Banerjee Ritu , Howard Leigh M , Grijalva Carlos G
Published: October 2019

Background

Understanding patterns of inpatient antibiotic use is necessary to enhance appropriate use and minimize preventable harm at hospitals. Few studies have characterized antibiotic use in the inpatient setting in children.

Methods

We conducted a cross-sectional study in children admitted to 51 freestanding US children’s hospitals included in the Pediatric Health Information System (PHIS). Overall and broad-spectrum antibiotic use (see Table) were measured using charge data, and prevalence of use was assessed on a single day of each 2017–2018 season over one year. Comparisons were made based on clinical setting (medical vs. surgical), clinical unit (PICU, NICU, and all others), hospital, and region. We assessed the relationship between antibiotic use and median hospital case-mix index (CMI), a surrogate for clinical complexity.

Results

Of 52769 hospitalized children assessed on a study day, 19174 (36%) received antibiotics, and 6575 (12%) received broad-spectrum antibiotics (table). Overall antibiotic use prevalence varied across hospitals from 22% to 52% (Figure 1). Median hospital CMI had no significant relationship with overall antibiotic use and only a weak correlation (ρ=0.29) with broad-spectrum antibiotic use (Figure 2). Antibiotic use prevalence varied minimally by season, ranging from 36% in fall to 37% in summer. Antibiotic use prevalence was 29% (9470/32436) among medical patients and 48% (9704/20333) among surgical patients. The antibiotics most commonly administered in medical patients were ceftriaxone and ampicillin, while surgical patients most commonly received cefazolin and vancomycin. Regional prevalence ranged from 33% (Midwest) to 40% (West). By unit, PICU patients had the highest prevalence of overall [58% (4006/6874)] and broad-spectrum [27% (1830/6874)] antibiotic use. Children with complex chronic conditions accounted for 63% of hospitalized children but represented 72% of children receiving any antibiotic and 85% of those receiving broad-spectrum antibiotics.

Conclusion

We observed large and apparently unexplained variability in antibiotic use prevalence among children’s hospitals, clinical settings, and regions. This indicates potential opportunities for enhanced antibiotic stewardship activities.

Disclosures

Ritu Banerjee, MD, PhD, Accelerate Diagnostics: Grant/Research Support; BioFire: Research Grant; Biomerieux: Research Grant; Roche: Research Grant
X-ray properties of high-richness CAMIRA clusters in the Hyper Suprime-Cam Subaru Strategic Program field
Authors: Ota Naomi , Mitsuishi Ikuyuki , Babazaki Yasunori , Akamatsu Hiroki , Ichinohe Yuto , Ueda Shutaro , Okabe Nobuhiro , Oguri Masamune , Fujimoto Ryuichi , Hamana Takashi , Miyaoka Keita , Miyazaki Satoshi , Otani Hanae , Tanaka Keigo , Tsuji Ayumi , Yoshida Atsushi
Published: October 2019

We present the first results of a pilot X-ray study of 37 rich galaxy clusters at 0.1 < z < 1.1 in the Hyper Suprime-Cam Subaru Strategic Program field. Diffuse X-ray emissions from these clusters were serendipitously detected in the XMM-Newton fields of view. We systematically analyze X-ray images of 37 clusters and emission spectra of a subsample of 17 clusters with high photon statistics by using the XMM-Newton archive data. The frequency distribution of the offset between the X-ray centroid or peak and the position of the brightest cluster galaxy was derived for the optical cluster sample. The fraction of relaxed clusters estimated from the X-ray peak offsets in 17 clusters is 29 ± 11(±13)%, which is smaller than that of the X-ray cluster samples such as HIFLUGCS. Since the optical cluster search is immune to the physical state of X-ray-emitting gas, it is likely to cover a larger range of the cluster morphology. We also derive the luminosity–temperature relation and found that the slope is marginally shallower than those of X-ray-selected samples and consistent with the self-similar model prediction of 2. Accordingly, our results show that the X-ray properties of the optical clusters are marginally different from those observed in the X-ray samples. The implication of the results and future prospects are briefly discussed.
Introducing and testing an advanced quantitative methodological approach for the evaluation of research centers: a case study on sustainability science
Authors: Kassab Omar , Mutz Rüdiger , Daniel Hans-Dieter
Published: October 2019

With the growing complexity of societal and scientific problems, research centers have emerged to facilitate the conduct of research beyond disciplinary and institutional boundaries. While they have become firmly established in the global university landscape, research centers raise some critical questions for research evaluation. Existing evaluation approaches designed to assess universities, departments, projects, or individual researchers fail to capture some of the core characteristics of research centers and their participants, including the diversity of the involved researchers, at what point in time they join and leave the research center, or the intensity of their participation. In addressing these aspects, this article introduces an advanced approach for the ex post evaluation of research centers. It builds on a quasi-experimental within-group design, bibliometric analyses, and multilevel statistics to assess average and individual causal effects of research center affiliation on participants along three dimensions of research performance. The evaluation approach is tested with archival data from a center in the field of sustainability science. Against a widely held belief, we find that participation in research centers entails no disadvantages for researchers as far as their research performance is concerned. However, individual trajectories varied strongly.