bluuebunny/crossref_metadata_2025 huggingface dataset:
Current Use of Intravenous (IV) Long Acting Antibiotic (LAA) Therapy in the Aetna Health Plan among Patients with Acute Bacterial Skin and Skin Structure Infection (ABSSSI)
Authors: Mehta Rajesh , Edwards Alison , Keyloun Katelyn R , Bonine Nicole , Juster Iver
Published: October 2017

Background

In an effort to lower costs and improve quality of care, there is potential to change the treatment landscape for low-risk (i.e., less severe) ABSSSI patients who historically required inpatient management, a costly option. Outpatient IV treatment pathways have been shown to be a cost-saving option for hospitals and insurers. The objective was to quantify the potential opportunity for reducing cost of ABSSSI treatment in an insured Commercial and Medicare Aetna population.

Methods

Adult patients between January 2013 and July 2016 were identified with a primary ABSSSI claim (Table 1) in the Aetna fully-insured Commercial and Medicare insurance claims database. ABSSSI encounters were identified with insurance eligibility for the 7 months prior to and no evidence of ABSSSI in the 30 days prior to the ABSSSI claim. Demographic and clinical data were described, including length of stay (LOS) and allowed cost for inpatient encounters with data. Inpatient encounters without evidence of severity (e.g., codes for major complications or comorbidities) were considered potential candidates for an outpatient LAA pathway. A sensitivity analysis for LOS and cost was run including all ABSSSI patients with LAA dispenses through 2016 (i.e., inclusion/exclusion criteria did not need to be met).

Results

194,023 ABSSSI encounters were identified, most receiving non-IV treatment (90%). 18,603 received IV treatment, where 83% initially presented to the emergency room and the majority were admitted (97%). Of the 28 encounters with LAA use, 7 were inpatient. Of all current inpatient encounters (N = 9,019 after Jan 1, 2015), the majority (N = 7,005; 78%) where considered potential LAA pathway candidates. Comparing inpatient encounters with vs. without LAA use, mean LOS and cost differed (Table 2: 4.1 days and $14,295 vs. 9.0 days and $23,194, respectively). A sensitivity analysis supported similar mean LOS and cost for all inpatient LAA dispenses.

Conclusion

Current use of LAA in an inpatient population is limited but resulted in potential cost-savings. Most of the inpatient population was identified as potential candidates for an outpatient LAA pathway. Research on utilization and quality of care for outpatient IV treatment pathways with LAA is warranted.

Disclosures

K. R. Keyloun, Allergan: Employee, Salary N. Bonine, Allergan: Employee, Salary
Peripherally Inserted Central Catheter Complications in Rural vs. Uban Children Receiving Long-Term Parenteral Antimicrobial Therapy
Authors: Beachum Natasha , Dehority Walter
Published: October 2017

Background

Peripherally inserted central catheters (PICC) are used for treating infections requiring prolonged intravenous antibiotic therapy (IVAT) in children. Given the lack of data on rural PICC use as well as the rural nature of our state, we studied the safety of home PICC use for treating infections in children living in rural settings.

Methods

We identified children <18 years admitted from January 1, 2005 to March 1, 2014 to the University of New Mexico Hospital (UNMH) through analysis of 43 different ICD-9 and CPT codes indicative of PICC placement, with analysis of the medical record to identify patients discharged on IVAT. All data were entered into REDCap and analyzed on Stata. We recorded demographic data, the antibiotic used, the duration/indication for the PICC, and the type/timing of complications. To classify rural vs. urban residence, we used the rural-urban continuum code (RUCC) from U.S. Census data, and the driving time in hours (h) to the nearest level 1,2 or 3 trauma center and UNMH using MapQuest. All patients had either weekly home health or clinic visits, but none utilized an outpatient parenteral antimicrobial therapy (OPAT) clinic. Linear regression models assessed for differences between outcome and response variables.

Results

Of 866 subjects with a PICC, 221 were discharged on IVAT. 134 (60.6%) were boys and 87 (39.4%) were girls (mean age 9.8 years). The mean driving time to the nearest level 1, 2, or 3 trauma center was 0.6 hours (range 0.1–3.0 hours), while the mean driving time to UNMH was 1.3 hours (range, 0.1–5.0 hours). PICCs were utilized for a mean of 26.1 days at home. The most common antibiotics used were tobramycin (n = 41) and nafcillin (n = 40). Osteoarticular infections and cystic fibrosis exacerbations were the most common indications for PICC use (68.8%). 47 children (21.3%) experienced complications associated with their PICC at a mean of 24.7 days from insertion, most commonly occlusion (n = 13, 27.7%) or accidental removal (n = 13, 27.7%). 40 PICC’s (18.1%) were removed prematurely due to a complication. No association was found between RUCC’s or driving times to UNMH or the nearest level 1, 2 or 3 trauma center with any of these complications nor with complications overall (P = 0.11 to 0.96).

Conclusion

Our study demonstrates that home IVAT with a PICC is safe in children in rural locales.

Disclosures

All authors: No reported disclosures.
Implementation of a Standardized Protocol for Hospitalized Patients Who Inject Drugs and Require Long-Term Antibiotics Reduces Length of Stay Without Increasing 30-Day Readmissions
Authors: Rolfe Robert J , Mathews Ronnie E , Rodriguez J Martin , Paddock Cayce S , Lane Peter S , Taylor Benjamin B , Lee Rachael A
Published: October 2017

Background

Injection drug use (IDU) is a growing epidemic, and persons who inject drugs (PWID) are at high risk for infection. IDU is a barrier to outpatient parenteral antimicrobial therapy (OPAT) and provider experience and knowledge may lead to variation in patient care. Recognizing this problem, a multi-disciplinary team implemented a protocol for management of PWID requiring IV antibiotics. The main goals were to standardize the evaluation and risk assessment of PWID with infections and to provide substance abuse counseling and treatment in order to decrease length of stay (LOS).

Methods

A protocol was developed outlining the evaluation, diagnosis, risk-assessment, treatment, maintenance, and follow up of PWID requiring prolonged IV antibiotics (Figure 1). Patients meeting inclusion criteria were identified and the multidisciplinary team assessed the patient. ID confirmed the diagnosis and outlined the treatment plan, and addiction medicine performed a 9-point risk assessment. Low-risk patients were discharged to complete OPAT. Medium risk and high-risk patients remained hospitalized and were offered group therapy, opioid replacement therapy if applicable, and were reassessed weekly for discharge. These patients were compared with previously identified PWID requiring antibiotics prior to the protocol implementation.

Results

37 patients pre-protocol were compared with 34 patients following implementation. Demographics were similar except 56% of the post-implementation group were diagnosed with a concomitant psychiatric disorder vs. 27% in the pre-implementation group (P = 0.01). There was no statistical difference between the number of patients who left AMA in either group (13.5 % pre; 23.5% post; p 0.28) or the number of readmissions (51.4% pre; 32.4% post; P = 0.10). However, the median LOS was significantly reduced in the post implementation group (18. days vs. 42 days; P <0.001). There have been 418 hospital days saved post implementation.

Conclusion

Implementation of a standardized protocol with a multidisciplinary team and risk stratification to determine appropriate patients for discharge has led to improvement in LOS as well as improved addiction care for hospitalized PWID requiring long-term antibiotics.

Disclosures

All authors: No reported disclosures.
Adverse Drug Reactions Among Patients Enrolled in an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program 2015–2016 at UNC Medical Center
Authors: Chundi Vahini , Eichholz Anh , Nwankwo Onyeka , Kinlaw Alan , Kufel Wesley , Medlin Tenesha , Fletcher Lisa , Marx Ashley , Farel Claire
Published: October 2017

Background

The UNC Medical Center OPAT program was started in 2015 to provide multidisciplinary monitoring and management of patients discharged on parenteral antimicrobials. We examined characteristics of incident adverse drug reactions (ADRs) observed in our initial cohort of OPAT patients.

Methods

We abstracted electronic health records for the first 250 patients enrolled in the OPAT program. 223 patients with sufficient recorded data for entire OPAT course were included in the analysis. ADRs meeting criteria as detailed in Table 1 were collected and further stratified by antimicrobial regimen.

Results

57 patients (26%) experienced at least one ADR during OPAT therapy. The frequency of specific ADRs associated with OPAT therapies are provided in Figure 1. Β-lactam regimens were most frequently associated with liver dysfunction, while combinations of β-lactams and vancomycin were associated with kidney dysfunction. Median days on OPAT regimen was 19 days (IQR: 10–29) for patients who experienced an ADR compared with 39 (IQR: 30–44) for patients who did not experience an ADR.

Conclusion

ADRs were most commonly observed within the first three weeks of therapy, particularly for patients receiving vancomycin and a β-lactam antimicrobial in combination. These results underscore the critical role of a multidisciplinary team in providing laboratory monitoring and response to abnormal results for OPAT patients. In addition, closer monitoring within the first three weeks of therapy may provide opportunities for regimen changes or dose adjustment to avoid toxicities.

Disclosures

All authors: No reported disclosures.
Adverse Events Releated to Antibiotic Use in Patients with Myasthenia Gravis
Authors: Zeitler Kristen , Jariwala Ripal , Montero Jose
Published: October 2017

Background

Myasthenia gravis is a medical condition involving the neuromuscular junction, characterized by weakness and fatigue of voluntary muscles. While the understanding of myasthenia gravis has progressed over the years, questions remain regarding which antimicrobial agents can be administered safely to these patients. Traditionally, aminoglycosides and fluoroquinolones have been avoided in this patient population, while other antimicrobials may be prescribed with caution. With minimal literature to guide practice, our aim was to review antimicrobial prescribing in patients with myasthenia gravis at our institution.

Methods

We conducted a retrospective chart review of adult patients 18 years of age and older with a diagnosis of myasthenia gravis who were admitted from January 2012 through December 2015. Charts were reviewed for the receipt of any antimicrobial during the course of hospitalization and any adverse events related to receipt of antimicrobial agents.

Results

205 patients with a diagnosis of myasthenia gravis were admitted to our institution during the study period. 132 (64.4 %) patients were female and ages ranged from 20 to 98 with a median age of 59 years. 159 (77.6 %) patients received at least 1 dose of an antimicrobial agent during their hospitalization. It was notable that 12.2 % and 11.7 % of patients received at least 1 dose of ciprofloxacin or levofloxacin, respectively. Additionally, 3.9 % of patients received at least 1 dose of an aminoglycoside (gentamicin or tobramycin). Five patients experienced a worsening of their myasthenia gravis symptoms with antibiotic use; 2 cases involved levofloxacin and 1 case each involved ciprofloxacin, cefazolin, or clindamycin. Of note, the average duration of therapy prior to symptoms being noted was 2.6 days.

Conclusion

This study highlights the wide variation in antimicrobial prescribing for patients with myasthenia gravis. Our chart review identified few adverse reactions exacerbating disease symptoms related to antimicrobial use. As it is still unclear the exact mechanism for the development of reactions in select patients with myasthenia gravis, further research may be needed to elucidate this information.

Disclosures

All authors: No reported disclosures.
Acute Kidney Injury Associated with Combination Antimicrobial Therapy in the Medical Information Mart for Intensive Care (MIMIC) III Database
Authors: Rutter W Cliff , Burgess David S
Published: October 2017

Background

Increased acute kidney injury (AKI) incidence is linked with coadministration of vancomycin (VAN) and piperacillin-tazobactam (TZP) in the general hospital population when compared with VAN and cefepime (FEP); however, this phenomenon was not found in critically ill patients.

Methods

Patients receiving VAN in combination with FEP or TZP for at least 48 hours during an intensive care unit stay were included in this retrospective review. AKI was defined with the Risk, Injury, Failure, Loss, and End-stage (RIFLE) criteria. Exposure to common nephrotoxins was captured within 24 hours of combination therapy initiation through the entire treatment window. Basic descriptive statistics were performed, along with bivariable and multivariable logistic regression models of AKI odds.

Results

In total, 2230 patients were included, with 773 receiving FEP+VAN and 1457 receiving TZP+VAN. The groups were well balanced at baseline in most covariates, with the exception of hepatorenal syndrome diagnosis (TZP+VAN 1.4% vs. FEP+VAN 0.3%, P = 0.02) and vasopressor exposure (TZP+VAN 26.2% vs 21.5%, P = 0.01) being more common in the TZP+VAN group. Patients in the FEP+VAN group had a higher underlying severity of disease (Charlson comorbidity index [CCI] 2.7 vs. 2.3, P =0.0002). AKI incidence was higher in the TZP+VAN cohort (35.1% vs. 26.5%, P = 0.00004), with each stratification of the RIFLE criteria being higher. The time until onset of AKI was similar between groups (TZP+VAN median 1 [0–3] days vs. FEP+VAN 1 [0–4] days, P =0.2). After multivariable logistic regression, TZP+VAN therapy was associated with an adjust odds ratio (aOR) of AKI of 1.54 (95% confidence interval [CI] 1.25–1.89) compared with FEP+VAN. Other variables associated with increased odds of AKI included: age >= 65, duration of antibiotic therapy, higher baseline renal function, sepsis, endocarditis, hepatorenal syndrome, thiazide diuretic exposure, and increased CCI.

Conclusion

Treatment with TZP+VAN is associated with significant increases in AKI incidence among critically ill patients, independent of other risks for AKI.

Disclosures

All authors: No reported disclosures.
Impact of Vancomycin-Associated Acute Kidney Injury on Patient Outcomes in MRSA Bacteremia
Authors: Luther Megan , Timbrook Tristan , Lopes Vrishali , Caffrey Aisling , LaPlante Kerry
Published: October 2017

Background

Acute kidney injury (AKI) is a well-known adverse effect of vancomycin. Varying degrees and causes of AKI have demonstrated different effects on patient outcomes. Since AKI with vancomycin is typically reversible, we investigated how AKI associated with vancomycin therapy impacts patient mortality and time to discharge.

Methods

Unique patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and who received at least one dose of vancomycin were identified in a national Veterans Affairs cohort from January 1, 2002 to October 14, 2015. Patients with a history of dialysis in the previous year and those with AKI on admission were excluded. AKI was defined according to RIFLE criteria, as an increase in serum creatinine (SCr) of 0.5 mg/dL or 1.5× from the admission SCr, on a day they received vancomycin. Patient characteristics including demographics and comorbidities defined by ICD9 codes were compared between groups. Effect estimates for inpatient mortality were determined with a backward stepwise logistic regression model in SAS 9.2. For patients without inpatient mortality, time to discharge was analyzed using Wilcoxon rank-sum test.

Results

There were 7691 included patients with MRSA bacteremia, and 23.8% (n = 1830) developed AKI during therapy. Mean age was 66.7 (±12) years and 97.8% (n = 7525) were male. Patients with AKI were more likely to have congestive heart failure, diabetes, chronic kidney disease, and to be admitted to the intensive care unit (all P < 0.001). Overall inpatient mortality was 17.7% (n = 1361). The crude odds of inpatient mortality were 67% higher in patients with AKI. In the adjusted model, AKI was an independent predictor of mortality (OR 1.19, 95% CI 1.02–1.40, P < 0.03). Median (IQR) time to discharge was 11 (6–19) days without AKI and 18 (11–31) days with AKI (P < 0.0001).

Conclusion

Vancomycin-associated AKI is associated with increased inpatient mortality and longer time to discharge. Further research is needed to compare clinical outcomes for other groups of patients, and to determine the impact of monitoring interventions to improve safety and decrease AKI.

Disclosures

A. Caffrey, Merck: Grant Investigator, Grant recipient The Medicines Company: Grant Investigator, Grant recipient Pfizer: Grant Investigator, Grant recipient K. LaPlante, Merck: Grant Investigator, Grant recipient Pfizer: Grant Investigator, Grant recipient Cempra: Scientific Advisor, Consulting fee The Medicines Company: Grant Investigator, Grant recipient Allergan: Scientific Advisor, Consulting fee Bard/ Davol: Scientific Advisor, Consulting fee Ocean Spray: Grant Investigator and Scientific Advisor, Consulting fee and Grant recipient Zavante: Scientific Advisor, Consulting fee Achaogen: Scientific Advisor, Consulting fee
National Cohort Study of Preoperative Bacteriuria, Surgical Prophylaxis, and Postoperative Outcomes
Authors: GallegosSalazar Jaime , Strymish Judith , Branch-Elliman Westyn , Itani Kamal , O’Brien William , Gupta Kalpana
Published: October 2017

Background

Despite recommendations against screening urine for bacteriuria prior to non-urological surgery, it is still a common practice. If the urine culture (Ucx) is positive, clinicians often feel compelled to give targeted therapy or expand the peri-operative prophylaxis (PPX) regimen to cover the urinary organism. Large multicenter studies are lacking. We aimed to evaluate rates and results of preoperative urine screening and postoperative outcomes among a national cohort of surgical patients.

Methods

All patients who underwent cardiac, orthopedic implant, or vascular surgery within the national VA health care system during the period from 10/1/08–9/30/13 and had the PPX regimen manually validated were included. Rates of positive Ucx and wound cultures during the 90-day post-operative period were compared between patients with and without pre-operative bacteriuria. Among patients with a positive pre-op urine culture the association between activity of surgical PPX and positive post-op cultures was evaluated.

Results

N = 78,810 surgeries were evaluated (21,889 cardiac, 46,565 orthopedic implant, 10,356 vascular). A pre-op Ucx was performed in 26% (Fig); of these, 6.6% were positive and 852 (63%) received PPX active against the uropathogen. Positive pre-op Ucx was associated with higher rates of positive post-op Ucx and wound cultures (Fig). Among patients who received active PPX, post-op Ucx was positive in 46% compared with 39% who received inactive PPX. The rate of post-op wound cultures was not different between patients who received active (25%) vs. inactive (24%) PPX. The pre-op and post-op organisms were the same in 117/221 (52.9%) Ucx and 17/104 (16.3%) wound cultures, respectively. PPX activity did not affect the match rate.

Conclusion

This is the largest, multicenter study demonstrating no difference in post-op urine and wound cultures in patients receiving active vs. inactive surgical PPX for pre-op bacteriuria. Prevalence of bacteriuria was similar to other surgical populations. Limitations include predominantly male population and need for further characterization of pre-op antibiotic therapy and UTI and SSI outcomes.

Disclosures

All authors: No reported disclosures.
Susceptibility Trends of Urinary Tract Infections Over a 15 Year Period on a University Campus
Authors: Hoffmann Wesley , Donnelley Monica , Ferguson Thomas
Published: October 2017

Background

Acute uncomplicated cystitis (AUC) is one of the most common infections for which antimicrobials are prescribed. Despite IDSA AUC guideline recommendations, prescribing practices are varied throughout the US. Per IDSA recommendations, nitrofurantoin (NTF), fosfomycin, and trimethoprim/sulfamethoxazole (TMP/SMX) are all considered first line therapy for AUC, however there is concern of resistance to some of these agents. Quality improvement activity at the University of California, Davis Student Health Center (UCDSHC) has made prescribing NTF preferred for acute cystitis since 2001 as TMP/SMX has community resistance rates of ~20%. Ciprofloxacin is the second line agent at UCDSHC.

Methods

UCDSHC reviewed all urine cultures and susceptibilities for clinical and epidemiologic purposes. Susceptibility results were gathered from the UCDSHC microbiology laboratory from 2001–2016. Prescribing data was obtained from UCDSHC under diagnosis codes consistent with cystitis or UTI to demonstrate antibiotic prescribing trends. Susceptibilities were evaluated over the 15-year time period (2001–2016). TMP/SMX, FQ’s, and NTF were the primary agents evaluated in this study.

Results

From 2001–2016, 3,831 E. coli and 296 S. saprophyticus isolates were evaluated, accounting for 88% of the total number of organisms. E. coli susceptibilities to NTF remained >98% from 2001–2016. E. coli susceptibilities to FQ’s trended down from 99% in 2001 to 88% in 2016. E. coli susceptibilities to TMP/SMX remained stable around 80% from 2001–2016. S. saprophyticusremained highly susceptible to NTF, FQ’s, and TMP/SMX (95%, 97%, and 100% respectively at the end of the study period). In total, 12,298 prescriptions were written from 2008–20016. Eighty percent (9,875) were NTF and 17% (2,016) were FQ’s. The remaining 1% and 2% were TMP/SMX and ‘Other’, respectively.

Conclusion

After changes in prescribing practice in 2001, NTF was used in 80% of cystitis cases over 15 years and retained excellent activity against common urinary pathogens. FQ’s retained acceptable activity for empiric use for urinary tract infections, but susceptibilities trended down notably despite limited FQ use. TMP/SMX did not regain increased activity over the time period.

Disclosures

All authors: No reported disclosures.
Poor Clinical Outcomes Associated with Community-Onset Extended-Spectrum Cephalosporin-Resistant Enterobacteriaceae Urinary Tract Infections
Authors: Anesi Judith , Lautenbach Ebbing , Nachamkin Irving , Garrigan Charles , Bilker Warren , Dankwa Lois , Wheeler Mary K , Tolomeo Pam , Han Jennifer
Published: October 2017

Background

Urinary tract infections (UTIs) are the most common bacterial infection among adults in the community. Recent data suggest an increase in bacterial resistance to first line antibiotics used for UTI, though the impact on clinical outcomes is unclear. The objective of our study was to determine clinical outcomes associated with community-onset extended-spectrum cephalosporin-resistant (ESC-R) Enterobacteriaceae (EB) UTI.

Methods

A retrospective cohort study was conducted in a large health system from 2010 to 2013. All patients presenting to an emergency department or outpatient clinic with UTI due to EB were included. Exposed subjects were those with an EB demonstrating resistance to an ESC (ceftriaxone or ceftazidime). Unexposed subjects were those with ESC-susceptible EB UTIs and were matched to cases 1:1 based on study year. Multivariable logistic regression analyses were performed to evaluate the association between ESC-R EB UTI and 1) clinical failure (defined as ongoing symptoms, repeat positive culture, or need for additional antibiotics within 7 days); 2) inappropriate initial antibiotic therapy (IIAT) (defined as failure to receive an antibiotic to which the organism was susceptible within 48 hours of presentation).

Results

A total of 302 patients with community-onset EB UTI were included. On multivariable analyses, a UTI with an ESC-R EB was significantly associated with clinical failure (odds ratio [OR] 5.12, 95% confidence interval [CI] 2.79–9.39, P < 0.01). Other variables independently associated with clinical failure included presence of pyelonephritis at the time of UTI diagnosis (OR 2.15, 95% CI 1.14–4.03, p 0.02) and infection with Citrobacter species (OR 29.56, 95% CI 4.46–195.91, P < 0.01). ESC-R EB UTI was also associated with IIAT on multivariable analysis (OR 3.73, 95% CI 2.25–6.21, P < 0.01).

Conclusion

Community-onset UTI due to an ESC-R EB organism is associated with a significantly increased risk of clinical failure, which may be due in part to the use of inappropriate initial antibiotic therapy. Further studies are needed to determine which patients in the community are at high risk for drug-resistant infection to help inform prompt urine culture ordering and appropriate antibiotic prescribing for ESC-R EB.

Disclosures

All authors: No reported disclosures.
Antibiotic Susceptibilities and Appropriateness of Initial Drug Selection for Community-Acquired Urinary Tract Infections (UTI) Caused by Extended-Spectrum Β-Lactamase (ESBL)-Producing Pathogens
Authors: Lee Stephen , Fish Douglas N , Barber Gerard , Barron Michelle
Published: October 2017

Background

Community-acquired (CA) UTI caused by ESBL-producing pathogens pose challenges related to initial antibiotic (AB) selection. Better characterization of AB susceptibilities in CA ESBL infections may improve empiric drug selection for outpatient therapy. The objectives of this study were to describe AB susceptibilities of isolates in CA ESBL UTI and provide recommendations for appropriate treatment at our institution.

Methods

Adult patients with CA ESBL UTI (cystitis) from 2009 through 2013 were retrospectively matched 1:1 with a control group of non-ESBL CA UTI based on age within 5 years, gender, and organism. The primary outcome in this phase of the study was description of AB susceptibilities in CA ESBL UTI vs. controls. Secondary outcomes were comparison of appropriate initial AB therapy (defined as concordance of initial AB with in vitro susceptibilities) and development of recommendations for initial antibiotics for CA UTI.

Results

Eighty-five patients were matched into each of the ESBL and non-ESBL CA UTI groups. E. coli was the pathogen in 94% of ESBL UTIs and 96% of controls. Patients with ESBL UTI most often received ceftriaxone or oral β-lactam (BL, 31%), fluoroquinolone (FQ, 27%), trimethoprim/sulfamethoxazole (TMP/SMX, 14%), or nitrofurantoin (NF, 14%); controls were similar. Besides non-carbapenem BLs, ESBL producers were significantly more resistant to FQs (78% resistant), NF (16%), TMP/SMX (60%), gentamicin (33%), and doxycycline (78%) vs. controls (P < 0.01 for each). Ertapenem and amikacin had 100% and 96% susceptibility, respectively. Initial AB were discordant in 64% of ESBL UTI vs. 14% of controls (OR 11.0, 95% CI 5.0–24.3; P < 0.0001). FQs and TMP/SMX were discordant in 83% and 42% of ESBL UTI, respectively, while NF was concordant in 100% of patients with ESBL UTI and 89% of controls.

Conclusion

Patients with CA ESBL UTI were significantly more likely to receive inappropriate initial AB therapy. Although ESBL-producing strains were resistant to multiple AB classes, NF retained activity against 84% of ESBL isolates and was associated with appropriateness of initial therapy in 100% of patients with ESBL UTI. Nitrofurantoin is an appropriate oral option for treatment of CA UTI, even in patients with ESBL infection.

Disclosures

D. N. Fish, Merck & Co.: Grant Investigator, Research grant M. Barron, Merck & Co.: Grant Investigator, Research grant
Significance of Prior Culture History for Predicting Urinary Tract Infection Caused by Multi-drug Resistant Enterobacteriaceae
Authors: Bohan Jefferson , Remington Richard , Madaras-Kelly Karl
Published: October 2017

Background

Extended-spectrum β-lactamase (ESBL) -producing E. coli, Klebsiella spp., and Proteus spp. (EKP), that cause urinary tract infections (UTI) are resistant to first-line therapies (e.g., ceftriaxone). Prediction of UTI caused by ESBL-producing organisms is important for selection of empirical therapy. The objective was to develop a prediction model to identify UTI caused by ceftriaxone (CRO)-resistant EKP and compare the model to other commonly cited predictive models (Tumbarello M et al. AAC Jul 2011; Johnson SW et al. ICHE Apr 2013).

Methods

A single-center, matched, case–control of Veterans Affairs (VA) outpatients with a positive (≥10^4 CFU/mL) urine culture was conducted. Patients were excluded if they had no UTI diagnosis or documented symptoms, age <18, transfer from another hospital, or a significant urine culture result. Cases were defined as any patient with a CRO-resistant EKP; controls were matched 4:1 to cases based on incident density (≤ 30 days) by random selection. Logistic regression and receiver operator curves were used to develop and assess models.

Results

One hundred subjects were included in the analysis. Demographics were similar except for age [Case 73.5 years (13.7); Control 64.5 years (15.2); P = 0.02] and history of CRO-resistant EKP in last 6 months (Case 40%; Control 0%; P < 0.01). Predictor variables in the final model (Likelihood Ratio 44.2, P < 0.01) included history of CRO-resistant EKP in last 6 months (131.5, 12.2–18308.0), cephalosporin use in past 60 days (12.7, 1.9–94.5), residence in a skilled nursing or assisted living facility (8.0, 1.6–40.5), and hospitalization in last 6 months (OR 3.0, 95% CI 0.7–12.5). In the VA population, the other models predicted significantly although less accurately (Figure 1).

Conclusion

Prior cephalosporin use, hospitalization, and residence were important predictors of UTI caused by CRO-resistant EKP; however, prior history of CRO-resistant EKP was the most important predictor. A Model that included prior culture results predicted CRO-resistant UTIs better than other commonly cited models that do not contain prior ESBL history. Prior culture data should be considered when selecting empirical antibiotics for UTI. Validation in a larger cohort is warranted.

Disclosures

All authors: No reported disclosures.
Percutaneous Nephrostomy Tube-related Infections
Authors: El Haddad Hanine , Viola George , Jiang Ying , Raad Issam , Rolston Kenneth V , Szvalb Ariel
Published: October 2017

Background

Percutaneous nephrostomy tubes (PCN) are indicated for relief of urinary tract obstruction. These devices are prone to mechanical and infectious complications. The infection rate at 90 days is ±20%. Our objective was to determine whether discordant antimicrobial coverage provided prior to PCN exchange was associated with a higher rate of recurrent infection compared with those who received concordant therapy.

Methods

We retrospectively reviewed 780 patients that had undergone initial PCN placement at our institution between July 2014 and February 2017. We only included patients that had developed a definite PCN infection, subsequent PCN exchange, with a minimum 30 day post-PCN exchange follow up. We defined PCN infection as the presence of a positive urine culture (≥104 cfu/mL) plus symptoms consistent with a urinary tract infection. Recurrence was defined as a new PCN infection with the isolation of the same organism to the initial episode. Antibiotics were defined as concordant if they had activity against all organisms’ isolated based on antimicrobial susceptibilities.

Results

A total of 47 patients met our inclusion criteria. The median age of patients was 59, with 49% being male. The most common underlying tumors were urothelial (45%), cervical (17%) and prostate cancer (15%). Clinical characteristics included ureteral stents (17%), diabetes (19%), history of GU surgery (38%), and active chemotherapy at the time of PCN insertion (70%). The median time to onset of infection was 42 days. Infections were polymicrobial in 50% of the cases. The most common organisms encountered were Pseudomonas spp. (36%), Enterococcus spp. (23%) and Escherichia coli (18%). The median length of follow up of PCN tubes after exchange was 55 days. There were 12 (26%) recurrences occurring at a median time of 27 days. The provision of discordant antibiotics preceding PCN exchange was significantly associated with recurrence of infection (66.7% vs. 12.8%; P < 0.002).

Conclusion

Discordant antimicrobial therapy provided during PCN exchange, in the setting of a PCN infection is associated with a higher rate of relapse. Therefore, to decrease the high rate for PCN reinfection, we propose that prior to PCN exchange secondary to infection, patients should be receiving concordant antimicrobial therapy.

Disclosures

All authors: No reported disclosures.
Characterizing Clinical Demographics, Susceptibility Patterns, and Development of Resistance in Raoultella ornitholytica Infections in Southern Virginia
Authors: Fuh Jennifer , Kouchakzadeh Katayoun , McDaniel Kori , Desai Balaji
Published: October 2017

Background

Raoultella ornitholytica (R. ornitholytica) is a waterborne Gram-negative bacilli increasingly found in hospitals. Multi-drug resistance has been reported, including to carbapenems. Our objective was to identify demographics of R. ornitholytica at Danville Regional Medical Center (DRMC) to determine predisposing factors to infection and potential antibiotic resistance.

Methods

Cultures positive for R. ornitholytica were identified through DRMC’s electronic medical records (EMR) from 1/2010 to 3/2017. Site of infection, concurrent infections, isolate susceptibilities, prior antibiotic exposure, and appropriateness of treatment were extracted from the EMR. Healthcare associated was defined as occurring in the hospital, nursing home, long-term acute care, or inpatient rehabilitation facility within the past 90 days. Those with diabetes, cancer, and end stage renal disease (ESRD) were qualified as immunosuppressed.

Results

Thirty-two cases were isolated, of which 20 had associated clinical data. One urine isolate was consistent with colonization. Of the 19 infections, the majority (n = 15) were urinary tract infections (UTIs) and one case each from bronchial washing, heel wound, blood culture, and vulvar lesion. Clinical demographics are shown in Figure 1. Thirteen (65%) had concurrent infections, of which 5 (26%) were co-infected with Enterococcus faecalis, one which was vancomycin resistant. Three had chronic Foley catheters, constituting 20% of the UTIs. Susceptibilities are reported in Figure 2. Prior antibiotic use is shown in Figure 3.

Conclusion

Most of the isolates from our institution were relatively sensitive, with most resistance to ampicillin. Two isolates were pansensitive, however one case was sensitive only to nitrofurantoin and ertapenem. All isolates which were resistant to cefazolin and ceftriaxone had prior exposure. The elderly and diabetics had the greatest association with infection. A majority of patients had a concurrent infection, which may suggest this as an opportunistic organism. Our findings warrant further studies to better characterize clinical associations and development of resistance in response to prior antibiotic exposure.

Disclosures

All authors: No reported disclosures.
Impact of Procalcitonin (PCT)-Guided Antibiotic Therapy on Mortality in Critically Ill Patients: A Systematic Review and Meta-Analysis of 18 Randomized Controlled Trials
Authors: Pepper Dominique , Sun Junfeng , Rhee Chanu , Welsh Judith , Powers John H , Danner Robert L , Kadri Sameer
Published: October 2017

Background

Procalcitonin (PCT)-guided antibiotic therapy has been shown to reduce antibiotic use in critically ill patients with suspected or proven infection, but its impact on mortality remains uncertain. Our meta-analysis examines the effect of PCT-guided antibiotic therapy on survival in critically ill patients.

Methods

We searched PubMed, the Cochrane Library, Scopus, Web of Science, EMBASE and clinicaltrials.gov electronic databases up to October 2016. The meta-analysis was restricted to randomized controlled trials (RCTs) of critically ill patients receiving PCT-guided antibiotic treatment and reporting survival or antibiotic duration. Study quality was assessed using the Cochrane risk of bias tool. Two reviewers conducted all review stages independently, and a third reviewer adjudicated any differences. Data was pooled using random-effects meta-analysis.

Results

Of the 18 RCTs selected (n = 5,183 patients; Table), 17 assessed mortality and 11 assessed antibiotic duration; 8 scored ≥3 and 10 scored ≤2 out of 6 on the risk of bias assessment. Compared with controls, PCT-guided antibiotic treatment was associated with a significant reduction in mortality (20.7% vs. 23.0%; risk ratio [RR] 0.90[95% CI, 0.81–0.99], I2=0%; Figure 1). Survival benefit was retained in the RCT subset with a lower risk of bias (score ≥ 3; RR 0.87 [95% CI, 0.77,0.98], I2=0%; Figure 2) but not with higher risk (score ≤ 2; RR 0.98 [95% CI, 0.80–1.20], I2=0%). Our analysis of the effect of PCT-guided antibiotic therapy on antibiotic duration displayed significant heterogeneity (I2=61.2%, P = 0.004), which precluded reporting on aggregate effect. Important limitations were: single center RCT (n = 9), lack of double blinding (all studies) and variable protocol non-adherence and timeframes examined for mortality.

Conclusion

In a meta-analysis of RCTs of critically ill patients with suspected or proven infection, PCT-guided antibiotic treatment was associated with a significant reduction in mortality. The observed survival benefit was weighted towards RCTs of relatively higher quality. However, the plausibility of this finding, as well as the impact of protocol non-adherence on outcome needs further study.

Funded by Intramural NIH and NCI Contract# HHSN261200800001E

Disclosures

All authors: No reported disclosures.
Biomarker-based Assessment of Urinary Tract Infection in Persons with Spinal Cord Injury
Authors: Mansouri M David , Thiagarajan Perumal , Mansouri Dena , Holmes S Ann
Published: October 2017

Background

Urinary tract infection (UTI) is the most common infection and the second leading cause of death in spinal cord injury (SCI) patients. However, there is currently no consensus about the clinical criteria for UTI in SCI patients and the lack of a universal definition of asymptomatic bacteriuria (ABU) make the diagnosis even more complex and the treatment recommendations problematic. Prompt diagnosis and timely treatment of UTI are important to prevent possible progression to sepsis. Elevated concentrations of some biomarkers may be correlated with infection and their serial measurements may be helpful to assess the effectiveness of antibiotic therapy.

Methods

Fifteen SCI participants were enrolled for either lower UTI, upper UTI (pyelonephritis), ABU, or control. Patients suspected of having any inflammation or infection other than UTI were excluded. Participants were monitored for their serum procalcitonin (PCT) and c-reactive protein (CRP) levels initially and every 3 days once the UTI was confirmed and antibiotics prescribed. In addition, the urine was cultured initially and every three days in patients with UTI for correlation with biomarkers. UTI/ABU was assessed by patient’s physician.

Results

Both mean initial PCT and CRP were significantly higher in patients with lower UTI (P = 0.027 and P = 0.001, respectively) and those with upper UTI (P = 0.044 and P < 0.0001, respectively) compared with control and ABU participants. PCT and CRP were generally reduced to the normal levels gradually during the course of antibiotic therapy for those patients with UTI that were placed on antibiotic therapy. Mean bacterial colonies grown from initial urine cultures in patients with upper or lower UTI were >100,000 CFU/mL. Control participants had urine cultures of ≤1,000 CFU/mL). Generally, cultures from UTI patients placed on antibiotics were negative for the organism(s) treated for during or after the completion of antibiotic therapy.

Conclusion

Serum concentrations of CRP and PCT may be used to aid in the early assessment of UTI in SCI patients in the absence of other sources of inflammation and/or infection. In general, CRP measurements are more pronounced than PCT measurements in patients with ABU or lower UTI. However, PCT levels elevate conspicuously in patient with pyelonephritis.

Disclosures

All authors: No reported disclosures.
Serum Procalcitonin as a Marker for Infection in Patients with Acute Myocardial Infarction
Authors: Vitkon-Barkay Itzhak , Lazarovitch Tsilia , Marchaim Dror , Segaloff Hannah , Zaidenstein Ronit , Minha Sa’ar
Published: October 2017

Background

Significant proportion of patients with acute myocardial infarction (AMI) also present with systemic inflammatory response syndrome (SIRS). Thus it is difficult to determine in certain situations, whether empiric antibiotic treatment is warranted. Serum procalcitonin (PCT) is known to be elevated in bacterial infections, but its performances in predicting bacterial infection among patients with AMI, who might benefit from appropriate empiric management, is unknown.

Methods

A prospective observational study was conducted at Assaf Harofeh Medical Center, Israel. Serum PCT was collected within 48 hours from patients presenting with AMI. Demographic, clinical, and laboratory data, were collected prospectively. Two experienced Infectious Diseases (ID) specialists who were blinded to the PCT results, independently determined the gold standard for infection in every patient. By utilizing sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the area under the ROC curve (AUC), the performance of PCT, fever, white-blood cells (WBC) count and C-reactive protein (CRP) for infection diagnosis was calculated.

Results

The analysis included 230 AMI patients (age 63.0 ± 13.0 years), of which 36 (15.6%) were determined to be infected. The best cutoff for PCT as a differentiating marker between infected and non-infected patients was achieved at 0.09ng/dl (sensitivity 94.4%, specificity 85.1%, AUC ROC 0.94). This test outperformed CRP, WBC, and fever, for infection diagnosis (figure).

Conclusion

PCT should be utilized for ruling out infection in AMI patients by utilizing serum PCT>0.09ng/dl (i.e., ≥0.1ng/dl) as a cutoff.

Disclosures

All authors: No reported disclosures.
Impact of a Pharmacist-Driven Respiratory Viral Panel Stewardship Program on Antibiotic Exposure Within a Multicenter Community Health System
Authors: Cubillos Ashley , Estrada Sandy , Bachmeier Harrison , Turner Edgar
Published: October 2017

Background

Strategies to ensure optimal use of multiplex polymerase chain reaction (mPCR) testing results for antimicrobial stewardship in acute respiratory infections remain to be elucidated. This study sought to assess the impact of pharmacist intervention (by means of prospective feedback to prescribers) on overall antibiotic exposure in patients with viral-positive mPCR Respiratory Viral Panel (RVP) laboratory test results.

Methods

This retrospective cohort study included patients ≥18 years of age admitted to an acute care hospital with a viral-positive nasopharyngeal FilmArray Respiratory Panel test result receiving antibiotics for a suspected respiratory tract infection. Immunocompromised patients, patients with RVP samples from bronchiolar lavage, patients in the intensive care unit when samples were obtained, and patients receiving antibiotics for non-respiratory infections were excluded. Antibiotic exposure days, antibiotic discontinuation at 72 hours, and culture-positive bacterial superinfection were compared in two cohorts of patients, before and after the rollout of an educational pharmacist RVP stewardship initiative.

Results

Median antibiotic exposure days did not differ between the pre- and post-intervention groups (6 days vs. 7 days, P = 0.20). Antibiotic discontinuation at 72 hours was significantly lower in the post-intervention group (38% vs. 25%, P = 0.02). More patients in the post-intervention group had positive bacterial respiratory cultures (2.7% vs. 10%, P = 0.007) and chest radiographs suggestive of pneumonia (34.7% vs. 46%, P = 0.05). Patients with peak serum procalcitonin levels <0.25 ng/mL were more likely to have antibiotics discontinued at 72 hours than those with peak levels ≥0.25 ng/mL (36% vs. 0%, P = 0.02).

Conclusion

An antimicrobial stewardship initiative by pharmacists among patients with viral-positive RVP results did not appear to impact antibiotic exposure days. Serum procalcitonin levels appeared to influence antibiotic discontinuation decisions. Alternative strategies for maximizing the antimicrobial stewardship impact of RVP testing should be explored.

Disclosures

All authors: No reported disclosures.
Multidisciplinary Approach to Improve Utilization and Cost Savings of Multiplex Polymerase chain reaction (PCR) Respiratory Pathogen Testing in a Large Community Hospital
Authors: Hassoun Ali , Edwards Jonathan
Published: October 2017

Background

PCR technology can be used for precise detection of infectious agents and improves antibiotic stewardship through: Accelerated de-escalation of therapy Rapid identification of pathogens Detection of resistance genes. In our center, basic respiratory Panel detect 11 targets and cost $100 while Complete panel detect 31 targets and cost $230.The purpose of the study is to improve utilization of these panel testing in a large community hospital.

Methods

Retrospective chart review of all patients with an order for a complete or basic panel and excluding Patients discharged or deceased prior to result reporting or insufficient specimen quantity to perform. Each patient was evaluated for appropriate respiratory panel collection site and antibiotic regimen changes within 48 hours of results. The preintervention period conducted from 10/2015- 12/2015, evaluated how respiratory panels were being utilized in antibiotic decision-making. Three primary interventions were enacted: Eliminated nasal swabs as a source option for respiratory panels in the clinical information system, restricted complete panel ordering to ID physicians and Eliminated PCR ordering options from all order sets. The postintervention period conducted from 5/2016 – 8/2016, re-evaluated the utilization and costs of respiratory panels.

Results

270 tests ordered preintervention (13% basic and 87% complete) and 196 postintervention (84% basic and 16% complete), nasal swab was done in 78% in preintervention vs. 8% in postintervention, action was taken in 51 vs. 44 in pre-vs. post intervention. cost in preintervention period was 57,420 in preintervention vs. 23,660 in post intervension. No difference between ID vs. non-ID specialist in utilization of PCR.

Conclusion

Nasal swab collections for PCR decreased post-intervention from 78% to 8%. Appropriate sources for PCR specimen, such as sputum, were utilized during the post-intervention period. Post-intervention utilization of the panel results was comparable to pre-intervention period. Elimination of PCR respiratory panels from order sets and restrictions of complete respiratory panel ordering to ID physicians resulted in $33,760 saved.

Disclosures

All authors: No reported disclosures.