bluuebunny/crossref_metadata_2025 huggingface dataset:
1998. Impact of Rapid Blood Culture Identification with Real-Time Antimicrobial Stewardship (ASP) in Patients with Staphylococcus aureus (S. aureus) and Enterococcus spp. Bacteremia at a Large Academic Medical Center
Authors: Ryan Russo Hannah , Phe Kady , Al Mohajer Mayar , Hirase Jessica
Published: October 2019

Background

The initiation of appropriate antimicrobial therapy is dependent on timely identification of the pathogen. FilmArray Blood Culture Identification Panel (BCID) is a rapid, multiplex polymerase chain reaction (PCR) panel that identifies 24 pathogens and 3 antibiotic resistance genes associated with bloodstream infections within 1 hour of growth. The purpose of this study was to compare the clinical impact of rapid BCID testing vs. standard blood culture processing, both coupled with real-time ASP, in patients with S. aureus and Enterococcus spp. bacteremia.

Methods

This was a single-center, retrospective chart review conducted as a pre-post intervention quasi-experimental study. The pre-intervention group included adult patients with S.aureus and Enterococcus spp. bacteremia identified by standard blood culture processing (PRE) and the post-intervention group included those identified by rapid BCID testing (POST). The primary endpoint was time in hours from positive Gram stain to initiation of optimal antimicrobial therapy [defined as vancomycin (VAN), linezolid (LZD), daptomycin (DAP), or ceftaroline for methicillin-resistant S. aureus (MRSA); nafcillin or cefazolin for methicillin-susceptible S. aureus (MSSA); DAP or LZD for VAN-resistant Enterococcus (VRE); VAN or ampicillin (if susceptible) for VAN-susceptible Enterococcus (VSE)]. Secondary endpoints included time to active therapy (defined as an antimicrobial to which the organism was susceptible), time to identification of pathogen, length of hospital stay (LOS) after positive culture, and 30-day mortality.

Results

132 patients were included. Mean time to optimal therapy decreased from 21.4 hours PRE to 10.7 hours POST (P = 0.048). Time to optimal therapy was shorter POST for MSSA [59.2 hours PRE vs. 25.8 hours POST (P < 0.001)] and VRE bacteremia [24.6 hours PRE vs. 5.6 hours POST (P = 0.005)]. Time to identification of pathogen decreased from 75.6 hours PRE to 2.7 hours POST (P < 0.001). Groups did not differ in time to active therapy, LOS, nor 30-day mortality.

Conclusion

Antimicrobial Stewardship coupled with rapid BCID testing significantly decreased time to pathogen identification as well as time to optimal therapy in patients with S. aureus and Enterococcus spp. bacteremia, most notably for MSSA and VRE.

Disclosures

All authors: No reported disclosures.
1999. Does Pharmacist-Driven Methicillin-Resistant Staphylococcus aureus PCR Nasal Screening Decrease Time to De-Escalation of MRSA Coverage in Patients with Pneumonia?
Authors: Waters Dustin , Putich Anthony
Published: October 2019

Background

Vancomycin and linezolid are antibiotics used in cases where methicillin-resistant Staphylococcus aureus (MRSA) is suspected, including in cases where MRSA is suspected to be the cause of pneumonia. MRSA nasal PCR has been shown to have a high negative predictive value when used to rule out MRSA pneumonia. The purpose of the current study was to determine whether a pharmacist-driven MRSA PCR nasal screening protocol would decrease the time to de-escalation or discontinuation of anti-MRSA therapy when utilized for pneumonia.

Methods

Patients were analyzed in two cohorts, those who received vancomycin or linezolid therapy from October 2012 to February 2013 (before pharmacist-driven MRSA nasal PCR protocol; n = 88) and those who received vancomycin from October 2016 to February 2017 (pharmacist-driven MRSA nasal PCR protocol; n = 105). During the study period, pharmacists were given the authority, via protocol to order an MRSA nasal PCR when vancomycin or linezolid was ordered for the indication of pneumonia. Subsequently, after a negative MRSA nasal PCR, pharmacists would contact the prescriber, and let the prescriber know that the MRSA PCR was negative, and then discontinue anti-MRSA therapy. The primary outcome was duration in hours of active anti-MRSA therapy. Secondary outcomes evaluated were the number of anti-MRSA antibiotic doses ordered, and the number of vancomycin troughs ordered.

Results

Patients in the pre-pharmacist driven cohort received vancomycin or linezolid for a median of 44.19 hours, whereas patients in the pharmacist-driven MRSA PCR protocol period received anti-MRSA therapy for a median of 19.1 hours (P < 0.0001). Additionally, prior to the initiation of the pharmacist-driven MRSA nasal PCR protocol, patients received 349 doses of anti-MRSA therapy, compared with 283 doses in the pharmacist MRSA nasal swab protocol group (P < 0.0001). There were also fewer vancomycin troughs ordered in the pharmacist MRSA nasal PCR protocol group (76 vs. 48, P < 0.0009).

Conclusion

A pharmacist-driven protocol for ordering MRSA nasal PCR led to a statistically significant decrease in the time to discontinuation of vancomycin or linezolid for suspected MRSA pneumonia when the MRSA nasal PCR was negative.

Disclosures

All authors: No reported disclosures.
2022. Antibiotic Prescribing Behavior Among Surgeon
Authors: Apisarnthanarak Anucha , Jantarathaneewat Kittiya , Chansirikarnjana Siriththin , Tidwong Nattapong , Mundy Linda
Published: October 2019

Background

A comparative study was conducted to evaluate prescribed antibiotic (AB) use in surgical patients with the Transtheoretical Model of Behavior (TTM) and Theory of Planned Behavior (TPB).

Methods

A survey was conducted at Thammasat University Hospital from January 1 to 31, 2019. We evaluated the appropriateness of AB uses in the surgical department reported per the hospital’s Drug Use Evaluation (DUE) form. After review of the DUE, in-depth interviews were conducted to all prescribers to explore antibiotic prescribing behavior based on TTM vs. TPB, using a standardized data collection tool. Data collected included demographics, indications, appropriateness of AB uses, the individual prescriber’s behavior based on TTM and TPB. The five TTM stages of change were categorized precontemplation, contemplation, preparation, action, and maintenance. In TPB assessment, we evaluated attitude toward AB uses, subjective norm to AB uses behavior, and perceived behavior control of AB uses behavior.

Results

There were 92 AB uses from 64 prescribers; 70 (70/92; 76%) used antibiotics appropriately. The majority of AB uses (62/92; 67%) were for treatment of infections. The most common reasons for inappropriate AB uses included inappropriate AB choices for treatment and prophylaxis of SSIs (n = 11, 50%) and inappropriate duration (n = 8, 36%). Physicians categorized in higher stages of TTM (action and maintenance) were strongly correlated with appropriate AB uses, while there was no correlation between the total TPB score and appropriateness of AB uses. By multivariate analysis, the TTM action and maintenance (aOR = 7.95; P = 0.02) and self-reported prescribers who considered patients as first priority (aOR = 4.02; P = 0.04) were associated with appropriate AB uses, while neurosurgical procedures (aOR = 0.13; P = 0.003) and antibiotic prescriptions for surgical prophylaxis (aOR = 0.15; P = 0.04) were associated with inappropriate AB uses.

Conclusion

Antibiotic prescribers categorized by TTM stages strongly correlated with appropriate AB uses. Additional studies to assess appropriate AB prescribing behavior, based on TTM stages of change, offer an opportunity to optimize surgical care.

Disclosures

All authors: No reported disclosures.
2025. Evaluation of the Impact of an Antimicrobial Stewardship Program in a Tertiary Hospital in Northern Italy: Efficacy of a Persuasive Approach on Antibiotics Consumption and Rate of Clostridium difficile Infection
Authors: Chiari Erika , Mangioni Davide , Pollastri Ester , Signorini Liana , Moioli Giovanni , Paraninfo Giuseppe , Van Hauwermeiren Evelyn , Saccani Barbara , Bertelli Davide , Festa Elena , Caruso Arnaldo , Stellini Roberto , Castelli Francesco
Published: October 2019

Background

Antimicrobial resistance (AMR) situation in Italian hospitals and regions represents a major public health threat [ECDC, 2017]. Antimicrobial stewardship programs (ASPs), particularly when based on local epidemiology, have been beneficial in optimizing antibiotic therapy as well as reducing hospital rates of Clostridium difficile infection (CDI) and AMR [Akpan MR, Antibiotics 2016]..

Methods

Our ASP program has been conducted at Spedali Civili General Hospital of Brescia, Northern Italy (1300-bed tertiary hospital), between the beginning of 2016 and the end of 2017. A preliminary analysis of local epidemiological data was performed (Table 1). Seven groups (“districts”) were identified according to microbiological and clinical similarities. This was a persuasive-based ASP. First, we trained physicians on general principles of AS, then guidelines for the management of “difficult-to-handle” infections were drafted based on international guidelines and local microbiological data (Table 2)..

Results

Here we show the results of pre-ASP (2015) vs. post-ASP (2018) analysis on antibiotic consumption (AC) and CDI rates. AC is expressed in DDD/100 bed-days. The overall hospital AC decreased from 84.31 to 76.84 (−9%), consistently with national recommendations [Italian National Plan against AMR, 2017]. In accordance with the local guidelines developed within our ASP, carbapenem consumption decreased from 5.77 to 4.87 (−16%) and fluoroquinolones (FLQ) from 14.45 to 9.94 (−31%). At the same time piperacillin/tazobactam use increased from 5.53 to 8.46 (53%). 3°–4°G cephalosporins and glycopeptides consumption slightly reduced from 11.78 to 11.42 (−3%) and from 4.07 to 3.83 (−6%), respectively. AC of the different districts involved is reported in Table 3. CDI rates decreased from 0.0434/100 bed-days in 2015 to 0.0315/100 bed-days in 2018 (−27%) (Figure 1).

Conclusion

Our ASP was a persuasive-based program in a setting of high AMR rates. In the short term, it has shown a positive impact in improving AC (in particular of broad-spectrum antibiotics with a high risk of resistance selection and CDI) and CDI rates. Audits for local guidelines adherence and the evaluation of AC, AMR and CDI rates are ongoing as long-term quality measures for assessing the impact of our ASP.

Disclosures

All authors: No reported disclosures.
2027. What Are the Views Among Pakistani Physicians Toward Antimicrobial Resistance and Hospital Antimicrobial Stewardship Programs? A Multi-Site Qualitative Study
Authors: Hayat Khezar , Rosenthal Meagen , Hassan Gillani Ali , Zhai Panpan , Ji Wenjing , Chang Jie , Hu Hao , Fang Yu
Published: October 2019

Background

Antimicrobial resistance (AMR) is a major public health issue that the world is facing in the 21st century and implementation of antimicrobial stewardship program (ASP) is one of the recognized approaches to combat AMR. Little is known on the views among Pakistani physicians regarding AMR and the benefits of hospital ASP implementation. This study was aimed to investigate the perception and attitude of physicians about AMR and ASP.

Methods

Qualitative face-to-face and telephonic interviews were conducted by using purposive sampling method with 22 physicians working in seven tertiary care public hospitals of Punjab, Pakistan. All interviews were audio-recorded and transcribed verbatim. Qualitative software was used, and a thematic analysis conducted.

Results

Three major themes were identified: (1) the growing concern of AMR in Pakistan, (2) the role(s) of healthcare professionals in antibiotic prescribing and infection control, and (3) managing antibiotic resistance in hospitals. Poor healthcare facilities, insufficient trained medical staff, and inadequate resources were the key barriers in the implementation of ASP in Pakistan.

Conclusion

Physicians of public sector tertiary care teaching hospitals have shown poor familiarity toward hospital ASPs but the concept of hospital ASPs in Pakistan can be established by using the distinct themes that originated during this study. Overall, the attitude of physicians was positive toward its enforcement in all types of hospital settings including teaching hospitals.

Disclosures

All authors: No reported disclosures.
2032. First National Survey of Antimicrobial and Antifungal Stewardship in Japan
Authors: Moriyama Yuki , Ishikane Masahiro , Kusama Yoshiki , Matsunaga Nobuaki , Tajima Taichi , Hayakawa Kayoko , Ohmagari Norio
Published: October 2019

Background

To manage antimicrobial resistance, both antimicrobial stewardship (AMS) and antifungal stewardship (AFS) are needed. However, limited data show AMS and AFS practices among hospitals in Japan.

Methods

We conducted a cross-sectional nationwide study using a questionnaire distributed to hospitals that participated in a hospital epidemiology workshop in Japan in July 2018. The questions addressed activities of preauthorization, notification, and intervention within 7 or 28 days about broad-spectrum antibiotics (third- and fourth-generation cephalosporins and piperacillin–tazobactam, carbapenem, intravenous quinolone) and antifungals. Interventions to use broad-spectrum antibiotics and antifungals were compared between large (≥501 beds) and small/medium-sized (≤500 beds) hospitals.

Results

Of 240 hospitals, 39 (16%; 18 large and 21 small/medium-sized) responded. Preauthorization of using broad-spectrum antibiotics and antifungals was found in 4 (10%) and 1 (3%) hospital(s), respectively. Notification of broad-spectrum antibiotics and antifungals was found in 37 (95%) and 2 (5%) hospitals, respectively. The numbers of hospitals that intervened in the use of broad-spectrum antibiotics within 7 and 28 days were 17 (44%) and 34 (87%), respectively; those of antifungals were 3 (8%) and 10 (26%), respectively (Table 1). Interventions to use broad-spectrum antibiotics within 7 days were statistically more frequent in small-/medium-sized hospitals than in large hospitals [13 (61.9%) vs. 4 (22.2%),odds ratio = 5.7, 95% confidence interval = 1.4–23.3, p = 0.023]. All hospitals had less-frequent interventions to use antifungals within 7 days than those for antibiotics[3 (14.3%) vs. 0 (0%)] (Table 2).

Conclusion

Small-/middle-sized hospitals had more frequent interventions within 7 days of broad-spectrum antibiotics than those of large hospitals, possibly because small-/medium-sized hospitals are agile and have few barriers against interventions to use broad-spectrum antibiotics. Compared with broad-spectrum antibiotics, interventions of antifungals were less frequently conducted in all hospitals. We need to emphasize the importance of AFS in Japan. Further studies on related factors are needed.

Disclosures

All authors: No reported disclosures.
2045. GAIN (Generating Antimicrobial Stewardship Initiatives in Chicago Skilled Nursing Facilities) Collaborative Survey Results: CDC Core Elements of Antimicrobial Stewardship Compliance Assessment in 27 Chicago Skilled Nursing Facilities
Authors: Hanson Amy P , Pacilli Massimo , Xydis Shannon N , Walblay Kelly , Black Stephanie R
Published: October 2019

Background

Antimicrobial Stewardship Programs (ASPs) in long-term care facilities is a Centers for Medicare and Medicaid Services requirement as of 2017. The CDC recommends that ASPs in skilled nursing facilities (SNFs) fulfill 7 Core Elements: leadership commitment, accountability, drug expertise, action, tracking, reporting and education.

Methods

An electronic survey utilizing REDCap was sent to the 76 Chicago SNFs representatives (Administrator, Director of Nursing, and/or Assistant Director of Nursing). Survey questions were adopted from the CDC Core Elements of Antimicrobial Stewardship for Nursing Homes Checklist.

Results

Twenty-seven (36%) of Chicago SNFs responded. Bed size ranged from 36 – 307 (median 150). Although 93% of facilities had a written statement of leadership support for antimicrobial stewardship, only 22% cited any budgeted financial support for antimicrobial stewardship activities. While Pharmacist Consultants visited all SNFs (most visiting monthly), only 33% of SNFs had an Infectious Disease Provider that consulted on-site. Dedicated time for antimicrobial stewardship activities was less than 10 hours per week in 78% of facilities, with half of all respondents reporting less than 5 hours per week. Treatment guidelines were in place for 63% of SNFs, 56% had an antibiogram, and only 7% utilized the Loeb criteria to guide appropriate antibiotic prescribing. Many facilities tracked antimicrobial stewardship metrics (93%) and reported out to staff (70%). Annual nursing training on antimicrobial stewardship occurs more frequently (85%) than prescriber education (56%). The top 3 barriers identified in implementing ASPs were financial limitations (33%), lack of clinical expertise (33%), and provider opposition (30%). Facilities’ compliance in all seven core elements varied from partially compliant (65%), majority compliant (19%), and majority non-compliant (16%).

Conclusion

Data from this baseline survey informed focused antimicrobial stewardship initiatives for the GAIN Collaborative. Targeted areas to incorporate into facility action plans include treatment guideline development, antibiograms, annual staff antimicrobial stewardship education, and adoption of the Loeb minimum criteria for antibiotic prescribing into clinical practice.

Disclosures

All authors: No reported disclosures.
2047. GAIN (Generating Antimicrobial Stewardship Initiatives in Chicago Skilled Nursing Facilities) Collaborative: Cumulative Results of Point Prevalence Surveys Assessing Antibiotic Appropriateness in Four Chicago Skilled Nursing Facilities
Authors: Hanson Amy P , Pacilli Massimo , Xydis Shannon N , Walblay Kelly , Black Stephanie R
Published: October 2019

Background

Antimicrobial Stewardship Programs (ASPs) in long-term care facilities are a Center for Medicare and Medicaid Services requirement as of 2017. The CDC estimates 40–75% of antibiotic prescribing in skilled nursing facilities (SNFs) is inappropriate. Overuse of antibiotics can cause harm by increasing the risk of adverse drug events (including C. difficile infections) and antimicrobial resistance.

Methods

The GAIN Collaborative was launched to assist SNFs in improving antibiotic prescribing. A list of antibiotics prescribed was generated from the electronic health records, and a chart review was performed.

Results

Antibiotic orders from September 2018 to March 2019 were randomly selected at 4 SNFs, and 120 antibiotic courses were reviewed (23, 40, 25, and 32 at SNFs A-D). Bed size ranged from 72 to 156 (median 88). Inappropriate antibiotic prescribing ranged from 60 to 78% (median 71%) among facilities. Urinary tract infections (UTIs) were the most frequent indication (40%), followed by lower respiratory tract infections (LRTIs), and skin and soft-tissue infections (SSTIs), accounting for 26% and 19% of indications, respectively. Inappropriate prescribing rates by indication were 90% for UTIs, 78% for SSTIs, and 47% for LRTIs. The most common reasons for inappropriate antibiotic prescribing were: insufficient signs and symptoms based on the Loeb minimum criteria for starting antibiotics (43%), inappropriate agent selection (30%), and lengthy treatment durations (29%). The majority of antibiotics prescribed were β-lactams (42%) or fluoroquinolones (29%). The median antibiotic prescription duration for non-catheter-associated UTIs was 5 days, LRTIs was 7 days, catheter-associated UTIs was 10 days, prophylaxis was 10 days, and SSTIs was 13 days.

Conclusion

Inappropriate antibiotic use was common in the four Chicago SNFs assessed. Results were presented at each facility’s Quality Assurance meeting to deliver provider-focused feedback. Additionally, provider and nursing education has been conducted at the four SNFs aimed at reducing unnecessary treatment of asymptomatic bacteriuria. Any improvements in antibiotic use will be captured through repeat point prevalence surveys post-implementation of a UTI SBAR communication tool and common infection treatment guidelines.

Disclosures

All authors: No reported disclosures.
2063. Using Twitter Data and Machine Learning to Identify Outpatient Antibiotic Misuse: A Proof-of-Concept Study
Authors: Sullivan Timothy
Published: October 2019

Background

Outpatient antibiotic misuse is common, yet it is difficult to identify and prevent. Novel methods are needed to better identify unnecessary antibiotic use in the outpatient setting.

Methods

The Twitter developer platform was accessed to identify Tweets describing outpatient antibiotic use in the United States between November 2018 and March 2019. Unique English-language Tweets reporting recent antibiotic use were aggregated, reviewed, and labeled as describing possible misuse or not describing misuse. Possible misuse was defined as antibiotic use for a diagnosis or symptoms for which antibiotics are not indicated based on national guidelines, or the use of antibiotics without evaluation by a healthcare provider (Figure 1). Tweets were randomly divided into training and testing sets consisting of 80% and 20% of the data, respectively. Training set Tweets were preprocessed via a natural language processing pipeline, converted into numerical vectors, and used to generate a logistic regression algorithm to predict misuse in the testing set. Analyses were performed in Python using the scikit-learn and nltk libraries.

Results

4000 Tweets were included, of which 1028 were labeled as describing possible outpatient antibiotic misuse. The algorithm correctly identified Tweets describing possible antibiotic misuse in the testing set with specificity = 94%, sensitivity = 55%, PPV = 75%, NPV = 87%, and area under the ROC curve = 0.91 (Figure 2).

Conclusion

A machine learning algorithm using Twitter data identified episodes of self-reported antibiotic misuse with good test performance, as defined by the area under the ROC curve. Analysis of Twitter data captured some episodes of antibiotic misuses, such as the use of non-prescribed antibiotics, that are not easily identified by other methods. This approach could be used to generate novel insights into the causes and extent of antibiotic misuse in the United States, and to monitor antibiotic misuse in real time.

Disclosures

All authors: No reported disclosures.
2065. Reducing Inappropriate Antibiotic Prescriptions in the Primary Care Setting
Authors: Klein Marlena , Zackey Diana , Sathe Niharika , Balogun Ayobamidele S , Domadia Mona , Ferrero Gina , Glickman Cynthia , Kim SangHoon , Marden Kyle R , Piazza Michael J , Richmond Jessica , Zander Miriam , Gaughan John , Rose Lucia , Byrne Dana D , Melli Jenny
Published: October 2019

Background

In 2015, the CDC established the National Action Plan for Combating Antibiotic-Resistant Bacteria, with the goal of reducing inappropriate outpatient antibiotic use by 50% by 2020. Upper respiratory infections, (URIs) account for one of the top three diagnoses prompting outpatient visits, and despite viral pathogens being the etiology of most URIs, many patients are treated with antibiotics. This study aimed to reduce inappropriate antibiotics prescribing for URIs at Cooper Primary Care offices.

Methods

Using the electronic medical record, we analyzed office visits (OVs) of 63 primary care providers during the influenza season (November 1, 2017–February 28, 2018) that were associated with a URI diagnosis code and resulted in an antibiotic prescription. The intervention was a personalized digital URI score card (Figure 1) emailed to each primary care physician. It included (1) Cooper Hospitals’ Primary Care Department Average Rate of Antibiotic Prescribing for URI OVs and (2) each physician’s average rate of antibiotic prescribing for URI office visits. Data were collected post-intervention (November 1, 2018–February 28, 2019) to evaluate for changes in antibiotic prescribing patterns.

Results

Using Fischer’s Exact test we analyzed the pre vs. post-intervention rate of antibiotic prescribing for URI OVs. There were 7,295 total pre-intervention office visits. Of these, 41.03% resulted in an antibiotic prescription. There were 6,642 total post-intervention office visits. Of these, 35.85% resulted in an antibiotic prescription. There was a 5.18% overall decrease in antibiotics prescribed for all URI office visits (P < 0.001) (see Figure 2).

Conclusion

Increasing providers’ awareness of their own prescribing patterns compared with their department’s prescribing patterns utilizing a single report card decreased the rate of antibiotics prescribed for URIs by 5.18% for all URI-related office visits. Specifically, there was 10.19% decrease in antibiotics prescribed for bronchitis, which is by definition, of viral etiology. This is significant given the potential side-effects of unnecessary antibiotics, and the emergence of antibiotic resistance. Limitations include a lack of certainty in “true” inappropriate prescriptions and diagnosis coding.

Disclosures

All authors: No reported disclosures.
2068. Outpatient Antimicrobial Stewardship: Optimizing Patient Care Via Pharmacist Led Culture Review
Authors: Wattengel Bethany A , Mergenhagen Kari A , Sellick John A
Published: October 2019

Background

Antimicrobial stewardship programs are well established in the inpatient setting; however, progress has lagged in the outpatient setting. With a growing need for outpatient stewardship, data are needed to guide the development of new services to improve patient care. Many times, cultures are taken in the outpatient setting but results are not acted upon, leading to unnecessary re-presentations to the healthcare setting.

Methods

This study was a prospective chart review via the computerized patient record system with interventions made as needed between January 1, 2018 and January 1, 2019. Infectious Diseases received alerts when oral antibiotics for outpatient use were ordered. Cultures were reviewed daily to ensure drug-bug match and timely interventions. The primary objective of this study was to compare outcomes in patients with accepted interventions vs. rejected interventions: 30-day re-presentation rates, 30-day admission rates, and 30-day treatment failure. Descriptive statistics were used to summarize data.

Results

A total of 7,360 antibiotic orders were reviewed in real time by Infectious Diseases. Of which, 965 encounters with cultures were included in the culture review service. Pharmacists intervened on 20.1% (n = 194) of patient encounters. The majority of antibiotic prescriptions that required intervention were from the emergency department (42%) and primary care (39%), with the remaining 19% being from various outpatient specialty clinics. The most common antibiotics prescribed for patients requiring intervention were ciprofloxacin (26%), third-generation cephalosporins (22%), and sulfamethoxazole/trimethoprim (18%). The most common indication for use was urinary tract infection. The intervention acceptance rate was 76%. Intervention significantly decreased rates of 30-day treatment failure (5% vs. 28%, P < 0.0001) and 30-day admission (0.7% vs. 11%, P = 0.0005) when interventions were accepted rather than rejected.

Conclusion

Culture review service positively impacted outcomes for patients in the outpatient setting. For those antibiotic orders that required intervention, the intervention significantly decreased rates of 30-day treatment failure and 30-day admission when interventions were accepted.

Disclosures

All authors: No reported disclosures.
2070. Assessing Primary Care Physicians’ Attitudes and Perceptions Toward Antibiotic Resistance and Outpatient Antibiotic Stewardship: A National Survey
Authors: Zetts Rachel M , Garcia Andrea , Doctor Jason , Gerber Jeffrey , Linder Jeffrey A , Hyun David Y
Published: October 2019

Background

At least 30% of outpatient antibiotic prescriptions are unnecessary. Outpatient antibiotic stewardship can improve prescribing and minimize the threat of antibiotic resistance. We assessed primary care physicians’ (PCPs) perceptions of antibiotic resistance, inappropriate antibiotic use, and the need for and impact of antibiotic stewardship activities.

Methods

We conducted a national survey of 1,550 internal and family medicine physicians and pediatricians recruited from a medical market research panel. Quotas were established to recruit participants by geographic region and specialty. For sample representativeness, survey weights were generated according to these characteristics using the American Medical Association’s Masterfile.

Results

Among respondents, 94% agreed that resistance is a problem in the United States, but only 55% felt it was a problem for their practice; 65% of respondents agreed they had seen an increase in resistant infections in their patients over the past 5 years. Responses about inappropriate antibiotic use were similar: 91% agreed that it was a problem, but 37% agreed that it is a problem in their practice. Additionally, 60% felt they prescribed antibiotics more appropriately than their peers. For antibiotic stewardship, 91% felt it was appropriate for office-based practices, but 53% believed that discussions with patients on the appropriate use of antibiotics is sufficient to address the problem. The majority of respondents indicated they were likely, very likely, or extremely likely to implement stewardship interventions in response to feedback or incentives from payers or health departments. The activities with the strongest likelihood to spur stewardship adoption included the state health department publishing local resistance patterns (82%), a payer creating a stand-alone incentive program for stewardship (80%), or a payer including it in a broader quality incentive program (76%).

Conclusion

PCPs feel that antibiotic resistance, inappropriate prescribing, and stewardship are important in the United States, but not for their own practices. This disconnect poses a challenge for the success of outpatient stewardship programs. Incentive or data feedback activities may help encourage stewardship uptake.

Disclosures

All authors: No reported disclosures.
2093. Prescribing of Antibiotics by Provider Type Across the Veterans Health Administration (VHA), 2015–2017
Authors: Suda Katie J , Gibson Gretchen , Jurasic Marianne M , Poggensee Linda , Gonzalez Beverly , Fitzpatrick Margaret A , Echevarria Kelly , McGregor Jessina C , Evans Charlesnika T
Published: October 2019

Background

Antibiotic stewardship frequently targets high prescribing providers. Our objective was to determine differences by provider type in antibiotic prescribing rates, high prescribing and trends over time.

Methods

Cross-sectional study in 2015–2017 of non-trainee dental and medical providers actively practicing (defined as ≥20 VHA visits). Medical providers included all physicians and advanced practice providers (APP). Antibiotics prescribed within 7 days of a visit were included. “High prescribing” was defined as providers with visit-based rates ≥75th percentile. Chi square assessed differences in the frequency of high prescribing. Poisson and logistic regression were applied; models were clustered within the facility.

Results

At 130 VHA facilities, there were 32,000 unique medical providers and 1300 dentists actively practicing/year. From 2015–2017, overall antibiotic prescribing rates decreased by 6.4% (P < 0.0001 for trend); decreasing by 1.8% for dentists (P < 0.001) and 6.6% for all medical providers (P < 0.001). More antibiotics were prescribed/visit among dentists vs. medical providers (6.7 vs. 4.3/100 visits; IRR = 1.7). Among medical providers, APP had higher rates (5.0 vs. 4.1/100 visits; P < 0.001). Among dentists, specialty dentists had higher rates compared with general dentists (7.6 vs. 6.5/100 visits; P < 0.001), increasing by 1.9% for specialty dentists and decreasing by 3.1% for general dentists. At the facility-level, dentists who were high prescribers (≥ 75th percentile) of antibiotics were at different facilities as medical providers who were high prescribers (P < 0.001). However, there was no difference in the odds of being a high antibiotic prescriber for dentists when compared with medical providers. Specialty dentists (OR = 1.7; 95% CI: 1.4–2.1) had higher odds of being high prescribers when compared with general dentists. There was no difference among the type of medical provider.

Conclusion

As compared with physicians, dentists and APP have higher antibiotic prescribing rates, though prescribing may differ based on the frequency of infection-related visits. Facility-level interventions to curb the high use of antibiotics may not be reaching high prescribing dentists. Stewardship should be targeted to non-physician providers.

Disclosures

All authors: No reported disclosures.
2098. Applying Antimicrobial Consumption Metrics to Characterize Inpatient Stewardship Opportunities
Authors: Bohn Brian C , Neuner Elizabeth A , Athans Vasilios , Wesolowski Jill , Fraser Thomas G , Gordon Steven M
Published: October 2019

Background

The purpose of this study was to evaluate antimicrobial consumption metrics as a means for differentiating patient populations and antimicrobial stewardship (AMS) opportunities.

Methods

This single-center, retrospective, descriptive study included all patients from January 1, 2018 to June 30, 2018 that received ≥1 day of therapy (DOT) of any antimicrobial included in the National Healthcare Safety Network Antimicrobial Use and Resistance (NHSN AUR) module. The cohort was then grouped into 4 quartiles based on DOT (Q1 lowest; Q4 highest). The primary outcome was a Lorenz Curve of DOT per patient over the study period. Secondary outcomes included a comparison of patient characteristics and number/type of AMS-related opportunities present (using a randomized convenience sample of 25 patients per quartile). AMS opportunities were defined as any unnecessary, inappropriate, or suboptimal antimicrobial use with pharmacist intervention or potential for intervention occurring 24 hours after the antimicrobial initiation.

Results

During the 6 month study period, 24,743 patients accounted for 163,859 days present, and 13,039 (52%) received ≥ 1 DOT. After dividing the population into quartiles of antimicrobial use, median (range) DOT were as follows: Q1 [2 (1–2)], Q2 [4 (3–4)], Q3 [7 (5–10)], Q4 [20 (11–636)] (Figure 1). The top 24% of patients according to antimicrobial use accounted for 74% of total antimicrobial DOT. Patient-level DOT data are displayed by SAAR grouping in Figure 2. In the cohort of 100 patients, differences between quartiles included Infectious diseases consultation in 76% of patients in Q4 compared with 4–24% in other quartiles, ICU admission during hospitalization in 68% in Q4 compared with 28–40% in other quartiles, and any surgical procedure in 88% in Q1 compared with 48–60% in Q2–4. The number of AMS opportunities present were 4 (0.5/1000 DOT) in Q1, 13 (1.6/1000 DOT) in Q2, 28 (1.4/1000 DOT) in Q3, and 86 (0.8/1000 DOT) in Q4. The most common type of AMS opportunity differed by quartile: inappropriate prophylaxis for Q1-3, and de-escalation in Q4.

Conclusion

Evaluating antimicrobial consumption from a patient-level perspective at a large academic medical center reveals heterogeneity and variable AMS opportunities across quartiles

Disclosures

All authors: No reported disclosures.
2110. Treatment of Coccidioidomycosis with Isavuconazole
Authors: Jamros Christina , Maves Ryan C , Chinn Patricia E , Tang Kathy , Johns Scott T , Fierer Joshua , Berjohn Catherine M
Published: October 2019

Background

There are limited prospective data available to guide the management of severe coccidioidomycosis. In particular, the treatment of disseminated coccidioidomycosis often requires extended courses of antifungal therapy, for which there are often intolerable side-effects, toxicities, and failures. In recent years, newer oral triazole antifungals with in vitro activity against Coccidioides have become available, but data are lacking on their efficacy in coccidioidomycosis. Isavuconazole lacks many of the toxicities of older triazole antifungals, such as QT prolongation and certain key drug interactions, making it an appealing option in selected patients.

Methods

Based on pharmacy prescription history at two federal facilities in southern California, we identified adult patients with coccidioidomycosis who received isavuconazole from 2017 to 2019. Patient records were reviewed to identify age, sex, ethnicity, sites of infection, prior antifungal therapy, indication for switch to isavuconazole, duration of follow-up, and outcomes.

Results

12 patients were identified between the ages of 36 and 86 years; 3 were women. 6 were of Pacific Islander descent, 4 were African American, 1 European-American, and 1 Latino. 6 (50%) had significant pre-infection comorbidities. 8 (67%) had evidence of extrapulmonary dissemination, including 1 patient with meningitis. All but one had received prior treatment with other azoles; two had previously been treated with amphotericin B. Six (50%) were switched to isavuconazole due failure or progression of disease on prior therapy; 3 (25%) due to drug toxicity; and 2 (17%) due to drug interactions. Seven (58%) patients improved on isavuconazole; 4/12 (33%) were stable; one developed hepatotoxicity but improved on posaconazole, and one patient deteriorated.

Conclusion

Isavuconazole appears to be a promising agent for the treatment of coccidioidomycosis. Long-term follow-up will be required to assess the risks of toxicity, disease progression, or relapse. For patients who are clinically stable but with an extensive disease burden or toxicity from older agents, isavuconazole may present an amphotericin-sparing option.

Disclosures

All authors: No reported disclosures.
2117. Fluconazole vs. Echinocandins as Initial Therapy for Candidemia Caused by Fluconazole-Susceptible Species in the Era of Rapid Diagnostic Testing
Authors: Roshdy Danya , Ginn Tyler , Jaffa Rupal K , Anderson William E , Green Elizabeth , Ann Medaris Leigh
Published: October 2019

Background

Echinocandins (ECH) are recommended first-line for initial therapy (IT) of candidemia (CD) over fluconazole (FLU) due to their broad spectrum of activity. This recommendation was made prior to widespread implementation of rapid diagnostic testing (RDT), allowing prompt species identification and targeted therapy. The objective of this study was to compare clinical outcomes in patients with CD caused by FLU-susceptible species who received either FLU or ECH as IT.

Methods

This was a multicenter, retrospective cohort study of adults with CD caused by C. albicans, C. tropicalis, or C. parapsilosis. Patients who received FLU or ECH as IT for at least 48 hours from May 2012 to October 2018 were included. Patients who died within 48 hours of first positive blood culture were excluded. The primary endpoint was the rate of clinical failure (persistent CD for >72 hours, recurrent infection within 30 days, change in therapy, and all-cause mortality within 30 days). Secondary endpoints included 90-day all-cause mortality and time to culture clearance. A subgroup analysis in critically ill patients was conducted.

Results

Of the 371 patients evaluated, 128 met criteria for inclusion, 57 received FLU and 71 received ECH. Patients in the ECH group had a higher incidence of sepsis at the time of first positive blood culture (45.1% vs. 19.3%, P = 0.002). A line-associated source was more common in the ECH group (56.3%) vs. urinary source in the FLU group (21.1%). C. albicans was most common in both groups (63%). Clinical failure was similar in the FLU and ECH groups (38.6% vs. 35.2%, P = 0.69). 90-day mortality and time to culture clearance (1.6 vs. 1.5 days, P = 0.63) did not yield significant differences. In the subgroup analysis of critically ill patients, there was a trend suggesting higher rate of failure in patients who received FLU vs. an ECH (60.9% vs. 47.7%, P = 0.31), though underpowered to detect such a difference. Length of stay (LOS) was shorter in patients who received FLU (12 vs. 18 days, P = 0.018).

Conclusion

FLU as IT for FLU-susceptible CD may be a reasonable option in non-critically ill patients in the setting of RDT. This may lead to shorter LOS given the availability of an oral formulation. Additional prospective studies are needed to validate these conclusions.

Disclosures

All authors: No reported disclosures.
2123. Rapid Phenotypic Detection of Gram-Negative Bacilli-Resistant to Oximinocephalosporins and Carbapenems in Positive Blood Cultures Using a Novel Protocol
Authors: Josa Diego , Bustos-Moya Gisell , Yusef Soad , Crevoisier Stephanie , Silva Edwin , Lopez Natalia , Leal Rafael , Torres Isabel , Pablo Osorio Juan , Arias Gerson , Felipe. Reyes Luis
Published: October 2019

Background

Early and adequate antibiotic treatment are the cornerstones to improve clinical outcomes in patients with Bloodstream infections (BSI). Delays in appropriate antimicrobial therapy have catastrophic consequences for patients with BSI. Microbiological characterization of multi-drug-resistant pathogens (MDRP) allow clinicians to provide appropriate treatments. Current available microbiologic techniques may take-up to 96 hours to identify causative pathogens and its resistant patterns. Therefore, there is an important need to develop rapid diagnostic strategies for MDRP. However, rapid detection techniques are costly and are not widely available. We tested a modified protocol designed to detect Gram-negative bacilli (GNB) resistant to oximinocephalosporins and carbapenems from positive blood cultures.

Methods

This is a prospective, cohort study of consecutive patients with bacteremia. We developed a modified protocol using HB&L® system to detect MDRP. We then attempted to determine accuracy, concordance and reduction of identification time of this novel method in a reference hospital. Descriptive statistics and logistical regressions were used.

Results

Ninety-six patients with BSI were included in the study. A total of 161 positive blood cultures were analyzed. Escherichia coli (50%, 81/161) was the most frequently identified pathogen followed by Klebsiella pneumoniae (15%, 24/161) and Pseudomonas aeruginosa (8%, 13/161). 32% of isolations had usual resistance patters. However, in 29/161 (18%) of identified pathogens were producer of carbapenemasases and 21/161 (13%) of extended-spectrum β-lactamases. Concordance among our HB&L® modified protocol and traditional method was 99% (159/161). Finally, identification times were significantly shorter using our HB&L® modified protocol than traditional methods (Mean, hours [SD], 20.8 [6.22] vs. 62.8 [6.22], P < 0.001).

Conclusion

Here we provided novel evidence that using our HB&L® modified protocol is an effective strategy to reduce the time to MDRP detection/identification; with a great concordance rate when compared with the gold standard. Further studies are needed to confirm these findings and to determine whether this method may improve clinical outcomes.

Disclosures

All authors: No reported disclosures.
2126. Comparison of Time to Appropriate Antibiotic Between Using Microarray Assay and Mass Spectrometry Technique for Identification of Positive Blood Cultures
Authors: Sakulkonkij Parichart , Salee Parichat , Katip Wasan
Published: October 2019

Background

Microarray-based, multiplexed, automated molecular method is a rapid diagnosis of bloodstream infections by directly identify bacterial pathogens and antibiotic resistance by detection resistance genes from positive blood culture. Previous studies showed significantly reduce time to organism identification from positive blood culture and antibiotic resistance gene with 97.1% sensitivity and 100% specificity. This study aimed to evaluate time to appropriate antibiotic between using Microarray Assay and Mass Spectrometry technique for bacterial identification.

Methods

one hundred and forty-five patients with bloodstream infection in medical ward were enrolled between 1 June 2018 and 31 January 2019. There were 2 study periods (pre-intervention and post-intervention), using MALDI-TOF combined with the conventional microbiological method as the current standard diagnostic method in pre-intervention group (N = 70) and microarray technique was used add-on to post-intervention group (N = 75). Antibiotic therapy was adjusted by infectious disease team in both periods of study.

Results

There were significantly faster bacterial identification and detection of antibiotic resistance (39.34 hours vs. 5 hours, P = 0.0001) as well as time to adjust specific antibiotic therapy (75 hours vs. 27.65 hours, P = 0.0001) resulted in earlier appropriate antibiotic therapy (31 hours vs. 0 hours, P = 0.005) and decrease unnecessary of antibiotic adjustment (51.4% vs. 37.3%). However, all-cause mortality within 2 weeks was not significantly reduced (11.4% vs. 14.7%), no differences cost of antibiotic therapy and length of hospital stay (13 days vs. 17 days).

Conclusion

Microarray technique has rapid turnaround time to bacterial identification and detection of some resistant genes. A combination of this technique and clinical judgement encourage earlier appropriateness antibiotic therapy and may be helpful in antibiotic stewardship program.

Disclosures

All authors: No reported disclosures.
2128. Murine Typhus and Pregnancy: Case Series and Literature Review
Authors: Tanabe Melinda , Blanton Lucas , La Rosa de Los Rios Mauricio , Webb Camminati Camille
Published: October 2019

Background

Murine typhus is an arthropod borne disease of worldwide distribution with recent reemergence in the United States of America. There is limited data about the presentation, treatment and outcomes in the pregnant population. We report two cases of murine typhus in pregnancy, as well as a case series based in literature published between 1990 and 2019.

Methods

A comprehensive search in Pubmed database using words murine typhus, pregnancy, R. typhi and endemic typhus was done. Exclusion criteria were asymptomatic murine typhus in pregnancy and undiagnosed febrile illness in pregnancy.

Results

Six articles met the criteria of symptomatic pregnant murine typhus infection. Four case reports plus our own 2 case reports, and 2 observational population studies. A total of 35 pregnancy patients were identified. Distribution was worldwide. Gestational age at presentation varied. Patients frequently presented with prolonged duration of fevers prior to presentation, headache, rash, thrombocytopenia and elevated hepatic transaminases. Diagnosis was mainly based on serology. Treatment varied and 8 cases did not receive any treatment at all. Overall pregnancy outcome was favorable, except in an Asian cohort reporting 6 patients with poor pregnancy outcomes.

Conclusion

The lack of data about murine typhus in pregnancy is of serious concern. Increase awareness of different presentations is needed in this population. Murine typhus infection can mimic other pregnancy-related pathologies that have very different treatments and outcomes. More data are needed about effective treatment and safety of doxycycline use during pregnancy.

Disclosures

All authors: No reported disclosures.