bluuebunny/crossref_metadata_2025 huggingface dataset:
788. Outcomes of Multidisciplinary Care Conferences for Patients with Substance Use Disorders Requiring Prolonged Antimicrobial Therapy for Severe Infections
Authors: Gore Sara J , Strnad Luke , Englander Honora , Gregg Jessica , Sikka Monica , Sikka Monica
Published: October 2019

Background

Infectious complications in people with substance use disorders (SUD) are rising, and while outpatient parenteral antimicrobial therapy (OPAT) is widely used in the general population, OPAT failure rates in SUD are high. Due to perceived PICC risks and OPAT safety, serious infections in people with SUD at our institution often resulted in hospitalization for the duration of treatment. Prolonged inpatient treatment is difficult to tolerate and increases healthcare costs. Our OPAT and addiction medicine teams initiated multidisciplinary discharge planning conferences (OPTIONS-DC) for inpatients with SUD requiring prolonged antimicrobials. The goal was to prioritize patient preferences regarding OPAT setting while incorporating harm-reduction principles. The goal of this study is to assess the impact and outcomes of the OPTIONS-DC.

Methods

We prospectively recorded comprehensive notes at OPTIONS-DC and retrospectively performed chart review for conferences held from February 2018 to March 2019.We performed a content analysis of OPTIONS-DC notes and patient records to identify ways that OPTIONS-DC modified care plans and prioritized patient preferences.

Results

Thirty-one conferences were held during the study period. Twenty-eight patients reported substance use within 90 days, 24 used intravenous substances, 12 were homeless, 24 had a mental health diagnosis, and 20 started medication-assisted treatment during hospitalization (Table 1). For 16 patients the conference altered the definitive treatment plan to align with patient preferences while emphasizing safety, and 13 of those were changed to an outpatient setting. A total of 10 patients had a decreased length of stay, with a total of 238 hospital days saved overall. OPAT was planned at discharge for 15 patients, 11 of whom completed their OPAT course. Overall, 21/31 (68%) completed their recommended antimicrobial course and 3 were lost to follow-up.

Conclusion

A multidisciplinary conference that prioritizes patient preferences and uses harm reduction strategies to optimize infection treatment plans is feasible and effective. The OPTIONS-DC model has potential to expand treatment options for infections in SUD, reduce hospital days, and may serve as an example for other institutions.

Disclosures

All authors: No reported disclosures.
1013. Electronic Assessment of Empiric Antibiotic Prescribing Using Diagnosis Codes
Authors: Dodds Ashley Elizabeth , Nelson Alicia , Johnson Melissa D , Jones Travis M , Davis Angelina , Dyer April , Moehring Rebekah W
Published: October 2019

Background

Antimicrobial stewardship programs (ASPs) must understand empiric choices for specific disease syndromes to assess adherence to local empiric treatment guidelines. Electronically-derived metrics to track empiric therapy choices would allow ASPs to target areas for intervention without significant data collection burden.

Methods

Admissions from 10 community hospitals between 7/2016 and December 2018 were reviewed to identify those with common infectious syndromes: pneumonia (PNA), urinary tract infection (UTI) and skin and soft-tissue infection (SSTI). Admissions with a syndrome of interest were identified using AHRQ clinical classifications software codes based on ICD-10 codes for infection at the time of discharge. Admissions were categorized as having the syndrome of interest with or without sepsis. Antibiotics received during the first 48 hours of inpatient admission were obtained from electronic medication administration records. The proportion of syndrome admissions receiving specific antibiotic agents was determined to evaluate initial treatment choices as compared with local empiric guidelines. Antibiotic categories were not mutually exclusive, admissions receiving combination therapy were included in the count for each individual agent as well as the combination group. The denominator was the count of admissions with the syndrome of interest. Distributions were tracked over time to observe the effects of ASP intervention.

Results

The analysis included 49,303 admissions. The most common diagnosis was UTI (30%) followed by PNA (23%). Empiric antibiotic use varied by syndrome (Figure 1). In general, patients with a targeted infectious diagnosis and sepsis received more broad-spectrum agents than those without sepsis. SSTI was an exception, but few patients admitted with SSTI did not also have presumed sepsis. Longitudinal analysis demonstrated shifts from less preferred agents to guideline-concordant choices. For example, for admissions with a diagnosis of PNA, we observed a steady year on year increase in ceftriaxone (preferred) while levofloxacin (avoided in local guidelines) declined. (Figure 2)

Conclusion

Syndrome-specific diagnosis codes were helpful in assessing empiric antibiotic selection and may assist ASPs in improving empiric guideline adherence.

Disclosures

All authors: No reported disclosures.
1018. Using prediction modeling to inform risk-adjustment strategy for hospital antimicrobial use: Can we predict who gets an inpatient antimicrobial?
Authors: Moehring Rebekah W , Phelan Matthew , Lofgren Eric , Nelson Alicia , Neuhauser Melinda M , Hicks Lauri , Dodds Ashley Elizabeth , Anderson Deverick J , Goldstein Benjamin
Published: October 2019

Background

Hospital antimicrobial stewardship program (ASP) assessments based on comparisons of antimicrobial use (AU) among multiple hospitals are difficult to interpret without risk-adjustment for patient case-mix. We aimed to determine whether variables of varying complexity, derived retrospectively from the electronic health record (EHR), were predictive of inpatient antimicrobial exposures.

Methods

We performed a retrospective study of EHR-derived data from adult and pediatric inpatients within the Duke University Health System from October 2015 to September 2017. We used Random Forests machine learning models on two antimicrobial exposure outcomes at the encounter level: binary (ever/never) exposure and days of therapy (DOT). Antimicrobial groups were defined by the NHSN AU Option 2017 baseline. Analyses were stratified by pediatric/adult, location type (ICU/ward), and antimicrobial group. Candidate variables were categorized into four tiers based on feasibility of measurement from the EHR. Tier 1 (easy) included demographics, season, location, while Tier 4 (hard) included all variables from Tier 1–3 and laboratory results, vital signs, and culture data. Data were split into 80/20 training and testing sets to measure model performance using area under the curve (AUC) for the binary outcomes and absolute error for DOT.

Results

The analysis dataset included 170,294 encounters and 204 candidate variables from three hospitals. A total of 80,190 (47%) encounters had antimicrobial exposure; 64,998 (38%) had 1–6 DOT, and 15,192 (9%) had 7 or greater DOT. Models strongly predicted the binary outcome, with AUCs ranging from 0.70 to 0.95 depending on the stratum (Figure A, B). The addition of more complex variables increased accuracy (Figure Model Tiers 1–4). Model performance varied based on location and antimicrobial group. Models for infrequently used groups performed better (Figure C, D). Models underestimated DOTs of encounters with extremely long lengths of stay.

Conclusion

Models utilizing EHR-derived variables strongly predicted antimicrobial exposure. Risk-adjustment strategies incorporating measures of patient mix may provide more informative benchmark comparisons for use in Antimicrobial Stewardship Program assessments.

Disclosures

All authors: No reported disclosures.
1020. Variations in inpatient and outpatient antibiotic use – opportunities for improvement and facility-level feedback
Authors: Goetz Matthew B , Graber Christopher J , Jones Makoto M , Madaras-Kelly Karl , Youn Sarah Y , Samore Matthew H , Glassman Peter A
Published: October 2019

Background

Participation in the Antibiotic Use (AU) option of the National Health Safety Network (NHSN), provides medical facilities with the Standardized Antibiotic Administration Ratio (SAAR), a normalized ratio of facility antibiotic use. However, the range of antibiotic use by similar facilities is not provided and thus the opportunity to “nudge” behavior by comparing use with “best facilities” is lost. We developed reports of variations of antibiotic use that allow comparisons of local antibiotic use with that of 107 other VA facilities.

Methods

Data for 2018 were extracted from the VA Corporate Data Warehouse. Antibiotic use in CY2018 on acute inpatient care units was assessed as days of therapy (using CDC-defined drug classes) per 1000 days-present. In addition, we assessed the proportion of patients with pneumonia, urinary tract infections or skin-soft-tissue infections (collectively, PUS) who received anti-MRSA therapy or ß-lactam therapy directed against multi-drug-resistant and hospital GNR (anti-MDRGNR) during hospital days 0–2 (CHOICE, a timeframe representing empiric therapy).

Results

Rates of total antibiotic use by VA facility varied over two-fold from 460 to 965 days of therapy (DOT)/1000 days-present (DP); anti-MRSA and anti-MDRGNR varied over four-fold, from 44 to 184 and, 55 to 262, respectively. Fluoroquinolone variation was even higher, ranging over 8-fold, from 17 to 145 DOT/1000 DP (Figure 1). Substantial variations were also observed in the frequency of administration of anti-MRSA and anti-MDRGNR therapy for PUS during CHOICE (14 to 49% and 15 to 65%, respectively; Figure 2).

Conclusion

The large variations in the use of total antibiotic therapy, anti-MRSA, anti-MDRGNR and fluoroquinolone therapies are greater than can be readily explained by known variations in antibiotic resistance or differences in case-mix within the VA. Efforts are underway in the VA to strengthen antimicrobial stewardship programs. In other work, we have shown improvements in antimicrobial use among sites that have access to reports that provide the data described herein and that participate in group collaboratives. Our group is now making these data available to all VA facilities.

Disclosures

All authors: No reported disclosures.
1023. Isavuconazonium Use at an Academic Transplant Center
Authors: Servais Abigail , Schoen John , Van Schooneveld Trevor C , Stohs Erica J , Bergman Scott
Published: October 2019

Background

Isavuconazonium is an appealing anti-fungal due to its broad spectrum of activity, predictable pharmacokinetics, oral bioavailability, and lack of QTc prolongation, but real-world experience with it is limited. At our academic medical center, isavuconazonium is restricted to the infectious diseases (ID) service for treatment of invasive fungal infections, including endemic mycoses due to high prevalence, and is recommended for patients intolerant of first-line agents. The purpose of this study was to describe isavuconazonium use at our institution and assess adherence to its formulary guidelines.

Methods

Inpatients with an order for isavuconazonium between June 2016 and November 2018 were analyzed via retrospective chart review. Prescribing team, indication, and rationale for use were evaluated.

Results

There were 97 inpatient encounters with an isavuconazonium order among 57 patients. Of those, 30 were solid-organ transplants and 9 had bone marrow transplants. Indications for isavuconazonium were: histoplasmosis 25%, high-risk fungal prophylaxis 21%, invasive aspergillosis 9%, candidiasis 2%, and other 44% (Table 1). Preceding anti-fungal therapy included: voriconazole 49%, posaconazole 12%, fluconazole 9%, micafungin 7%, amphotericin B 5%, itraconazole 4%, and none 35%. The rationale for the use of isavuconazonium is described in Table 2. ID consultation occurred in 79% of patients. Those without a consult had an indication of prophylaxis or were continuation of therapy started outpatient or at an outside hospital (OSH).

Conclusion

Histoplasmosis was the most common infection treated with isavuconazonium, despite limited data for that indication. Further investigation of the clinical course for these patients is warranted. Reasons for use most commonly centered on concern for QTc prolongation, clinical failure, and drug interactions. Over one-third of patients received no anti-fungal therapy prior to initiation. Adherence to required ID consultation was high. Patients on isavuconazonium for prophylaxis or as continuation therapy without a consult may still benefit from ID review to assess the appropriateness of therapy.

Disclosures

All authors: No reported disclosures.
1036. Clinical impact of an antibiotic time out initiative at an academic medical center
Authors: Taylor Amy P , Coe Kelci E , Stevenson Kurt , Wardlow Lynn , El Boghdadly Zeinab , Reed Erica E
Published: October 2019

Background

The Infectious Diseases Society of America’s guideline for implementing antibiotic (abx) stewardship recommends routine review of abx use. Several studies demonstrate antibiotic time out (ATO) programs result in de-escalation, but there is limited evidence of improved outcomes. The aim of this study was to evaluate the clinical impact of ATO.

Methods

This retrospective study included hospitalized patients at The Ohio State University Wexner Medical Center receiving abx and a documented ATO from 7/1/2017 to 6/30/2018. ATO patients were matched by infection type to abx-treated patients lacking an ATO note. Patients were excluded if they were identified as a protected population, were in the ICU at the time of ATO, had an ATO within 48 hours of discharge, cystic fibrosis, or febrile neutropenia. The primary objective was to evaluate abx optimization in patients with documented ATO vs. those without ATO. Abx optimization was defined as the selection of ideal abx based on guidelines, culture and susceptibility results, or expert opinion when undefined. Secondary outcomes included vancomycin-associated acute kidney injury (VAN-AKI), infection-related length of stay (LOS), all-cause 30-day readmission or mortality, abx days, and nosocomial C. difficile infection (CDI) rates. The Student t-test/Fisher’s exact test and Wilcoxon-rank sum were utilized as appropriate.

Results

One hundred ATO patients were compared with 100 non-ATO patients. Baseline characteristics and infection types were similar between groups. ATO resulted in improved optimization of abx selection (P = 0.05) and duration (P < 0.01), and reduced piperacillin/tazobactam (P/T) and vancomycin (VAN) utilization. No difference was observed in VAN-AKI (22 vs. 20%, P = 0.73), 30-day readmission (28 vs. 27%, P = 0.87), mortality (5 vs. 5%, P = 1), or CDI rates (6 vs. 5%, p = 0.76) in the ATO vs. non-ATO group. However, inpatient abx days (12 vs. 8, P = 0.004) and infection-related LOS (10 vs. 8, P = 0.0006) were shorter in the non-ATO group.

Conclusion

ATO improved optimization of abx selection and duration, and reduced P/T and VAN use. Despite this, clinical outcomes were not improved.

Disclosures

All authors: No reported disclosures.
1064. Antimicrobial Stewardship Program at a Large Academic Medical Center, Impact Over 12 Years
Authors: Kline Susan E , Boeser Kimberly , Houseman Jeana , Saunders Samantha , Johnson Shawnda , Helmin Derrek , Mason Joycelyn , Phelps Pamela
Published: October 2019

Background

The University of Minnesota Medical Center (UMMC) is a tertiary care facility, which has had a comprehensive antimicrobial stewardship program (ASP) for 12 years.

Methods

The antimicrobial stewardship team is comprised of a full-time PharmD and ID staff physicians. Recommendations are placed in the electronic medical record as a progress note. Verbal recommendations may also be made.

Results

There was a downward trend in Hospital-acquired (HA) C. difficile diarrhea from 2007 to 2014 from 1.2 to 0.5/1000 patient-days (pt day). Rates appear stable from 2014 to 2019 with adjustment for change to NHSN lab-based CDI surveillance (Figure 1). From 2009 to 2019 a decrease was seen in VRE hospital-acquired infections (HAI) from 0.53 to 0.21/1,000 patient-days and in MRSA HAIs from 0.2 to 0.14/1,000 patient-days. Newly acquired ESBL HAIs have remained relatively stable from 2009 to 2019 at 0.09 to 0.05/1,000 patient-days. CRE HAIs are low but stable rates at 0.02/1,000 patient-days (Figure 2). We track antimicrobial utilization for internal and national reporting (starting in July 2017). A SAAR for all Antibacterial agents (ICUs, wards, and oncology units) of 1.33 in 2018. Our top four agents average DOT; piperacillin/tazobactam (66.81), cefepime (34.40), oral levofloxacin (23.56) and intravenous meropenem (21.49). We demonstrate lower average DOT for our restricted antimicrobials (206.21) as compared with our nonrestricted antimicrobials (236.74) (Figure 3). Cost savings continued from year to year. After adjusting for inflation annually, our expected costs ($84.08) compared with actual costs ($40.12 ytd 2019), demonstrates effective cost management of antimicrobial agents. (Figure 4)

Conclusion

We observed a decrease in HAIs VRE and C. difficile infections after 3 years of operation, and MRSA after 5 years. This downward trend has continued. ESBL HAIs remain relatively stable and CRE are stable at low rates but remain emerging HAIs of concern. We are now focusing efforts on limiting unneeded fluoroquinolone and carbapenem use. We continue to analyze our SAAR data and internal DOT data to identify areas of opportunity to improve antimicrobial use. The ASP outcomes have continued to cost justify ongoing efforts. The effects of the program and the Infection Prevention Department appear to be synergistic.

Disclosures

All authors: No reported disclosures.
1066. Antimicrobial Stewardship Program: Audit and Feedback for Continued Improvement
Authors: Wang Joseph , Alexander Bryan , Bergman Scott , Ma Jihyun , Stohs Erica J , Van Schooneveld Trevor C , Marcelin Jasmine R , Marcelin Jasmine R
Published: October 2019

Background

Audit and feedback is a foundational approach used by antimicrobial stewardship programs (ASP) and has been our primary method for ASP intervention for over 7 years. We sought to evaluate and improve our ASP methods as well as identify barriers to effective antimicrobial management.

Methods

We distributed an online survey at our institution, to clinicians (prescribers and pharmacists). Results compared their perceptions of the ASP and barriers to antimicrobial stewardship. Descriptive statistics include counts and percentages for categorical variables. Fisher’s exact test was performed to describe the comparison groups for each survey response. We reviewed survey comments and categorized according to themes.

Results

We distributed the survey to 459 clinicians over 4 months with 110 surveys completed for a response rate of 24%. Prescribers comprised 77.3% of respondents. 74.5% of clinicians reported that antibiotic overuse is a problem at our institution. Prescribers were more likely to agree that conflicting priorities to core measures was a barrier to stewardship as well as disagree with current guidelines (P < 0.05) compared with pharmacists. Figure 1 demonstrates other barriers. Prescribers found ASP more helpful than pharmacists in antimicrobial dose adjustments (P < 0.05). Figure 2 demonstrates other scenarios where ASP provided input with varying degrees of perceived helpfulness. Pharmacists used the ASP website more than prescribers (P < 0.05). Text message and phone call were preferred methods of contact with prescribers favoring messages and pharmacists favoring phone calls. Clinicians infrequently used order-sets; Figure 3 demonstrates reasons for lack of use. 17.2% of participants commented about the ASP; of these, 42% were positive and 32% contained suggestions to improve communication and education. Comments are summarized in Figure 4.

Conclusion

Overall, clinicians agree that antimicrobial overuse is a concern at our institution. ASP is generally well received; however, after 7 years of operation, this survey shows that continued improvement is needed, notably in communication, education, and EMR order-sets. Results will be used to refine methods of effective communication and information delivery to nurture an effective relationship.

Disclosures

All authors: No reported disclosures.
1074. Evaluation of a Pharmacist-led Antimicrobial and Anticoagulant Monitoring Initiative
Authors: Hsiang Lin Wei , Binkley Amanda , Cimino Christo L , Talati Naasha J , Mehta Jimish M , Lamore III Raymond
Published: October 2019

Background

Adverse drug events are associated with an increase in hospital stay and cost. Risks from these events are minimized by adjusting a medication’s dose or frequency, and changes in renal function may necessitate adjustments. Currently, there is no formal procedure for a prospective audit of renal function over the weekend at our institution. This pharmacist-driven initiative will evaluate if a prospective review identified by real-time clinical decision support alerts over the weekend will reduce the time from change in renal function to dose adjustment of select antimicrobials and/or anticoagulants.

Methods

This monitoring initiative is comprised of a pre- and post-cohort population. The pre-cohort population included patients admitted to Penn Presbyterian Medical Center (PPMC) from January to March of 2018 on select antimicrobials and/or anticoagulants, who were identified to have a change in renal function (serum creatinine change of 0.3 mg/dL or greater) over the weekend. The post-cohort population was identified with a clinical decision support system (ILÚM Health Solutions, Kenilworth, NJ) and included patients admitted to PPMC from January to March of 2019. A pharmacy resident reviewed alerts in the clinical decision support system over the weekend and contacted providers with dose adjustment recommendations. The Mann–Whitney U test was used to analyze the primary endpoint while descriptive statistics were used for the secondary endpoints

Results

Eighteen interventions were completed within the 3-month post-cohort intervention period, with a time to dose adjustment between the pre/post-cohort being reduced by 50 hours (P = 0.0001) resulting in a median time to change of 11 hours in the post-cohort. All pharmacy recommendations were accepted by the provider, and 94% of medication adjustments were antimicrobials.

Conclusion

The application of this prospective weekend initiative utilizing a clinical decision support system demonstrated a clinically and statistically significant reduction in the time to dose adjustments for antimicrobials and/or anticoagulants. Implementation of this initiative will further establish a role for pharmacist-led evaluations and could potentially be expanded to other clinical areas.

Disclosures

All authors: No reported disclosures.
1076. Antimicrobial Stewardship Program Achieves Marked Decrease in the use of Vancomycin in a Veterans Hospital
Authors: Ford Florence M , Belal Maymonah , Froehlich Morgan , Lobo Zeena , Creed Mary , Psevdos George
Published: October 2019

Background

Methicillin-resistant Staphylococcus aureus (MRSA)is the most common nosocomial infection worldwide. Infection control measures using molecular tests [polymerase chain reaction (PCR) on nares swabs] aid to prevent hospital transmission of MRSA. Nares screening for MRSA has proven to be a valuable tool for antimicrobial stewardship programs (ASP) to de-escalate empiric anti-MRSA therapy in patients with pneumonia (community/nosocomial acquired) not nasally colonized with MRSA. In January 2016, an ASP was initiated at our institution with emphasis on rational use of antibiotics, decrease antibiotic duration and timely de-escalation of all empiric antibiotics, including IV vancomycin using nares PCR for MRSA.

Methods

We compared the vancomycin use at the Northport Veterans Affairs Medical center by days of therapy/1,000 patient-days from 2011–2015 to 2016–2019. Screening for MRSA is by DNA PCR (Cepheid GeneXpert Infinity). ASP reviewed all restricted antibiotic requests via electronic consults and rendered approval or disapproval. In addition, ASP requested empiric vancomycin to be discontinued for patients hospitalized for pneumonia, if PCR was negative for MRSA; PCR results were available within 24hours of admission.

Results

There were 21,330 admissions (including ICU) from March 1, 2011 to February 28, 2019. Since initiation of ASP in 2016, 4,021 total antibiotic approvals were requested and 483 were denied. 484 IV Vancomycin were requested and 43 were denied. There has been a statistically significant decrease in vancomycin use from 2011–2015 vs. 2016–2019, median by quarter (year divided in 4 quarters) 250 vs. 233, P = 0.012; Comparing the same time periods there has been a decrease in positive MRSA nares screening upon admission median annual rate 354 vs. 220, P = 0.011. There was no difference in vancomycin-resistant enterococci in clinical isolates, median 16 vs. 14.5, P = 0.465. Inpatient infectious diseases consultations increased by 30% since ASP was initiated.

Conclusion

Our ASP was successful in decreasing use of vancomycin through both disapproval of medication when a request was deemed inappropriate, and by promoting de-escalation of therapy by the use of MRSA nares screening in patients who were started empirically on MRSA antibiotic therapy for pneumonia.

Disclosures

All authors: No reported disclosures.
1077. Reduce Anti-Microbial Use in Extracorporeal Membrane Oxygenation: Reduce AMMO Study
Authors: Shah Aditya , Dhungana Prabij , Vashistha Kirtivardhan , Sampathkumar Priya , Bohman John , O’Horo John C
Published: October 2019

Background

The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. Patients on ECMO are at high risk for infections, with 20.5% of adults acquiring infections while on ECMO. An Extracorporeal Life Support Organization (ELSO) Infectious Disease Task Force statement concluded that no antibiotic prophylaxis is needed for patients on ECMO though it also noted that this was based on limited data. We implemented an antimicrobial prophylaxis protocol for patients on ECMO at our institution and analyzed antimicrobial use and outcomes in these patients with a pre- and post-analysis.

Methods

We conducted a retrospective review of 294 patients on ECMO between July 1, 2011 and July 1, 2017. An ECMO antimicrobial prophylaxis guideline was initially implemented on July 1, 2014; there was poor adherence to the guideline and antimicrobial use actually increased. A more restrictive protocol was implemented in November 2018 with input from stakeholders including cardiac surgeons, critical care and infectious disease (ID) providers. We had a cohort of 161 patients before (July 2014–November 2018) and 37 patients after (November 2018–April 2018) the implementation of the updated protocol. We evaluated primary outcomes of gross days of antimicrobial use, percent of antibiotic-free days and days of individual antimicrobial use, adjusted for APACHE scores and ECMO duration.

Results

When adjusted for days on ECMO, mean antibiotic days decreased after implementation of the protocol; for vancomycin (0.27 vs. 0.02, P < 0.0003), cefepime (0.15 vs. 0.02, P < 0.02), meropenem (0.09 vs. 0, P < 0.02), zosyn (0.16 vs. 0, P < 0.002), caspofungin (0.346, 0.138 P < 0.003). This was accompanied by a nonsignificant increase in mean fluconazole use (0.29 vs. 0.37, P < 0.3). There was no impact on patient mortality or nosocomial infection rate. Additional results can be found in table.

Conclusion

The use of an antimicrobial prophylaxis protocol in ECMO patients led to improvement in antimicrobial usage without increasing nosocomial infections in a population at a high risk of infection.

Disclosures

All authors: No reported disclosures.
1081. Use of Antimicrobials at the End of Life (EOL): A Retrospective Cohort Study Analyzing Providers’ Reasons for Prescribing Antimicrobials at the EOL, Their Benefits and Adverse Effects
Authors: Vyas Pooja , Malhotra Prashant , Lopez Santiago , Hirsch Bruce , Finuf Kayla D
Published: October 2019

Background

Infections are common in terminally ill patients, and although antibiotics are frequently prescribed, their benefit for symptom relief is not clear. Antimicrobials at the end of life (EOL) increase the risk of antimicrobial resistance and Clostridium difficile infection. Very few studies have described the risks and benefits of antimicrobials in patients at EOL. Here, we describe a retrospective chart review of antimicrobial use at EOL.

Methods

We reviewed electronic medical records of patients admitted in a palliative care unit of a tertiary care hospital between 2017 and 2018 and assessed antimicrobial use in the last 14 days of life. The analysis excluded neutropenic patients. Differences in demographics and symptom control between patients who did or did not receive antibiotics (AB+ or AB−) were analyzed using chi-square analyses; P-values were computed using Mann–Whitney tests.

Results

Of a total of 133 patients included, 89 (67%) received antimicrobials (AB+); however, the role of antibiotics was documented in only 12% of patients. The AB− and AB+ groups were similar with respect to demographics, including sex, and Charleston Comorbidity Index except for age (table). Documented infections were similar between AB− and AB+ groups, except urinary tract infections. No statistically significant differences were noted in documented symptoms including pain, dyspnea, fever, lethargy, and alteration of mental state or length of stay (LOS).

Conclusion

Our study did not show differences in frequencies of documented symptoms with use of antimicrobials at EOL. These results indicate that the risks of antimicrobial use may outweigh potential benefits and their use should be a part of goals of care discussions at EOL.

Disclosures

All authors: No reported disclosures.
1092. Impact of Relieving Infectious Diseases Fellows from Off-Hour/Weekend Antimicrobial Stewardship Coverage
Authors: Lee Matthew S L , Chapin Ryan , Gold Howard , McCoy Christopher
Published: October 2019

Background

Antimicrobial stewardship programs (ASPs) often utilize Infectious Diseases fellows (IDFs) to cover pre-authorization processes during evening and weekend hours. IDFs often provide ASP coverage in addition to their inpatient consult roles. In response to increasing consult volume, we worked with our fellowship program to relieve IDFs of evening and weekend coverage (a decrease in fellow coverage by 26 hours per week) starting in October 2017. Members of the ASP assumed the majority of these evening and weekend hours. Additional post-prescriptive activities and a rotation in Infection Control and Antimicrobial Stewardship were implemented in response. We sought to analyze the impact of this intervention.

Methods

Intervention and medication data were extracted from the electronic medical record during 1 July 2017 through 30 September of 2017 (IDF Coverage) and the same 3 months of 2018 (ASP Coverage). Comparisons between the two periods were performed using descriptive statistics of the number of interventions, number of weekend interventions, types of interventions, and days of therapy (DOT; per 1000 patient-days).

Results

Comparing July-September of 2017 and 2018, total ASP interventions increased 16% (1192 to 1391); weekend ASP interventions increased 75% (139 to 243). The most common interventions were “Choice of Therapy” (41% in both years), “De-Escalation” (17% in 2017, 16% in 2018), and “Dose/Interval Optimization” (10% in both years). The most intervened agents were piperacillin–tazobactam, cefepime, vancomycin, meropenem, and ceftazidime.

Comparing the same time periods, total antibiotic DOT decreased 4% (714.1 to 684.9). There was a 28% decrease in piperacillin–tazobactam (41.47 to 29.85), 19% decrease in meropenem (28.08 to 22.61), and 7% decrease in vancomycin (125.09 to 116.17) use. Ceftazidime was unchanged (18.13 to 18.08). Cefepime increased by 9% (56.78 to 61.97).

Conclusion

Relieving IDFs of evening and weekend ASP coverage during busy inpatient consult rotations may help decrease burnout. The assumption of these hours by dedicated members of ASP led to an increase in documented total and weekend ASP interventions. In addition, the change was associated with a relative decrease in piperacillin–tazobactam, meropenem, and vancomycin use.

Disclosures

All authors: No reported disclosures.
1093. Evaluation of an Antimicrobial Stewardship Elective Rotation for Medicine Residents
Authors: Watanabe Mika , Jeng Arthur , Kim Brian
Published: October 2019

Background

In 2017, an Antibiotic Stewardship (ASP) elective was established for the medicine residents to engage directly in stewardship practice, learn how to communicate recommendations effectively to their peers, and gain further understanding of the rationale for antimicrobial stewardship. Recommendations are co-formulated with the ID Pharmacist and ID Attending Physician, and documented as an ASP Note in the electronic health record. Additionally, the residents disseminate recommendations via page and verbal communication to their peers. The purpose of this study was to evaluate the response of the primary care teams to guidance formulated and communicated by the residents while on this clinical elective.

Methods

Recommendations by the medicine residents participating on the ASP elective from January 2018 to July 2018 were reviewed. Response to the recommendations was categorized as accepted, not accepted, or partially accepted with alternative change. Recommendations were considered as accepted if changes were made by the primary team within 24 hours from time of the ASP note. Responses were further reviewed based on the following medical services: medicine (including hematology/oncology), surgery, and intensive care (ICU).

Results

A total of 124 recommendations were reviewed for response.11 of the patients were excluded as changes either occurred prior to the documentation of the ASP note, or proposed changes did not pertain to antibiotic management. Ninety-four of the included interventions were accepted. Medicine, surgery, and ICU services accepted 84%, 82.4%, and 83.3% of recommendations, respectively. The services did not accept 5%, 11.8%, and 11.1% of recommendations, and partial acceptance with alternative changes was 11%, 5.8%, and 5.6%, respectively.

Conclusion

Recommendations formulated and communicated by residents participating in the ASP Elective rotation resulted in a high degree of acceptance. The acceptance rates did not differ significantly between the medical services. The addition of the ASP Elective has demonstrated a benefit to the ASP program at Olive View-UCLA Medical Center, and other medical residency training programs should consider implementation of such an elective rotation to enhance stewardship efforts and medical resident education.

Disclosures

All authors: No reported disclosures.
1101. What Do Electrophysiologists Think about Peri-Procedural Antibiotics? A Qualitative Assessment of Factors Driving Use and Facilitators for Implementing Change
Authors: Branch-Elliman Westyn , Elwy Rani , Gupta Kalpana
Published: October 2019

Background

Prolonged courses of antimicrobials are common following cardiac device procedures, but there are little data to explain drivers of this practice and factors that may facilitate change.

Methods

We conducted formative evaluations consisting of semi-structured, qualitative interviews with electrophysiologists (EP) to identify perceived barriers to discontinuing post-procedure antimicrobial prophylaxis and factors that may facilitate improvements. A directed content analysis approach was used to map qualitative responses to key factors in the Proctor Implementation Outcomes Framework, with flexibility to allow for new themes to emerge. Interviews ceased after data saturation was reached.

Results

13 interviews were conducted with EPs representing diverse US regions (Northeast, Midwest, South, West) and diverse settings of care (academic, community, VA). Responses to questions about antimicrobial use and willingness (or lack thereof) to stop post-procedural antimicrobials most commonly mapped to the acceptability domain; feasibility, fidelity, cost and appropriateness were also frequently identified factors (see figure for exemplary quotes). Themes that emerged during the interview process associated with prolonged antimicrobial prescribing included beliefs and knowledge, local culture and normative behaviors, and organizational structure. There was a strong “cultural inertia” to conform to normative practices within an institution. Reasons for this ranged from reports of streamlining processes for clinical staff to ensure standardized care across all patients and concerns about being perceived as an “outlier.” Infectious diseases staff were important influencers of practice and potential facilitators of improvement.

Conclusion

Formative evaluations of stakeholders are essential for designing successful implementation interventions to facilitate behavioral change. Local culture appeared to be a major driver of antimicrobial use. The desire to conform to normative behaviors and to promote institutional standardization suggests that strategies to facilitate implementation of antimicrobial stewardship guidelines must include facility-level changes, rather than individual-provider-level interventions.

Disclosures

All authors: No reported disclosures.
LB11. A Single Dose of the MVA-BN Smallpox Vaccine Induces an Early Protective Antibody Response Similar to a Traditional Replicating Vaccine and Is Suitable for Emergency Scenarios
Authors: Maclennan Jane , Weidenthaler Heinz , Pittman Phillip , Schmidt Darja , Chaplin Paul
Published: October 2019

Background

Smallpox remains a high-priority threat due to its potential for re-emergence through events including bioterrorism and spontaneous mutation. While traditional replicating smallpox vaccines such as ACAM2000 are associated with serious side effects, the non-replicating MVA BN smallpox vaccine was developed as a safer alternative.

Methods

This phase 3 non-inferiority study compared indicators of efficacy between the MVA-BN smallpox vaccine and ACAM2000. The co-primary endpoints were (1) to compare vaccine-induced serum neutralizing antibodies (geometric mean titer [GMT]) at predefined Peak Visits, as measured by plaque reduction neutralization tests (PRNT) and (2) to assess the attenuation of ACAM2000-induced takes after MVA-BN administration by measuring maximum lesion area (MLA). Early neutralizing antibody GMTs at Day 14, a timepoint considered protective for traditional replicating smallpox vaccines, were also compared following single doses of either vaccine.

Results

A total of 440 subjects were evenly randomized to receive either 2 doses of MVA-BN followed by 1 dose of ACAM2000 at 4 week intervals (Group 1) or a single dose of ACAM2000 (Group 2). Peak neutralizing antibody GMTs were significantly higher following 2 MVA-BN doses (153.5) compared with ACAM2000 (79.3), with a ratio of 1.935 (95% CI: 1.562, 2.397). At Day 14, neutralizing antibody GMTs were equal following a single dose of either MVA BN or ACAM2000 (16.2, ratio of 0.997, 95% CI: 0.738, 1.348), with similar seroconversion rates (90.8% vs. 91.8%, respectively). The median MLA induced by ACAM2000 was significantly reduced when subjects received prior MVA-BN in Group 1 (0 mm2) compared with Group 2 (76.0 mm2), suggesting protection against orthopoxvirus. MVA BN was well tolerated, demonstrating a better safety profile than ACAM2000.

Conclusion

Two doses of MVA-BN induce significantly higher peak neutralizing antibody responses compared with ACAM2000. A single dose induces an early neutralizing antibody response equal to ACAM2000 at Day 14, demonstrating the suitability of MVA BN in both pre- and post-outbreak scenarios. This study was partly funded by BARDA under contract HHSO100200700034C.

Disclosures

Jane Maclennan, BSc MRPharmS, Bavarian Nordic (Employee), Bavarian Nordic (Employee, Shareholder), Heinz Weidenthaler, MD, Bavarian Nordic (Employee, Shareholder), Phillip Pittman, MD, Bavarian Nordic (Scientific Research Study Investigator), Darja Schmidt, PhD, Bavarian Nordic (Employee, Shareholder), Paul Chaplin, PhD, Bavarian Nordic (Board Member, Employee, Shareholder), Bavarian Nordic (Employee, Shareholder).
LB17. Randomized Trial to Prevent Congenital Cytomegalovirus (CMV)
Authors: Hughes Brenna
Published: October 2019

Background

Primary CMV infection during pregnancy carries a high risk of fetal transmission with the potential for severe sequelae. There is no universally accepted method of preventing congenital CMV. Our objective was to evaluate whether CMV hyperimmune globulin (HIG) administered to women with primary CMV during pregnancy reduces congenital infection.

Methods

Multicenter randomized double-masked trial of women with a singleton gestation <24 weeks with primary CMV infection defined by the presence of either CMV IgM and IgG with low avidity or IgG seroconversion, as assessed at a central reference laboratory. Those with presumptive or confirmed evidence of fetal CMV were not eligible. Monthly infusions of HIG (100 units/kilogram) or placebo were given until delivery. The primary outcome was fetal loss or neonatal CMV infection defined as CMV by PCR or culture in urine or saliva within 3 weeks of birth, in amniotic fluid prior to delivery or in postmortem tissue. A sample size of 800 was planned to detect at least 30% reduction in the primary outcome with 90% power and type I error 5%.

Results

From 2012 to 2018, 206,111 pregnant women were screened; 712 (0.35%) had primary CMV infection; of whom, 399 (56%) were enrolled at 17 centers. The trial was stopped for futility at the recommendation of the Data and Safety Monitoring Committee due to a planned interim analysis that revealed complete enrollment was unlikely to demonstrate a significant outcome. Mean gestational age at randomization was 16.2 and 15.6 weeks in the HIG and placebo groups, respectively. Primary outcome data were available for 394 participants (98.7%). The primary outcome rate was 22.7% in the HIG group and 19.4% in the placebo group (relative risk [RR], 1.17; 95% confidence interval [CI], 0.80 to 1.72; p=0.42). Overall, there was no significant difference in the proportion of women with a side effect; however, those receiving HIG had a higher rate of headache (P = 0.05) and shaking chills (P = 0.03). The rate of preterm birth was 12.2% in the HIG group and 8.3% in the placebo group (RR, 1.47; CI 0.81 to 2.67; P = 0.2) (table). No statistical interactions were found in pre-specified subgroup analyses.

Conclusion

CMV HIG was not effective at decreasing risk of congenital CMV infection or fetal death among women with primary CMV infection in early pregnancy.

Disclosures

Brenna Hughes, MD, Merck (Consultant).
LB18. Understanding Zika-Specific Immunity for Prevention and Protection
Authors: Espinoza Daniel , Zhu Yerun , Collins Matthew H
Published: October 2019

Background

Flavivirus infection represents a major public health problem, with over 2 billion people at risk for one or more infections each year. There are no licensed antiviral treatments for flaviviruses, and effective vaccines are lacking for several. Accurate diagnosis of flaviviruses is also complicated by serologic cross-reactivity. Thus, there is an urgent need to develop public health tools and interventions to reduce the burden of flavivirus infection worldwide.

Methods

We recently isolated two potently neutralizing human monoclonal antibodies (NmAb) against Zika, which exhibit activity against multiple strains of Zika but do not bind the closely related dengue virus. Mapping studies revealed that the NmAb target distinct epitopes on the envelope protein (E). A competition ELISA (ZE-BOB) was developed with the two NmAb to test the hypotheses that neutralizing Ab responses in the general population would target the same epitopes on Zika E as the novel NmAb.

Results

We found that competitive Ab responses were detected in 19 of 19 (100%) convalescent sera from travelers with confirmed Zika infection. We tested a panel of 20 sera from individuals with either primary or secondary prior dengue infection and found that 18/20 (90%) contained IgG reactive with Zika virus; however, 0/20 (0%) exhibited ZE-BOB activity. These results indicate that the epitopes targeted by these two Zika NmAb are consistently immunogenic humans infected by Zika. Additionally, these epitopes elicit type-specific Ab to Zika, providing a basis for development of simple serodiagnostic assays with utility in epidemiologic studies as well as in the clinical setting. Because NAb are key determinants of long-term protection against future flavivirus infection, we further hypothesized that the results of the ZE-BOB assay may simultaneously provide a correlate of immunity, which would be a critical tool for vaccine development. In comparing the 50% neutralization titer against Zika with the magnitude of competition by ZE-BOB, there was no correlation in these values, but sera tended to be positive in both or neither assay.

Conclusion

Therefore, the ZE-BOB assay constitutes a novel tool that is widely deployable for purposes ranging from clinical diagnosis to epidemiologic monitoring to vaccine development for Zika.

Disclosures

All authors: No reported disclosures.
Pharmacokinetics and Pharmacodynamics of Conventional-Dose vs Triple-Dose Oseltamivir in Severely Immunocompromised Children With Influenza
Authors: Bautista Francisco , Engelhard Dan , Rizzari Carmelo , Baka Margarita , Saavedra-Lozano Jesús , Lopez-Medina Eduardo , Nasmyth-Miller Clare , Hernández-Sánchez Jules , Sturm Stefan
Published: October 2019

This randomized phase 1b study evaluated the pharmacokinetics/pharmacodynamics of conventional-dose (30–75 mg twice daily [BID]) vs triple-dose (90–225 mg BID; weight-adjusted) oseltamivir for treatment of influenza in severely immunocompromised children <13 years. Oseltamivir carboxylate (OC) Cmax and AUC0-12h were ~2-fold higher with triple-dose vs conventional-dose oseltamivir. Increased dose/exposure of oseltamivir/OC did not improve virological outcomes or reduce viral resistance. Median time to cessation of viral shedding was similar with triple-dose and conventional-dose oseltamivir (150.7 vs 157.1 hours, respectively); median time to alleviation of baseline fever was longer with conventional-dose oseltamivir (28.4 vs 11.3 hours). No new safety signals were identified.
Aerococcus urinae Aortitis: A Case Report
Authors: Chhibber Aakash Varun , Muttaiyah Sharmini , Hill Andrew A , Roberts Sally A
Published: October 2019

Background

Aerococcus urinae is a Gram-positive coccus that is increasingly recognized as a urinary pathogen since the introduction of mass spectrometry for identification of bacteria. We report a case of abdominal aortitis (with aneurysm) caused by A urinae in a male with recurrent urinary tract infections and recently treated A urinae bacteremia. A 63-year-old gentleman with a history of A urinae urosepsis 7 weeks prior, presented to the Emergency Department with thoracolumbar back pain radiating bilaterally into the groin. Radiological and surgical findings were consistent with infective infrarenal aortitis with aneurysm.

Methods

The patient successfully underwent open surgical debridement and reconstruction of the infrarenal aorta with autologous vein graft.

Results

Aerococcus urinae was isolated from excised tissue. The patient completed a 4-week course of intravenous antimicrobial therapy.

Conclusions

Aurinae is a urinary pathogen with the ability to cause severe invasive disease including endovascular infections.