bluuebunny/crossref_metadata_2025 huggingface dataset:
2059. Antimicrobial Stewardship of Community Parenteral Antimicrobial Therapy: A Health System Approach
Authors: Buckel Whitney R , Olson Jared , Hersh Adam , Matheu Michelle , Stenehjem Edward A
Published: October 2019

Background

Community parenteral antimicrobial therapy (CoPAT) allows patients to receive intravenous (IV) antimicrobials outside the hospital; however, inappropriate use occurs and can lead to adverse outcomes. In addition, these patients are at high risk of readmission. Our objective was to assess the quality of CoPAT in a large healthcare system in order to guide implementation of an intervention requiring mandatory review by antimicrobial stewardship.

Methods

We identified patients with orders for IV antimicrobials at discharge between January 1 and December 10, 2018. Patients were excluded if transferred to an acute care facility, left against medical advice, or died. 250 patients were selected using a random number generator and reviewed consecutively until 100 confirmed CoPAT encounters were identified. Each encounter was evaluated for evidence of ID consultation, opportunities for stewardship interventions in seven categories (See Table 1), and adverse events such as emergency room (ER) visits and readmissions.

Results

The query identified 4,642 potential CoPAT discharges from 22 hospitals (see Table 2). 117 encounters were reviewed to reach 100 true CoPAT discharges (85% query accuracy). Of these, 55 (55%) received a formal ID consult, 6 (6%) had an ID pharmacist or ID physician curbside, and 5 (5%) had an ID clinic follow-up appointment scheduled without formal ID consult. Opportunity for stewardship intervention was found in 50 (50%) patients (see Table 1). There were 31 (31%) patients who were seen in the ER (n = 21) and/or re-admitted (n = 19) to the hospital during or shortly after completion of CoPAT, of which 25 (81%) were potentially related to CoPAT, including abnormal laboratory findings, PICC-line complications, and signs or symptoms of infection.

Conclusion

CoPAT patients are complex with high healthcare utilization. Mandatory ID review of patients receiving CoPAT has the potential to impact 2,000 lives annually in a large health system.

Disclosures

All authors: No reported disclosures.
2061. Private Practice Dentists and Orthopedic Surgeons (PPD&OS) Engage in a Novel Stewardship Forum: Consensus to Use Less Antibiotics Achieved
Authors: Goff Debra A , Mangino Julie E
Published: October 2019

Background

The American Dental Association (ADA) favors no antibiotic prophylaxis for joint implant patients (JIP), while the American Association of Orthopedic Surgeons’ (AAOS) guidance favors up to lifetime prophylaxis for JIP. Private practice dentists (PPD) represent 80% of all US dentists and to date, no one has attempted dental stewardship with PPD&OS to address this issue. Our purpose is to engage PPD&OS in the same room to address dental stewardship.

Methods

A town hall community evening forum led by an infectious diseases pharmacist and physician, including an oral surgeon, OS, hospital lawyers, and physicians from the CDC. One hour of didactics was presented to 28 PPD&OS followed by a breakout session with interdisciplinary groups to address 2 cases and 10 thought provoking questions to get at rationale for answers. Team leaders presented answers for discussion and “next-steps” to engage more PPD&OS. A pre- and post-survey was administered.

Results

PPD&OS’ “next-steps” were: online continuing education webinar, develop a process to inform PPD&OS if patients develop CDI or a “superbug,” more presentations by ASP experts at local/national meetings, and use local media to engage consumers. The opportunity to meet and work through cases together was highly valued.

Conclusion

An interdisciplinary community forum effectively allowed for consensus among PPD&OS to use fewer antibiotics for JIP receiving dental treatment. Fear of lawsuits impacts antibiotic use; as guidelines are updated and dental stewardship with PPD expands definitive recommendations and improved communications are key.

Disclosures

All authors: No reported disclosures.
2071. A Survey of Antibiotic Prescribing Practices Among Adult Primary Care Physicians in Idaho
Authors: Kanwar Anubhav , Heppler Susan , Madaras-Kelly Karl , Jaworski Martha , Donskey Curtis
Published: October 2019

Background

Prescribing an antibiotic is a complex process involving an interplay of prescriber’s knowledge, diagnostic acumen and patient factors. Understanding the prescriber rationale is key to provide feedback which might improve appropriateness of antibiotic prescribing. Currently, there are limited data on prescribing and test ordering practices among primary care physicians.

Methods

We surveyed primary care physicians taking care of adults (age 18 years and above). Physicians were contacted through the Idaho State Medical Board by a one-time email containing the survey link. The survey consisted of 25 questions under 2 major themes of diagnostic and antimicrobial stewardship (AS). It assessed physicians’ practice setting, ordering of diagnostic tests and antibiotics for common infections, delivery of patient education regarding antibiotics, availability of antibiogram and antimicrobial stewardship services, and assessment of penicillin allergy. Two infectious diseases physicians independently reviewed the results for appropriateness of testing and antibiotic prescribing per IDSA guidelines.

Results

Of 929 physicians surveyed, 157 (17%) responded. Of the respondents, 95 (61%) were male, the mean age was 50 years, and 72% worked in outpatient settings and were family medicine specialists. Only 55% of physicians reported having an AS program at their healthcare facility. Test-of-cure for C. difficile infection (24%) and UTI (13%) and use of superficial culture data to guide the treatment of osteomyelitis (27%) were the most common reasons for inappropriate testing. Longer than recommended duration, antibiotic combinations with overlap of spectrum, and guideline-discordant indications for prescribing antibiotics were the main reasons for inappropriate antibiotic use. The main factors influencing the decision to prescribe an antibiotic were diagnostic uncertainty (42%), being unsure of patient follow-up (23%) and cost of testing (21%).

Conclusion

The survey results highlight the need for prescriber education for decreasing inappropriate test ordering and antibiotic prescribing. Additional studies involving a review of patient records, lab and prescription data are needed to confirm these practices.

Disclosures

All authors: No reported disclosures.
2078. Patterns, Indications, and Appropriateness of Antibiotics Prescribed at a Private Dental Practice
Authors: Khan Mahnoor , Soltau Rhea , Sea Juehwan , Sofjan Amelia K
Published: October 2019

Background

Although dentists prescribe 10% of all outpatient antibiotics in the United States (US), prescribing patterns among dentists in the United States are largely unknown especially in private practice. We aimed to describe the patterns and indications of antibiotics prescribed at a United States private dental practice and evaluate prescription appropriateness.

Methods

This was a retrospective cohort study of all patients who received an antibiotic at a private dental practice in Baytown, TX, between 2017 and 2019. A thorough guideline and literature search was conducted to define the indication-specific appropriateness of antibiotics. The prescribing dentist and an antimicrobial stewardship pharmacist reviewed each patient chart to verify diagnosis and antibiotic indication. Each prescription was categorized as appropriate (evidence supports use), inappropriate (evidence does not support use), indeterminate (insufficient evidence to support or not support use), or not enough information (inadequate patient-specific data to determine appropriateness).

Results

Of 3,700 patient encounters, an antibiotic was prescribed for 230 (6.2%) encounters. Antibiotics prescribed were amoxicillin (52.2%), amoxicillin/clavulanate (27.8%), penicillin VK (7.8%), azithromycin (4.8%), clindamycin (3.5%), cephalexin (2.2%), and metronidazole (1.7%). Excluding antibiotics given as a single pre-operative dose (6% of antibiotics), the mean duration of antibiotics was 5 ± 0.6 days (mean ± SD). Antibiotic indications were symptomatic apical periodontitis or localized acute apical abscess (51.3%), symptomatic irreversible pulpitis (17.8%), prevention of implant failure (11.7%), pericoronitis (4.3%), acute apical abscess with systemic involvement (3.9%), and others (11%). Of the 230 antibiotic prescriptions, 27.8% were appropriate, 3.9% inappropriate, 66.1% indeterminate, and 2.2% not enough information.

Conclusion

Commonly prescribed antibiotics in this study were amoxicillin or amoxicillin/clavulanate for a mean duration of 5 days. The most common indication was symptomatic apical periodontitis or localized acute apical abscess. Two-thirds of antibiotics were prescribed without sufficient evidence to support or not support use.

Disclosures

All authors: No reported disclosures.
2092. Acceptability and Effectiveness of Implementation Strategies on Fluoroquinolone (FQ) Prescribing
Authors: Suda Katie J , Clore Gosia , Evans Charlesnika T , Reisinger Heather , Kale Ibuola , Echevarria Kelly , Reddy Sujan , Neuhauser Melinda M , Perencevich Eli , Goetz Matthew B
Published: October 2019

Background

The Food and Drug Administration (FDA) has issued multiple FQ safety warnings and recommends prescribing FQ only where alternatives are not available. We sought to assess the effectiveness and acceptability of differing implementation strategies on inpatient FQ prescribing.

Methods

Antimicrobial stewardship champions at 15 PBRN sites completed a survey in April 2018 regarding local use and acceptability of differing strategies to improve FQ prescribing. Sites with audit and feedback (PAF) and/or prior approval (PA) were compared with sites without these strategies. Antibiotic days of therapy (DOT) per 1000 days-present (DP) were extracted from the VA Corporate Data Warehouse for 2017–2018. Independent t-tests, contingency tables and simple linear regression were applied.

Results

60% of sites had PAF or PA implemented for FQ. When compared with sites with no strategies in place (64.2 ± 34.4 DOT/DP), mean FQ prescribing rates were lower for sites that employed PAF/PA (35.5 ± 9.8; P = 0.03) and decreased over the 2-year period (P < 0.001 for trend by month). This decrease occurred without an increase in third/fourth-generation cephalosporins for the PAF/PA group (83.5 ± 18.8; P = 0.1 for trend), but increased for sites with no strategies in place (93.6 ± 55.2; P < 0.01 for trend). However, total antibiotic prescribing rates were not different for sites with PAF/PA (561.7 ± 77.8) or without strategies (644.1 ± 157.7; P = 0.2) and did not change over time (p> 0.2). Sites with PAF/PA that reported FQ implementation strategies were “completely” accepted had lower FQ rates than where it was moderately accepted (34.2 ± 5.7 vs. 48.7 ± 4.5; P < 0.01). The PBRN sites perceived that clinical pathways/local guidelines (93% of 15 sites), PA (93%), and order forms (80%) “would” or “may” be effective in improving FQ use. While most sites (73%) indicated that requiring infectious disease consults “would” or “may” be effective in improving FQ use, 87% perceived implementation to be difficult.

Conclusion

PAF and PA implementation strategies focused on FQ were associated with lower FQ prescribing rates, but not overall antibiotic use, indicating class substitution. This may indicate increased acceptability of implementation strategies and/or sensitivity to the FDA warnings.

Disclosures

All authors: No reported disclosures.
2097. Antimicrobial Stewardship Programs in Missouri Hospitals: Facilitators, Barriers, and Complexity of Implementation
Authors: Sayood Sena , Hseuh Kevin , Newland Jason , Babcock Hilary , Warren David K , Turabelidze George , Burnham Jason P , McKay Virginia , Rachmiel Erin C , Habrock-Bach Tracey , MD Michael Durkin,
Published: October 2019

Background

Antibiotic stewardship programs (ASPs) in acute care hospitals reduce unnecessary antibiotic use and attendant complications. In the state of Missouri, all hospitals are required to have an ASP. Additionally, the Joint Commission mandates ASP implementation for accreditation based on core elements defined by the Centers for Disease Control (CDC). No studies have evaluated the uptake of ASP since the Missouri state law and Joint Commission mandate. Furthermore, data are limited examining barriers to implementation across hospitals with variable resources. We evaluated ASP uptake across Missouri hospitals, assessed differences in program complexity, and identified facilitators and barriers to implementation.

Methods

A 94-question survey was administered electronically in the spring of 2019 to 130 Missouri hospitals. Information was collected regarding implementation details of CDC-defined ASP core elements and tools used to overcome implementation barriers. Results were self-reported by the stewardship pharmacist, the director of pharmacy, or the person most familiar with antimicrobial stewardship if the former were not available.

Results

Preliminary results have been collected from 37 hospitals ranging in size from 15 to 1303 beds (IQR: 54, 274). 16% were critical access hospitals. 54% of hospitals had ASPs adherent to all 7 CDC core elements. Another 27% had implemented 6 of the core elements, with all of those reporting that they lacked a single pharmacist leader. All facilities had implemented at least some measures to improve antibiotic use, ranging from 4 to 13 measures. 45% of programs used state-based antimicrobial stewardship collaboratives, and 52% of those found such programs to be “very” or “extremely” useful.

Conclusion

All hospitals surveyed are performing ASP activities in concordance with Missouri state law. However, only half contain the 7 core elements required by the Joint Commission. Furthermore, ASP implementation and activities vary widely. While physician leadership was commonly defined, appropriate pharmacist support was frequently lacking. State-based collaboratives are the most widely used resource, and at least half who use them find them to be helpful.

Disclosures

All authors: No reported disclosures.
2112. Voriconazole for Primary Prophylaxis: A Decade of Trends and Outcomes
Authors: Mourad Ahmad , Johnson Melissa D , Perfect John R
Published: October 2019

Background

Invasive fungal infections (IFI) continue to affect the immunocompromised patient population. Many of these patients require antifungal prophylaxis. Voriconazole is an azole antifungal that has been utilized for preventing IFIs but does not have an approved indication for prophylaxis.

Methods

Adult patients admitted to Duke University Hospital from January 1, 2005 to December 31, 2015 who had received at least 2 days of systemic voriconazole as primary prophylaxis were included in this retrospective medical records review. Demographics, underlying comorbidities, adverse events, drug interactions, voriconazole blood concentrations, and microbiological data were assessed.

Results

Our review identified 403 patients receiving voriconazole for primary prophylaxis. 220 (55.6%) were male, 303 (75.2%) were Caucasian, and the mean age was 46.0 ± 15.7 years. 233 (57.8%) had leukemia, and 63 (15.6%) had lymphoma. 301 (74.7%) underwent hematopoietic transplant (BMT), and 45 (11.2%) had a solid-organ transplant. 176 (43.7%) patients received chemotherapy and 261 (64.8%) received immunosuppressive drugs. The mean voriconazole total daily maintenance dose was 416.1 ± 65.9 mg (5.5 ± 1.6 mg/kg/day). Patients received inpatient voriconazole for a mean of 19.5 ± 16.5 days. 371 (92.1%) patients received a concomitant interacting drug. Only 140 (43.7%) patients had therapeutic drug monitoring. The mean first voriconazole serum concentration was 1.8 ± 1.7 mg/L. 87 (21.6%) patients discontinued voriconazole prematurely; 41 (10.2% overall) of these patients had an adverse event requiring discontinuation. 5 had breakthrough fungal infections with microbiological data identifying a fungal species, which included Rhizopus spp. among others.

Conclusion

Voriconazole is frequently used for primary prophylaxis of IFIs and most commonly in BMT. It appears to be relatively well tolerated with some adverse side-effects (~10%) despite many potential drug–drug interactions and provides appropriate fungal coverage for many immunosuppressed patients. However, few patients had breakthrough fungal infections while receiving voriconazole. In a real-world setting, voriconazole can provide antifungal prevention in certain high-risk patients.

Disclosures

All authors: No reported disclosures.
2113. Evaluation of Empiric Antifungal Therapy in Critically Ill Patients with Liver Disease, Sepsis, and No Evidence of Active Fungal Infection
Authors: Britt Rachel S , Mahoney Monica V , Gold Howard , McCoy Christopher
Published: October 2019

Background

While candidemia is uncommon in the immunocompetent, critically ill population, it is associated with longer lengths of stay (LOS), higher cost, and higher mortality. In critically ill patients with liver disease and sepsis of unknown origin, antifungals (AF) are commonly used empirically. Recent studies suggest that this practice may not improve clinical outcomes but had little representation of patients with liver disease. This study aims to evaluate clinical outcomes of critically ill patients with liver disease, sepsis, and no evidence of active fungal infection who received empiric AF vs. those who did not.

Methods

This was a single-center, retrospective review of adults with liver disease and sepsis, identified by ICD-10 codes, who were discharged from the intensive care unit (ICU) between October 1, 2015 and December 31, 2018. Patients with neutropenia, marrow or organ transplant, HIV infection, systemic immunosuppressants, or fungal infection at sepsis onset were excluded. The primary outcome was inpatient mortality. Secondary outcomes included ICU LOS, total LOS, and development of fungal bloodstream infection (BSI) > 48 hours after sepsis onset. Fisher’s exact and Wilcoxon rank-sum tests were used to compare baseline characteristics. Multivariable logistic regression models were used to compare outcomes. Model covariates were variables with P-values < 0.2 in univariate analysis.

Results

A total of 119 patients were included with 92 receiving empiric AF (micafungin or fluconazole) and 27 receiving no AF. Patients receiving empiric AF were more likely to have hepatic disease upon admission and less likely to have a bacterial infection. Both groups were similar in intubation and vasopressor requirements, febrile episodes, and Candida score. Unadjusted inpatient mortality for empiric vs. no AF was 70.4% vs. 70.7%. Unadjusted ICU LOS, total LOS, and development of a fungal BSI were 10 vs. 11 days, 19 vs. 19 days, and 63.0% vs. 2.2% (P < 0.001). In multivariable models, there was no difference in inpatient mortality between groups (OR 1.20, 95% CI 0.77–1.63).

Conclusion

In critically ill patients with liver disease, sepsis, and no evidence of active fungal infection, receipt of empiric antifungal therapy did not improve inpatient mortality, ICU LOS, or total LOS but did reduce fungal BSI.

Disclosures

All authors: No reported disclosures.
2124. The Epidemiology, Demographics, and Geographical Distribution of Human Non-Tuberculosis Mycobacteria (NTM) Disease in the Endemic Central Florida Region
Authors: Vanessa. Garcia Cristina , E. Teo Greg Matthew , Morano Jamie P , Casanas Beata , Aslam Sadaf , Montero Jose , Zeitler Kristen , Jariwala Ripal , Cannella Anthony
Published: October 2019

Background

Of the >100,000 people in the United States infected yearly with non-tuberculosis mycobacteria (NTM), Florida has the highest yearly incidence and prevalence of NTM disease. However, little has been documented on the epidemiology and distribution of NTM disease within Central Florida.

Methods

A retrospective case review study was conducted from January, 2011 to December, 2017 at a large tertiary acute care medical center in Tampa, Florida to identify all NTM infection cases. Demographics (age, sex at birth, ethnicity), comorbidities, HIV testing status, residential zip code, NTM species, and specimen sources were collected.

Results

Of the 507 isolates, Mycobacterium abscessus group was the most common (45.4%; n = 230), and contained M. abscessus spp. abscessus (34.5%; n = 175), M. abscessus spp. massilense (8.7%; n = 44), and M. abscessus spp. bolletii (1.18%; n = 6). Other rapid growers were M. fortuitum species (6.9%; n = 35) and M. chelonae (2.56%; n = 13). Of the slower growers, M. gordonae (19.9%; n = 101) and M. avium complex (8.28%; n = 42) were the most common. Of the M. avium complex, M. chimera was most common (4.9%; n = 25). Samples were mostly isolated from sputum (51.7%; n = 262), bronchial lavage (26%; n = 132), skin and soft tissue (11%; n = 58), and blood (7.1%; n = 36). Of the 361 unique patients, average age was 59.2 years (12 to 95 years), with 47.6% (n = 172) greater than 65 years of age, and mostly male 57.9% (n = 208). Caucasians represented 73.4% (n = 265) of our cohort, and African Americans and Hispanics represented 16.3% (n = 59) and 6.8% (n = 24), respectively. Most cases were in those residing outside the Tampa Bay metro area 81.2% (n = 293/361). Notable comorbidities included COPD (n = 83), cystic fibrosis (n = 41), lung transplant (n = 40), heart transplant (n = 12), pulmonary fibrosis (n = 12), and renal transplant (n = 7). A total of 145 individuals received HIV testing at the hospital facility, and of these 44 individuals were living with HIV.

Conclusion

This study identified a diversity of NTM species across a wide geographical and demographic distribution in the endemic Central Florida region. M. abscessus group had the highest prevalence. This is valuable in understanding which populations are at risk for developing NTM infection in this area of Florida.

Disclosures

All authors: No reported disclosures.
2125. Staphylococcus Species Identification by Fourier Transform Infrared (FTIR) Spectroscopic Techniques: A Cross-Lab Study
Authors: Tsutsumi Tamao , Shah Alok , Lam Lisa M T , Schlebusch Sanmarie , Krueger Annika , Frazer Ian , Hugenholtz Phil , Soyer H Peter , Morrison Mark , Hill Michelle , Sedman Jacqueline , Ismail Ashraf
Published: October 2019

Background

Staphylococcus aureus is well known to be associated with atopic dermatitis. Recent studies also report S. aureus presence in lesional skin of squamous cell carcinoma (SCC) and its precursor lesion, actinic keratosis (AK). Therefore, it is of potential clinical interest to monitor skin S. aureus colonization on AK lesions. Fourier transform infrared (FTIR) spectroscopy is a cost-effective, nondestructive, and reagent-free technique for rapid microbial identification. It is based on the use of spectral databases developed with well-characterized strains in conjunction with the application of multivariate statistical analysis to elaborate classification models. In the present cross-lab study, spectral databases containing FTIR spectra of over 1000 staphylococcal isolates obtained from reference and clinical microbiology laboratories across Canada were employed in the FTIR spectroscopic identification of Staphylococcus spp. isolated from AK, SCC and perilesional skin of patients at the Princess Alexandra Hospital Dermatology Clinic in Brisbane, Australia.

Methods

FTIR spectra of 51 staphylococcal isolates from AK, SCC and perilesional skin were acquired by both attenuated total reflectance (ATR)-FTIR and transflection-FTIR spectroscopy. All isolates had been previously characterized by 16S rRNA sequencing. ATR- and transflection-FTIR spectra were recorded in triplicate from isolated colonies taken from the same agar plate. Identification of the bacteria was based on the similarities of their spectra with those in ATR- and transflection-FTIR spectral databases originating from the Canadian lab.

Results

Among the 51 staphylococcal isolates included in this study, identification of S. aureus (n = 24) with 100% specificity and 100% sensitivity was achieved by both ATR- and transflection-FTIR spectroscopy. Overall, FTIR-based species identification was in 90.2% concordance with 16S rRNA sequencing.

Conclusion

This cross-lab study demonstrates the applicability of Canadian isolate-based ATR- and transflection-FTIR spectral databases for the identification of clinical staphylococcal isolates obtained in Australia. The results support the potential utility of FTIR spectroscopic techniques to monitor skin S. aureus colonization on AK lesions.

Disclosures

All authors: No reported disclosures.
2145. Carbapenem-Resistant Enterobacteriaceae infections at the Maharaj Nakorn Chiang Mai Hospital
Authors: Chaiwarith Romanee , Supparatpinyo Wisarut
Published: October 2019

Background

Nowadays, carbapenem-resistant enterobacteriaceae (CRE) infection has been spreading worldwide in a tertiary care hospital and causing globally health damage. In Thailand, the studies of the epidemiology of CRE are scarce. This study aimed to describe epidemiology, clinical characteristics and treatment outcome of CRE infection.

Methods

A retrospective cohort study was conducted among patients admitted to the Maharaj Nakorn Chiang Mai Hospital between January 2014 and December 2016 who had clinical diagnosis of CRE infection. Characteristics between groups were compared using Chi-square, Fisher exact test or Student t-test, Mann–Whitney U test. Factors associated with mortality in univariate analysis were analyzed in the logistic regression model.

Results

Among 241 patients who had clinical specimens grew CRE, 51 had infection. Twenty-five patients (49%) were previously hospitalized within 90 days and 42 patients (82.4%) had exposed to antibiotics before documented CRE infection. The most common sites of clinical isolates were urine (33.3%), sputum (29.4%), and blood (21.6%). The mortality rate was 47.1%, which 17 (33.3%) patients’ death was attributable to CRE infection. Factor associated with mortality was higher body temperature (OR 4.8, P = 0.005) and thrombocytopenia.

Conclusion

CRE infections cause high mortality. Strategies to prevent emergence through prudent uses of antibiotics and transmission through infection control measures should be implemented in order to reduce mortality.

Disclosures

All authors: No reported disclosures.
2157. Evaluation of the Utility of the MRSA Nasal PCR Assay in a Community Healthcare System
Authors: Hobbs Athena L V , Turner Stephen , Parag Bhavyata , Shea Katherine M , Seligson Nathan
Published: October 2019

Background

The MRSA nasal PCR assay is a rapid, noninvasive test that has demonstrated a strong negative predictive value (NPV), as high as 99%, for ruling out MRSA pneumonia. These findings are based primarily on literature from large academic centers, which have evaluated both the positive predictive value (PPV) and NPV of MRSA nasal PCR assays. Investigators sought to assess the NPV of the MRSA nasal PCR assay to rule out MRSA pneumonia within a community healthcare system. To the best of our knowledge, this is the largest study from a community hospital and the only study from a community healthcare system for the utilization of a nasal PCR assay to rule out MRSA pneumonia.

Methods

This is a multicenter, retrospective study of adult patients with both an MRSA nasal PCR assay and positive respiratory culture (sputum, bronchoalveolar lavage, or endotracheal aspirate). Data were collected from September 2014 through August 2015 at three community hospitals (bed size ranging from 328 to 706) across two states within a healthcare system. The study was approved by the Baptist Memorial Hospital Institutional Review Board. PPV and NPV 95% confidence intervals (95% CI) were calculated as previously described in the literature.

Results

A total of 808 patients were included in the analysis across the three hospitals. The total incidence of MRSA in positive sputum samples was 14.9% across the three facilities. Our study demonstrated an overall NPV of 95.1% (93.2, 96.6%) and a PPV of 65.9% (95% CI 57.2, 73.9%). The high NPV was retained despite unit type, resulting in 94.9% (95% CI 92.7, 96.6%), 96.3% (95% CI 90.8, 99.0%), and 94.7% (95% CI 74.0, 99.9%) for the intensive care units (ICU), medical-surgical units, and the emergency department, respectively (Table 1).

Conclusion

We concluded that the high NPV of a negative MRSA nasal PCR assay to rule out MRSA pneumonia persisted within a community hospital system. With the results of our study, we plan to utilize institution-specific data along with previously published literature to encourage earlier discontinuation of anti-MRSA antibiotics in patients being treated for pneumonia with negative MRSA nasal PCR assays. Our study demonstrates the validity of the assay in the large community hospital setting with similar findings to studies at large academic institutions.

Disclosures

All authors: No reported disclosures.
2173. Detection of Chlamydia psittaci by rtPCR in Outbreak Specimens Tested at CDC—2018
Authors: McGovern Olivia L , Shaw Kelly , Szablewski Christine , Gabel Julie , Holsinger Caroline , Brennan Skyler , Wolff Bernard , Benitez Alvaro J , Diaz Maureen , Thurman Kathleen A , Winchell Jonas , Kobayashi Miwako
Published: October 2019

Background

Psittacosis is a respiratory illness caused by Chlamydia psittaci. The most commonly available diagnostic tests are serologic tests, which have low sensitivity and can cross-react with other chlamydial species. Serologic tests also require paired sera collected weeks apart, which is impractical for patient management. Real-time polymerase chain reaction (rtPCR) testing for C. psittaci is rapid, sensitive, and specific. However, rtRCR testing is only available at the CDC Respiratory Diseases Branch laboratory, and appropriate clinical specimen types need to be validated since psittacosis case detection is infrequent. In 2018, the first large psittacosis outbreak in the United States in 30 years occurred, allowing assessment of rtPCR performance among multiple clinical specimen types.

Methods

rtPCR test positivity rate and turnaround time were determined among 89 specimens tested at CDC from 54 outbreak patients with suspected psittacosis. rtPCR testing was performed on nucleic acid extracted from clinical specimens using oligonucleotides targeting the C. psittaci locus tag CPSIT_RS01985. Clinical information was collected by patient interview and medical record review.

Results

Positivity rates among the most common specimen types were 4.4% (2/46) for nasopharyngeal (NP) swab, 36.4% (8/22) for sputum, and 80.0% (4/5) for stool. Of 21 (24%) specimens with available data, the average time from patient symptom onset to specimen collection was 6 days (range 1–11 days). C. psittaci was detected in specimens from 13 of 54 outbreak patients tested (Table 1); all 13 patients had radiographically-confirmed pneumonia, and 7 were rtPCR-positive from a lower respiratory specimen only. Paired sputum and NP swab specimens were tested for 6 patients; C. psittaci was detected in all sputum but only 1 NP swab. The positive NP swab was from a patient requiring intensive care unit admission and intubation. All results were reported within 1 business day of specimen receipt in the lab.

Conclusion

These data suggest that lower respiratory specimens are more sensitive than NP swabs for rtPCR detection of C. psittaci; stool might be a suitable alternative. Widespread implementation of rtPCR testing using appropriate specimen types could improve psittacosis detection and inform timely public health interventions.

Disclosures

All authors: No reported disclosures.
2187. Prediction of Patient Outcome During Febrile Neutropenia Despite Anti-infective Treatment Using Machine Learning Algorithms
Authors: Jakob Carolin , Classen Annika , Stecher Melanie , Fuhrmann Sandra , Franke Bernd , Fuchs Frieder , Walker Sarah , Cornely Oliver , Janne Vehreschild Jörg
Published: October 2019

Background

Clinical management of prolonged febrile neutropenia despite broad-spectrum empirical antibacterial treatment is a clinical challenge, as standard empirical treatment has failed and a broad spectrum of differential diagnoses has to be considered. Growing prevalence of multi-resistant bacteria and fungi has made a balanced choice of effective anti-infective treatment more difficult. A reliable prediction of complications could indicate options for treatment optimization.

Methods

We implemented a supervised machine learning approach to predict death or admission to intensive care unit within 28 days in cancer patients with prolonged febrile neutropenia (neutrophils < 500/mm3 and body temperature ≥ 38°C longer than 3 days). We analyzed highly granular retrospective medical data of the Cologne Cohort of Neutropenic Patients (CoCoNut) between 2008 and 2014. Random forest and 10-fold cross-validation were used for classification. The neutropenic episodes from 2014 were used for evaluation of prediction.

Results

In total, 927 episodes of prolonged febrile neutropenia (median age 52 years, interquartile range 42–62; 562/927 [61%] male; 390/927 [42%] acute myeloid leukemia; 297/927 [32%] lymphoma) with 211/927 (23%) adverse outcomes were processed. We computed 226 features including patient characteristics, medication, clinical signs, as well as laboratory results describing changes of state and interactions of medical parameters. Feature selection revealed 65 features with an area under the receiver operating characteristic curve (AUC) of 0.75. In the validation data set the optimized model had a sensitivity/specificity of 36% and 99% (AUC: 0.68; misclassification error: 0.12) and positive/negative predictive values of 89% and 88%, respectively. The most important features were albumin, age, and procalcitonin.

Conclusion

Structured granular medical data and machine learning approaches are an innovative tool that can be used in a retrospective setting for prediction of adverse outcomes in patients with prolonged febrile neutropenia. This study is the first important step toward clinical decision support based on predictive models in high-risk cancer patients.

Disclosures

All authors: No reported disclosures.
2212. Burden of Community-Acquired Pneumonia Attributable to Co-morbid Conditions in Adults
Authors: Rolfes Melissa A , Jain Seema , Bramley Anna , Self Wesley , Wunderink Richard G , Anderson Evan J , Grijalva Carlos G , Fakhran Sherene , Balk Robert , Zhu Yuwei , Williams Derek , Edwards Kathryn , Reed Carrie
Published: October 2019

Background

Few studies have quantified the risk of community-acquired pneumonia (CAP) among adults with co-morbidities. Combining data from the population-based, prospective Etiology of Pneumonia in the Community study (EPIC) and the nationwide health-related Behavioral Risk Factor Surveillance System (BRFSS) telephone-survey, we estimated the annual risk of hospitalization for CAP among adults with co-morbidities.

Methods

We identified adults hospitalized with radiographic and clinical CAP at hospitals in Chicago, IL and Nashville, TN from July 2010 to June 2012. Using 2011 BRFSS data, we estimated the prevalence of the population with selected co-morbidities (chronic lung disease [CLD], cardiovascular disease [CVD], chronic kidney disease [CKD], or diabetes) in the EPIC study catchment counties, as well as the population without co-morbidities. We estimated the incidence of hospitalized CAP, age-adjusted relative risk (RR) using Poisson regression, and population attributable fraction for each co-morbidity.

Results

Among 2,061 adult patients enrolled in EPIC, 1,428 (69%) had at least one selected co-morbidity, most commonly CLD (42%) and CVD (35%). Among the adult population in the EPIC catchment area, 17% had ≥1 selected co-morbidity. The overall incidence of hospitalized CAP was 24.8/10,000, 118.7/10,000 among adults with ≥1 co-morbidity, and 11.2/10,000 among adults without a co-morbidity. Compared with patients without co-morbidities, the incidence of hospitalization for CAP was higher among patients with CLD (aRR: 20.7 [95% confidence interval [CI]: 20.0–21.5]), CKD (aRR: 14.5 [CI: 13.8–15.1]), CVD (aRR: 14.0 [CI: 13.5–14.6]), and diabetes (aRR: 6.2 [CI: 5.9–6.4]). While CLD and CVD accounted for high proportions of the incidence of CAP hospitalizations in the study population, the contribution of the selected co-morbidities varied by age groups (figure).

Conclusion

There is an increased risk of hospitalization for CAP among adults with co-morbidities, particularly chronic lung and cardiovascular disease. As a large portion of CAP is attributable to these co-morbidities, targeted public health interventions, such as vaccination and risk communication, need to be reinforced among these high-risk groups.

Disclosures

All authors: No reported disclosures.
2227. Outcomes in Patients with Renal Impairment from a Phase 3 Clinical Trial for Ceftolozane–Tazobactam (C/T) Treatment of Nosocomial Pneumonia (ASPECT-NP)
Authors: Huntington Jennifer A , Yu Brian , Li Linping , Jensen Erin , Bruno Christopher , Rhee Elizabeth G
Published: October 2019

Background

ASPECT-NP, a phase 3, randomized, double-blind study, evaluated C/T (at double the approved dose for other indications) vs. meropenem (MEM) in adults with ventilated nosocomial pneumonia. We compared safety and efficacy outcomes from this trial among patients with and without renal impairment (RI).

Methods

Patients were stratified by age and diagnosis and were randomized 1:1 to intravenous (IV) C/T 3 g every 8 h or IV MEM 1 g every 8 h. Study drug was administered for 8–14 days; doses were adjusted for moderate and severe RI. Eligible patients were mechanically ventilated; those on renal replacement therapy or with creatinine clearance (CrCL) < 15 mL/minute were excluded. Key efficacy endpoints included clinical cure rates at the test of cure (TOC) visit in the intent-to-treat (ITT) and clinically evaluable (CE) populations and Day 28 all-cause mortality (ACM) in the ITT population. In this analysis, patients were stratified based on renal function for outcome comparisons: normal renal function (CrCL ≥ 80 mL/minute); mild RI (CrCL > 50 to < 80 mL/minute); moderate RI (CrCL ≥ 30 to ≤ 50 mL/minute); and severe RI (CrCL ≥ 15 to < 30 mL/minute).

Results

A total of 726 patients were enrolled (C/T, N = 362; MEM, N = 364). Clinical cure rates at the TOC visit (CE and ITT populations) were robust across CrCL subgroups in both treatment arms and were similar based on 95% confidence intervals for treatment differences that included 0 (table). Day 28 ACM rates for patients with moderate and severe RI were numerically higher than those with mild RI in the MEM treatment arm. Rates of treatment-emergent adverse events (TEAEs) were similar in both treatment arms and across CrCL subgroups, with rates generally increasing with increasing RI severity. Rates of treatment-related TEAEs were low across treatment arms and CrCL subgroups with no treatment-related deaths reported.

Conclusion

Similar clinical cure and Day 28 ACM rates at the TOC visit were found across treatment groups for all CrCL subgroups, consistent with the overall primary and key secondary efficacy results for the ASPECT-NP study. Both drugs were well-tolerated. The results of this analysis indicate that the use of dose-adjusted C/T is appropriate in patients with nosocomial pneumonia and moderate or severe RI.

Disclosures

All authors: No reported disclosures.
2246. Improved Outcomes for Cancer Patients Treated With Ceftazidime–Avibactam vs. Polymyxin-Containing Regimens for Carbapenem-Resistant Enterobacteriaceae Bacteremia
Authors: Borjan Jovan , Shelburne Samuel A , Shelburne Samuel A , Bhatti Micah M , Aitken Samuel L , Aitken Samuel L
Published: October 2019

Background

Outcomes are improved with ceftazidime–avibactam (CZA) compared with polymyxin-based regimens (PBR) for carbapenemase-producing carbapenem-resistant Enterobacteriaceae. It is unclear whether this finding is true in non-carbapenemase (non-CP) producing CRE. The purpose of this study was to compare the efficacy and safety of CZA-based and PBR for CRE bacteremia in cancer patients with a high prevalence of non-CP CRE.

Methods

Adult cancer patients with first occurrence of CRE (i.e., meropenem non-susceptible) bacteremia treated with either CZA or PBR as directed therapy were included. Day 14 integrated benefit-risk outcomes based on desirability of outcome ranking (DOOR; (1) cured and discharged home, (2) cured and hospitalized, (3) cured and hospitalized with renal failure, (4) not cured, (5) dead) were used. DOOR is a recently developed statistical approach designed to unify important patient and clinician outcomes. Inverse probability of treatment weighted (IPTW) ordered logistic regression was used to model the odds of moving down ranked DOOR categories (i.e., having a worse outcome). The probability of a patient treated with CZA or a PBR having a worse DOOR category was also calculated. IPTW logistic regression was used to model the odds of 14-day mortality.

Results

43 patients (CZA, n = 24; PBR, n = 19) with similar demographics and relative illness were included. Klebsiella pneumoniae (n = 21) and Escherichia coli (n = 16) were most common. 16/43 (37%) were CP CRE, 19/43 (44%) were non-CP CRE, and the remainder were unknown. The probability of a better DOOR for patients treated with CZA was 58% (95% CI 53% - 62%). Patients treated with CZA had an 81% reduction in IPTW-adjusted odds of a worse DOOR (OR 0.19, 95% CI 0.05 – 0.76; P = 0.02). 14-day mortality was 2/24 (8%) for patients receiving CZA vs. 5/19 (26%) for patients treated with PBR (IPTW-adjusted OR 0.12, 95% CI 0.02 – 0.82, P = 0.03).

Conclusion

These data suggest that CZA-based treatment, compared with PBR, has a superior integrated benefit-risk profile for the treatment of CRE bacteremia in cancer patients with a high burden of non-CP CRE. These findings build upon available data and suggest that CZA is preferred to PBR for CRE with heterogenous resistance mechanisms.

Disclosures

Samuel L. Aitken, PharmD, Melinta Therapeutoics: Grant/Research Support, Research Grant; Merck, Sharpe, and Dohme: Advisory Board; Shionogi: Advisory Board.
2249. Impact of Minimum Inhibitory Concentration on Clinical Outcomes of Daptomycin for VRE Bloodstream Infection Among Neutropenic Oncology Patients
Authors: Caulder Elisabeth , Palavecino Elizabeth , Beardsley James , Johnson James , Luther Vera , Ohl Christopher , Williamson John
Published: October 2019

Background

Vancomycin-resistant Enterococcus (VRE) bloodstream infection (BSI) is a significant cause of morbidity and mortality in immunocompromised patients. This study aimed to assess the impact of daptomycin (DAP) MIC on outcomes of treatment for VRE BSI in neutropenic oncology patients.

Methods

This was a retrospective, observational, single-center, cohort study at an academic medical center. Included: age ≥ 18, neutropenia, admitted to oncology unit, and DAP for VRE BSI. Excluded: death within 24 hours after initiation of DAP, polymicrobial BSI, and linezolid use for > 48 hours before DAP initiation. Patients with VRE BSI 2008–2018 were identified using a report from the micro lab. Data were collected by electronic medical record review. The primary outcome of the study was clinical success, defined as culture sterilization, hypotension resolution, defervescence, and no need to change DAP due to persistent signs/symptoms of infection. Patients were analyzed according to DAP MIC ≤ 2 vs. ≥ 4 mg/L. Multivariable logistic regression analysis was performed to identify factors associated with clinical success.

Results

44 patients met study criteria (MIC ≤ 2, n = 26; MIC ≥ 4, n = 18). Mean age was 58 years, 59% were male, and median ANC was 0. Median Charlson Comorbidity Index Score and Pitt Bacteremia Score (Pitt) were 5 and 1, respectively. 34% required ICU admission. More patients achieved clinical success with MIC ≤ 2 (88% vs. 56%; P = 0.03). Time to success (2.4 vs. 4 days, P = 0.02) and time to culture sterilization (2.2 vs. 2.9 days, P = 0.24) were shorter with MIC ≤ 2. Mortality was similar between groups (31% vs. 33%). Time to culture sterilization (P = 0.008), neutropenia resolution (P = 0.02), MIC group (P = 0.096), and Pitt (P = 0.52) were included in the multivariable model.

Conclusion

DAP MIC should be considered when choosing therapy for VRE BSI among neutropenic oncology patients, particularly those expected to have prolonged neutropenia and those with persistently positive cultures.

Disclosures

All authors: No reported disclosures.
2251. Estimating the Need for Novel Gram-Negative Active Antibiotics in US Hospitals
Authors: Strich Jeffrey R , Warner Sarah , Ling Lai Yi , Demirkale Cumhur Y , Powers John H , Danner Robert L , Kadri Sameer S
Published: October 2019

Background

Assessing the unmet need for novel antibiotics could inform appropriate utilization, enrollment in trials and ensure balance in aligning incentives and investments in therapeutic development.

Methods

The Cerner Healthfacts electronic health record repository was queried to identify inpatient treatment opportunities for Gram-negative active agents (GNAA) displaying either difficult-to-treat resistance (DTR; resistance to all β-lactams including carbapenems and fluoroquinolones) or extended-spectrum cephalosporin resistance (ECR). The former was quantified by aggregating episodes of confirmed DTR infection (i.e., DTR strain isolated and concomitant antibiotic(s) received) or suspected (i.e., 1–2 days of empiric colistin/polymyxin-B or aminoglycosides and no DTR pathogen isolated). Aggregate days of therapy (DOT) were reported as a range, multiplying episodes by site-specific or uniform 14-day treatment durations, respectively. Recursive partition and cluster analyses were performed for hospital characteristics and contributions of outbreaks to DTR treatment opportunities, respectively.

Results

Between 2009 and 2015, across 2,996,271 encounters, 1,352 episodes of potential targeted treatment were identified, which combined with empiric treatment episodes, represent 39–138 DOT/10,000 encounters for a DTR-GNAA. Similarly, 9,535 episodes of potential targeted therapy for an ECR-GNAA were identified (representing 211-466 DOT/10,000 encounters). The most common candidate site and pathogens for DTR-GNAA were lower respiratory and A. baumannii and P. aeruginosa respectively; DTR bloodstream infections displayed the highest crude mortality at 45%. Enterobacteriaceae urinary infections dominated the ECR group. Teaching hospitals with ≥100 beds were the most likely to encounter a DTR infection; potential outbreaks contributed to 10.6% of DTR treatment opportunities.

Conclusion

The candidate population for new antibacterials directed against highly resistant GN infections with limited treatment options is small but critical, indicating a role for non-revenue-based strategies to develop more effective antibiotics, as well as mechanisms to support trials that address real-world unmet needs.

Disclosures

All authors: No reported disclosures.