bluuebunny/crossref_metadata_2025 huggingface dataset:
1770. Access to Kidney Transplantation in Persons Living with HIV and End-stage Renal Disease in Network 6
Authors: Adekunle Ruth O , Zhang Rebecca , Wang Zhensheng , Patzer Rachel , Mehta Aneesh
Published: October 2019

Background

As persons living with HIV (PLWH) live longer, end-stage renal disease (ESRD) is emerging as a significant cause of morbidity and mortality. PLWH had a three-fold increased risk of ESRD, while also experiencing lower survival rates on dialysis compared with the general population. There are limited data on the incidence and prevalence of PLWH on dialysis. Our objective was to determine the incidence of PLWH on dialysis in ESRD Network 6 (GA, NC, SC) and assess their referral to kidney transplantation and waitlisting on the deceased donor waiting list.

Methods

We merged data from the Southeast Transplant Referral Dataset with the United States Renal Data System Medicare Part D Prescription Claims. PLWH were defined as having a prescription for antiretroviral medications or primary cause of ESRD being HIV-associated nephropathy. Descriptive analysis was performed using Student’s t-test for continuous variables and chi-squared test for categorical variables.

Results

The dataset contained 24,587 patients (471 HIV positive) that initiated an ESRD service between 2012 and 2015. Incidence of PLWH on dialysis was 1.92%. Compared with HIV negative persons, PLWH were younger (median age 49 vs. 58, P < 0.001) and more often black (90% vs. 57%, P < 0.001). There were similar rates of referral among PLWH and HIV-negative persons (50% vs. 51%, P = 0.81), though PLWH were statistical significantly less likely to be waitlisted (8% vs. 15%, P < 0.001). PLWH had longer median time to be referred (240 days vs. 147 days, P < 0.001) and waitlisted compared with HIV-negative persons (611 days vs. 420 days, P = 0.04).

Conclusion

This pilot study offers the first ESRD Network-level characterization of PLWH receiving an ESRD service proceeding through the steps of kidney transplantation. PLWH were less likely to traverse the steps of kidney transplant compared with those HIV negative, highlighting the need for targeted interventions to improve access to kidney transplant in PLWH.

Disclosures

All authors: No reported disclosures.
1774. Impact of a Multiplex Polymerase Chain Reaction Assay on the Clinical Management of Adults Undergoing a Lumbar Puncture for Suspected Community-Onset Central Nervous System Infections
Authors: Moffa Matthew , Elrufay Rawiya , Walsh Thomas L , Carr Dustin R , Shively Nathan , Buchanan Carley , Bremmer Derek N
Published: October 2019

Background

Patients admitted from the community with a suspected central nervous system (CNS) infection require prompt antimicrobial treatment and diagnostic evaluation. Our health network recently implemented a multiplex polymerase chain reaction (PCR) assay in-house.

Methods

This was a pre-/post-intervention study evaluating the impact that a multiplex PCR assay had on the clinical management of patients ≥18 years of age admitted from the community with a lumbar puncture (LP) performed for a suspected CNS infection. The primary outcome was Herpes Simplex Virus (HSV) PCR turnaround time (TAT). Secondary outcomes included inpatient length of stay (LOS), total antimicrobial days of therapy (DOT), and antiviral DOT. Patients were excluded if an LP was performed after hospital day 3, if they were on a systemic antimicrobial for a non-CNS indication, if they were a neurosurgical patient, and if they had a fungal CNS infection.

Results

The pre- and post-intervention groups each had 57 patients. The average age was 51 and 52 years in the pre- and post-intervention groups, respectively. Four patients (7%) in the pre-intervention group were immunocompromised, compared with 9 (16%) in the post-intervention group. Four patients in the pre-intervention group had a positive PCR assay for either HSV or Varicella Zoster Virus (VZV), compared with 5 patients in the post-intervention group. Neither group had a positive cerebrospinal fluid culture, bacterial antigen assay, or bacterial PCR assay. The median (IQR) HSV PCR TAT was significantly longer in the pre-intervention group, 85 (78, 96) vs. 3.9 hours (2.9, 4.7), P < 0.001. The mean LOS was numerically greater in the pre-intervention arm (7 vs. 4.7 days, P = 0.069), as were the total antimicrobial DOT (9 vs. 7.4 days, P = 0.279) and antiviral DOT (3.9 vs. 2.7 days, P = 0.136). Pre-intervention antiviral DOT was significantly greater (3.1 vs. 1.6 days, P = 0.011) in patients without a positive HSV or VZV PCR.

Conclusion

Implementing a multiplex PCR assay for adults undergoing an LP for a suspected CNS infection significantly reduced the HSV PCR turnaround time. Antiviral DOT was significantly shorter in patients with a negative PCR result post-intervention. We also found a non-significant reduction in LOS, total antimicrobial DOT, and antiviral DOT.

Disclosures

All authors: No reported disclosures.
1776. Step-Wise Algorithm for the Detection of Respiratory Viruses: Integrating a Rapid Influenza A/B and RSV PCR with a Multiplex Respiratory Virus Panel to Target High-Risk Patient Populations
Authors: Matic Nancy , Lawson Tanya , Karakas Loretta , Jang Willson , Ritchie Gordon , Hinch Michelle , Leung Victor , Romney Marc G , Lowe Christopher F
Published: October 2019

Background

In clinical settings, multiplex molecular panels are becoming increasingly common for the detection of respiratory pathogens. Little evidence is available to guide appropriate use of respiratory multiplex panels, particularly with respect to the patient populations most likely to benefit from such testing.

Methods

During the 2018–2019 influenza season, all patients with a nasopharyngeal swab submitted for respiratory virus detection were initially tested on a commercial rapid PCR platform for influenza A/B and respiratory syncytial virus (RSV) (Cepheid GeneXpert, Sunnyvale, CA). Patients with negative swabs were reviewed by a laboratory physician based on pre-defined criteria (Table 1) for additional testing by a laboratory-developed multiplex assay for parainfluenza 1/2/3, adenovirus, and human metapneumovirus (hMPV).

Results

In total, 1144 nasopharyngeal swabs were tested. 287 (25.1%) were positive on the GeneXpert: influenza A (234, 81.5%), influenza B (13, 4.5%), and RSV (40, 13.9%). Of the patients who tested negative, 234 (27.3%) met criteria for further respiratory virus testing. The most commonly detected viral pathogens on the multiplex assay were hMPV (20/30, 66.7%), parainfluenza 3 (7/30, 23.3%) and adenovirus (3/30, 10%). The yield of the multiplex assay was highest for patients selected for antimicrobial stewardship (AS) criteria (13/56, 23.2%), followed by transplant (2/16, 12.5%), HIV (7/64, 10.9%), cystic fibrosis (2/19, 10.5%), critical care (6/68, 8.8%), and other/upon physician request (0/11, 0%). Of the patients who received multiplex testing for AS criteria and tested positive for a viral pathogen, only 3/13 (23.1%) had antibiotics discontinued by the medical team within 48 hours of the report.

Conclusion

Additional testing for respiratory viral pathogens had low overall diagnostic yield, and further refinement of the algorithm is needed to better target utilization of respiratory virus testing. The patient population with the highest yield (those who met AS criteria) failed to demonstrate consistent timely discontinuation of unnecessary antibiotics by the medical team. Implementation of respiratory multiplex panels would be strengthened by collaboration with AS teams.

Disclosures

All authors: No reported disclosures.
1777. Metagenomic Approach for the Detection of Viruses in Stool Samples from Infants and Children with Acute Gastroenteritis in Kuwait
Authors: Adel Hawraa , Madi Nada , Al-Nakib Widad
Published: October 2019

Background

Metagenomics techniques are target-independent tools that enable the identification of uncommon disease etiologies and genomic characterization of all microorganisms present in a sample in less time and at a lower cost than previous sequencing techniques. In this study, we developed a metagenomic approach using next-generation sequencing technology to identify known and unknown viruses in stool samples from infants and children with acute gastroenteritis in Kuwait.

Methods

We have investigated 84 stool samples from infants and children aged one month to 10 years old with signs and symptoms of gastroenteritis who attended Mubarak Al-Kabeer and Al-Amiri hospitals in Kuwait from January to December 2017 using both multiplex real-time PCR and metagenomics sequencing (Illumina Miseq instrument) methods.

Results

The metagenomics analysis of viral sequences verified that human adenovirus was the leading cause of gastroenteritis among infants and children in Kuwait, and was detected in 23% of the samples, rotavirus A was detected in 16% of the samples, and the combined infection of human adenovirus and rotavirus was detected in 7% of the samples. Also, newly discovered viruses known to cause gastroenteritis were identified; astrovirus MLB2 and primate bocaparvovirus-1 were detected in 5% of the samples. Also, each of the following new viruses was detected in 2% of the samples; aichivirus A, cardiovirus, parechovirus A, astrovirus VA4, cosavirus F, and bufavirus-3. On the other hand, multiplex real-time PCR showed that the combined infection of human adenovirus and rotavirus was the leading cause of gastroenteritis among infants and children in Kuwait, which was detected in 27% of the samples. However, the rotavirus was the second most common cause of diarrhea, which was detected in 20% of the samples. And the human adenovirus alone was detected in 18% of the samples. Our results showed a 69% agreement between both methods. By applying the Cohen’s Kappa statistics for a measure of agreement, the result gave fair agreement between the two methods (k = 0.388, P = 0.0).

Conclusion

Our findings revealed the capability of a metagenomic approach to detect many viruses causing gastroenteritis in stool samples from infants and children in Kuwait.

Disclosures

All authors: No reported disclosures.
1782. Real-World HIV Diagnostic Testing Patterns in the United States
Authors: Karichu James , Cheng Mindy , Rodriguez Pedro , Robinson Nicole , Burudpakdee Chakkarin , Near Aimee , Tse Jenny , Faccone Jillian
Published: October 2019

Background

Current HIV diagnostic laboratory testing guidelines from the US Centers for Disease Control and Prevention (CDC) recommend a sequence of tests for detection, differentiation, and confirmation of HIV-1 and HIV-2 diagnosis. There is a gap in knowledge about real-world implementation of the testing algorithm. The aim of this study was to characterize the population that underwent HIV antibody differentiation and confirmatory testing and to describe subsequent testing patterns from a large US clinical laboratory database.

Methods

Patients who received one or more HIV-1/2 antibody differentiation test (BioRad Geenius™ HIV 1/2 Supplemental Assay [Geenius]) in the Quest Diagnostics laboratory database between January 1, 2017 and December 31, 2017 were selected into the study; earliest test date was index date. Geenius tests, HIV-1 qualitative RNA (Aptima HIV-1 RNA Qualitative Assay [Aptima]), and HIV-2 DNA/RNA confirmatory tests subsequent to index date were captured. Study measures included pt demographic characteristics, testing frequency and sequencing, and test results. For patients with >1 Geenius test in 2017, concordance between index and subsequent test results was assessed.

Results

There were 26,319 unique patients identified who received ≥1 HIV antibody differentiation result from the Geenius assay. Mean age was 40.7 ± 14.3 years, 66.4% were male, and 42.5% were from southern states. Among the study population, there were 28,954 Geenius, 7,234 Aptima, and 298 HIV-2 DNA/RNA confirmatory tests. 26.4% of Geenius test results were discordant with the initial positive fourth-generation HIV screening results and required subsequent confirmatory testing. In terms of sequencing, the CDC-recommended HIV diagnostic algorithm was followed 74% of the time after screening. 8.5% of patients had >1 Geenius test in 2017; 11.2% of the retests returned different results compared with the first test.

Conclusion

The CDC recommended algorithm for HIV diagnosis is complex for laboratories to implement and currently available assays do not support testing efficiency. To mitigate observed inefficiencies and reduce the laboratory burden of HIV testing, a more accurate and reliable approach for HIV differentiation and confirmatory testing is needed.

Disclosures

All authors: No reported disclosures.
1787. The Effects of a Systemwide Diagnostic Stewardship Change on West Nile Virus Disease Ordering Practices
Authors: Karaba Andrew H , Blair Paul W , Martin Kevin M , Saheed Mustapha O , Carroll Karen C , Borowitz Mike J
Published: October 2019

Background

Neuroinvasive West Nile Virus (WNV) often leads to prolonged neurological deficits and carries a high case fatality rate. The CSF IgM (MAC-ELISA) is preferred over the CSF nucleic acid-based test (NAAT) by the CDC due to its higher sensitivity. However, our hospital system was observed to have an over-utilization of NAAT testing compared with MAC-ELISA testing. The primary objective was to compare the number of MAC-ELISA and NAAT WNV tests ordered before and after a diagnostic stewardship intervention. The secondary objectives were to determine whether this change to lead to any cost savings and increased detection of probable cases of WNV-ND.

Methods

In an effort to increase the use of the MAC-ELISA and to decrease unnecessary NAAT testing, the NAAT test was removed in April 2018 from the test menu in the electronic health record of a health system comprising five hospitals in the Maryland and Washington, D.C. area. NAAT testing remained possible via a paper order form. This study was a retrospective review of WNV testing done on CSF samples from July 2016 through December 2018. The seasonal and yearly number of total tests, positive tests, and total costs were determined from the period of July, 2017 to April, 2018 and were compared with May, 2018 to January, 2019. A paired t-test was performed to evaluate for differences in total testing, total positives, and total costs during non-winter months before and after the intervention.

Results

A total of 12.59 MAC-ELISA tests/month (95% CI: 10.29, 14.89) increased to 41 tests/month (95% CI: 34.35, 47.65) which was significantly different (P < 0.001). In contrast, there were 46.23 NAAT tests/month (95% CI: 39.55, 52.91) which decreased to 0 NAAT tests/month after the intervention (P < 0.001). This resulted in an average decrease in WNV test spending from $7200 per month to $471 per month (P < 0.001). Preceding the intervention in test ordering, 0.23% of WNV CSF tests were positive (NAAT+MAC-ELISA) while 2.44% WNV CSF tests were positive after the intervention (P = 0.03).

Conclusion

Elimination of electronic WNV NAAT ordering is an effective way of decreasing inappropriate WNV NAAT testing, decreasing associated costs, and may lead to improved diagnosis of WNV-ND.

Disclosures

All authors: No reported disclosures.
1980. Variability in Antifungal Stewardship Strategies Among Society for Healthcare Epidemiology of America (SHEA) Research Network Facilities
Authors: Fitzpatrick Margaret A , Albarillo Fritzie S , Ochoa Aaron , Suda Katie J , Evans Charlesnika T
Published: October 2019

Background

The incidence of invasive fungal infections (IFI) and antifungal utilization is increasing in many healthcare settings. Little is known regarding antifungal stewardship strategies within broader antimicrobial stewardship programs (ASPs). This survey aimed to identify the use of antifungal stewardship at a diverse range of hospitals.

Methods

A cross-sectional electronic survey of the SHEA Research Network (SRN) was completed August–September 2018 by a physician or pharmacist ASP leader. The SRN is a consortium of >100 hospitals participating in multicenter healthcare epidemiology research projects. Survey questions pertained to various aspects of antifungal stewardship, including audit and feedback, laboratory testing, and surveillance. Chi-square tested associations between ASP and hospital characteristics and use of antifungal stewardship strategies.

Results

45/111 (41%) facilities responded, including 10 international sites. Most facilities are academic medical centers (64.6%) and care for stem cell (73.3%) and solid-organ transplant (80.0%) patients. Most facilities have large, well established ASPs (60.0% > 5 members; 68.9% duration ≥6 years). 43 (95.6%) facilities use antifungal stewardship strategies in their ASP; most commonly prospective audit and feedback (33/43, 73.3%) performed by a pharmacist (23/33, 71.4%). Only half of ASPs (51.1%) create guidelines for IFI management. Most (71.1%) facilities offer rapid laboratory tests to diagnose IFI, but availability of PCR for fungal speciation and antifungal susceptibility testing varies (Figure 1). 29 ASPs (64.4%) perform surveillance of antifungal utilization, but only 9 (31.0%) report data to CDC’s National Healthcare Safety Network (NHSN). ASP size, ASP duration, and presence of transplant populations were not associated with a higher likelihood of using antifungal stewardship strategies (P > 0.05 for all).

Conclusion

Use of antifungal stewardship strategies is high at SRN hospitals, but mainly involves audit and feedback. ASPs should be encouraged to disseminate guidelines for IFI management, to promote access to laboratory-based tests for rapid and accurate IFI diagnosis, and to perform surveillance for antifungal utilization with data reporting to NHSN.

Disclosures

All authors: No reported disclosures.
1988. Impact of a Novel Pharmacist Practice Model on Antimicrobial Usage and Hospital-acquired Clostridium difficile (HACDI) Rates
Authors: Pourgolafshan Pegah , Ying Ivan , Chen Danny
Published: October 2019

Background

The Antimicrobial Stewardship Program (ASP) was implemented at our 425-bed community hospital in June of 2012. The ASP team, 1 pharmacist, and 1 infectious diseases physician reviewed all intensive care patients on antimicrobials as well as patients on select broad-spectrum antibiotics. In 2016, ASP expansion was undertaken without additional staffing using a novel unit pharmacist model. The effectiveness of in-house antimicrobial stewardship (AMS) training programs for unit pharmacists is not well described. We report the impact of our model on antimicrobial usage and HACDI rates.

Methods

In 2016, an extensive AMS training and certification program was developed for all unit pharmacists. The program consisted of learning modules, didactic lectures, competency assessments, and individual teaching by the ASP team. In 2017, the practice model was rolled out and the ASP team met with each pharmacist biweekly to review prospective audit and feedback cases with a focus on ceftriaxone and fluoroquinolones. Antimicrobial usage was tracked by defined daily doses (DDD) per 1,000 patient-days, as defined by the World Health Organization. HACDI rates per 1,000 patient-days were defined by the Ontario Ministry of Health and Long Term Care.

Results

Since the model launched in 2017 until March of 2019, total antimicrobial usage was decreased by 22% (P < 0.001), fluoroquinolones by 21% (P = 0.01), and ceftriaxone by 53% (P < 0.001). HACDI rates decreased from 0.30 to 0.16 cases per 1,000 patient-days (47%, P = 0.12) (Figure 1). Since ASP implementation in 2012, total antimicrobial usage has been reduced by 35% (P < 0.01), fluoroquinolones by 73% (P < 0.001), clindamycin by 70% (P = 0.05) and rates of HACDI by 73% (P < 0.0001) (Figure 2). Pseudomonas susceptibility rates improved (2012 vs. 2017) for meropenem (86% to 93%), ciprofloxacin (73% to 90%), and piperacillin–tazobactam (80 to 92%), but did not reach statistical significance.

Conclusion

To the best of our knowledge, this is the first description in the literature of an in-house AMS training and certification program for unit pharmacists and its impact on clinical outcomes. This novel approach creates a sustainable and staffing neutral practice model that effectively reduces unnecessary antimicrobial usage and HACDI, resulting in improved patient safety.

Disclosures

All authors: No reported disclosures.
1995. Serial Procalcitonin Measurement in a Community Intensive Care Unit: Is There Value in the Setting of an Established Antibiotic Stewardship Program?
Authors: Seah Jenny , Beriault Daniel , Langford Bradley , Schwartz Kevin L , Cirone Robert , Pasic Maria , Chan April , Downing Mark
Published: October 2019

Background

Procalcitonin (PCT) monitoring has been shown to result in reduced antibiotic use without an impact on patient outcomes. However, the real-world value of this biomarker has yet to be determined, particularly when efforts to optimize antibiotic use are already in place. We evaluated the feasibility and impact of PCT-guided antibiotic duration combined with an established antibiotic stewardship program (ASP) in a community hospital intensive care unit (ICU) in Toronto, Canada.

Methods

We conducted a quality improvement initiative in our ICU from November 2017 to October 2018 measuring daily PCT levels for immunocompetent patients receiving antibiotic therapy for suspected or proven bacterial infection with an expected duration between 48 hours and 21 days. Our protocol recommended stopping antibiotic therapy if PCT fell below 0.5 μg/L (absolute threshold) or if it dropped more than 80% from its peak value (relative threshold). ASP rounds took place twice weekly since 2013, integrating a regular discussion about PCT levels once this initiative was implemented. We evaluated the adherence to stopping criteria within 48h, antibiotic use (days of therapy per 1,000 patient-days), length of stay, 48h re-admission, and ICU-mortality. Interrupted time series with segmented regression was performed to evaluate pre-post intervention differences compared with the 12-months prior to implementation.

Results

A total of 297 antibiotic courses were monitored with PCT in 217 patients. Respiratory (62%), unknown infection (11%), and intra-abdominal infection (7%) were the most common reasons for antibiotics. Protocol adherence was 34% (absolute threshold: 39%, relative threshold: 12%). Adherence by ICU physician varied widely between 24% and 52%. Antibiotic use pre-PCT was 1,002 DOTs/1,000 PDs and post-PCT was 817 DOTs/1,000 PDs (adjusted change −15%, 95% CI: −28% to +8%) (Figure 1). No statistically significant changes in clinical outcomes were noted.

Conclusion

In the context of an active ASP in a community hospital ICU, PCT monitoring was associated with a non-significant decrease in antibiotic use. Further evaluation of reasons for inter-physician variability in adherence and opportunities for improved and sustained overall adherence should be explored.

Disclosures

All authors: No reported disclosures.
2026. A Current Status of Antimicrobial Stewardship Programs in Korean Large Hospitals: A Nationwide Survey in 2018
Authors: Kim Bongyoung , Jin Lee Myung , Mi Moon Song , Yoon Park Se , Song Kyoung-Ho , Lee Hyunju , Su Park Jeong , Suk Lee Mi , Choi Su-Mi , Yeom Joon-Sup , Yong Kim Jin , Kim Chung-Jong , Chang Hyun-Ha , Suk Kim Eu , Hyong Kim Tae , Bin Kim Hong
Published: October 2019

Background

The aim of this study was to examine the current status of antimicrobial stewardship program (ASP) in large hospitals in South Korea, identifying problems and hurdles for implementation of proper ASP, and providing a reference for the proposal of ASP policies.

Methods

The questionnaire was designed based on the “Seven Core Elements of Hospital Antibiotic Stewardship Programs” from Centers for Diseases Control and Prevention of the U.S. and modified from the questionnaire of the previous survey on ASP in Korea, 2015. The survey targeted all the hospitals with 500 beds or more in South Korea in 2018. The online-based survey using SurveyMonkey® platform was conducted for 3 weeks from June to July 2018. Only one ASP-associated physician per hospital participated in the survey.

Results

The response rate to the survey was 88.4% (84/95). The median number of medical personnel participating in ASP was 4 [interquartile range (IQR) 2.25–5], most of which were infectious diseases specialists (median 2, IQR 1–2). Besides, some pediatric infectious diseases specialists, pharmacists, etc. were participating in the ASPs. Only 6.0% (5/84) of hospitals had full-time workers for ASP. Restrictive measures for designated antibiotics was a widely accepted ASP strategy among Korean hospitals (88.1%, 74/84) and the median number of designated antibiotic classes was 16 (IQR 11–19). An 11.9% (10/84) of hospitals introduced monitoring and intervention program against inappropriate antibiotic combination therapy. The proportion of hospitals which had interventions for inappropriate long-term antibiotic use and parenteral to oral conversion strategy were 9.5% (8/84) and 1.2% (1/84), respectively. Lack of time, personnel, and appropriate reward were perceived as the major barriers to establishing ASP in Korean hospitals.

Conclusion

ASP in Korean hospitals were mainly carried out by 1–2 infectious diseases specialists and it heavily depended on restrictive measures for designated antibiotics. Supporting manpower and establishment of the appropriate reward system is necessary for improvement of ASP in Korean hospitals.

Disclosures

All authors: No reported disclosures.
2031. Impact of Education and Antibiotic Guidelines on Dispensing Antibiotics with Community Pharmacists in a Low- and Middle-Income Country
Authors: Gudipati Smitha , Bajracharya Deepak , Jimee Lenjana , Maki Gina , Zervos Marcus , Prentiss Tyler , Kaljee Linda
Published: October 2019

Background

Non-prescription use of antibiotics in low- and middle-income countries has contributed to significant antimicrobial resistance (AMR). Henry Ford Health System has partnered with multinational organizations in Nepal to address the need for increasing awareness of AMR and implementation of effective antimicrobial stewardship. This partnership confirmed the importance of increasing knowledge and awareness regarding AMR and antibiotic use to community pharmacists. The present pilot study assessed if outpatient antibiotic dispensing guidelines given to community pharmacists could result in a reduction of unneeded antibiotic use.

Methods

Nine community pharmacies from Kathmandu were selected of which two were used as controls. Seven pharmacists were educated on the appropriate use of antibiotics, and outpatient dispensing before and after guidelines at all pharmacies were evaluated. The pharmacists were given guidelines on antibiotic use and duration needed for common bacterial infections encountered. Controls were not given guidelines. At baseline and post-intervention (1 week), pill counts were performed of the top six antibiotics that were dispensed by the pharmacist. Pharmacists were requested to keep a log of how many antibiotics were dispensed for one week. The pharmacists also were requested to fill out a post-intervention educational assessment to evaluate retention.

Results

Pill count pre-intervention was 15,856 and 1512 and post-intervention was 11,168 and 1,440 in the intervention and control groups respectively (Table 1). A post-intervention educational assessment revealed that both the intervention and control groups believed antibiotics can treat viruses (57% vs. 50%) and that antibiotics do not kill good bacteria that protect the body from infection (57% vs. 50%) (Table 2).

Conclusion

There was no difference in the dispensing of antibiotics between pre- and post-intervention. The findings of this study show significant room for improvement in continuing education about antibiotic use in outpatient pharmacies. Further studies are needed to target outpatient antibiotic dispensing with education and identifying economic or other incentives in hopes of reducing the burden of AMR in low- and middle-income countries.

Disclosures

All authors: No reported disclosures.
2037. A Novel Strategy of Antimicrobial Stewardship in Shanghai: Preliminary Practice with Integration of Three Surveillance Networks
Authors: Wang Minggui , Hu Fupin , Hu Bijie , Lv Qianzhou , Wu Wenhui
Published: October 2019

Background

The bacterial resistance surveillance networks, antimicrobial clinical use surveillance networks and provincial hospital-acquired infection (HAI) surveillance have been well established in China. They aim to inform the current situation of bacterial resistance, antimicrobial use and HAI, and to guide the rational use of antimicrobials. However, these three networks presently are running separately. To increase the data value in antimicrobial stewardship (AMS)practice, those three surveillance networks are integrated in Shanghai

Methods

The Committee of Rational Use of Antimicrobials and AMS of Shanghai Municipal Health Commission, consisting of health administrators, clinical physicians and microbiologists, clinical pharmacologists and infection control experts, was formed in 2017. The oversight committee developed a comprehensive AMS score index mainly based on the surveillance data of the three networks to evaluate the AMS requirements in the hospitals. The AMS score index consists of 3 surveillance network indexes: resistance weight index; antimicrobial weight index and HAI weight index; each of the indexes is further divided into two parts, namely the surveillance quality score and data-related score. For example, the data-related score in the resistance index is calculated for the prevalence of 6 most important MDR/XDR bacteria (CRKP, CRAB, CRPA, ESBL, MRSA, VRE). A multi-disciplinary AMS team was convened to provide expert on-site visit of the hospitals and offered AMS support in the form of practical guidance and advice.

Results

AMS score and detailed score such as the prevalence of CRKP were ranked among 50 hospitals within the networks. These scores will support the AMS team to find out the main drivers of resistance/antibiotic use and thereby support appropriate interventions during the on-site visit. For example, a hospital visited which had a high consumption of carbapenems (ranked third in Shanghai) and also had a high percentage of carbapenems used in the department of liver transplantation. The advice of the on-site visit team was to encourage a more diverse group of antibiotics so as to spare carbapenems.

Conclusion

Involvement of the multi-disciplinary team and integration of surveillance networks are very helpful in AMS practice.

Disclosures

All authors: No reported disclosures.
2040. Evaluation of Inpatient Antimicrobial Prescribing Practices in Cochabamba, Bolivia
Authors: Campion Maureen G , Castro Rosario , Saavedra Borda Rocio , Wessolossky Mireya
Published: October 2019

Background

Many developed nations have made antimicrobial stewardship a priority, creating benchmarks and national standards. Little has been published on the antimicrobial use and stewardship efforts in resource-limited countries due to difficulties collecting data. Viedma Hospital (VH) is a 200-bed hospital in Cochabamba, Bolivia, with no formulized antimicrobial stewardship (AMS) program. To better understand the antibiotic (ABX) use at VH, a point prevalence study was conducted in partnership with UMass Medical School. Point prevalence studies comprehensively review patients prescribed antibiotics using standard criteria in the hospital at a specific point-in-time. Using prevalence studies, areas of opportunity can be identified to focus on limited AMS efforts.

Methods

This was an observational study completed through a 2-day chart review. Patients were included if they were greater than 16 y/o, admitted to the general medicine, surgical or intensive care floors at VH and receiving systemic ABXs at the time of review. Data were collected on location, clinical service, day of hospitalization, sex, age, fever, white blood cell count, immunocompromised status, ABXs prescribed including dose, duration and frequency, the indication for each ABX and microbiology results.

Results

161 patients were admitted to the hospital during the point prevalence study, of which 85 (52.7%) were prescribed ABXs. Most ABXs were empiric (83%) and frequent indications included intra-abdominal infections (21.3%) and cellulitis (14.5%). Based upon evaluation utilizing standard criteria, 60% of ABXs were considered unnecessary, inappropriate or suboptimal. Common reasons for unnecessary ABXs was the excessive length of antimicrobial therapy (14%), inappropriate dosing of ABXs (8.5%) and no documented infection (51%).

Conclusion

There is limited data discussing ABX utilization in Bolivia, despite continued use and growing resistance. The point prevalence review identified areas of inappropriate use. This evidence will be utilized to focus AMS efforts on the creation of empiric ABX selection, dose and duration recommendations for common indications.

Disclosures

All authors: No reported disclosures.
2042. Impact of an Antimicrobial Stewardship Program on the Healthcare-Associated Infections in a Third-Level Hospital in Yucatán, México
Authors: Torres Erazo Darwin Stalin , Judith Nuñez Caamal Nelda , Berenice Carrillo Basulto Milagros , Cicero Ancona Miguel , Armando Cuevas Sosa Luis , Meropenem Escuadron
Published: October 2019

Background

Antimicrobial stewardship programs (ASPs) promote the responsible use of antimicrobials by limiting inappropriate use. This study evaluates the impact of a prospective ASP implementation on the health-care-associated infections (HCAIs) in a third-level hospital in Yucatán, México, after the establishment of an ASP in October 2017.

Methods

This was a prospective, single-center (Hospital de Alta de Especialidad de la Península de Yucatán -HRAEPY-), pre and post-intervention study, designed to analyze the impact of an ASP on health-care-associated infections rate, during January–October 2017 (pre-ASP) and January–October 2018 (post-ASP) by using comparative descriptive statistic of the monthly and annual rate of health-care-associated infections according to hospital network of epidemiological surveillance (RHOVE) in Mexico.

Results

During 2017, RHOVE reported 225 cases of HCAIs equivalent to a rate of 7.46/1,000 days of hospital stay. After ASP in 2018, the RHOVE reported 111 cases of HCAIs, equivalent to a rate of 4.38/1,000 days of hospital stay. This difference represented a reduction of −41.28% of the rate of HCAIs in the HRAEPY (Graphic 1). Antimicrobial susceptibility increased (pre-ASP vs. post-ASP) for 3 Gram-negatives associated with HCAIs at HRAEPY: TMP/SMX for E. coli (49% to 62%), Ciprofloxacino for K. pneumoniae (42% to 51%) and Piperacillin/Tazobactam (62% to 93%); Meropenem (61% to 72%) and Ciprofloxacino (67% to 79%) for P. aeruginosa (Graphic 2).

Conclusion

ASP contributed to reducing the rate of HCAIs in the HRAEPY when it was implemented as an additional measure to the strategies for control of nosocomial infections. Additionally, this ASP caused an increase in the bacterial susceptibility of the most important microorganisms as a cause of infections associated with healthcare in HRAEPY.

Disclosures

All authors: No reported disclosures.
2074. A Successful Acute Respiratory Tract Infection Campaign to Improve Antibiotic Prescribing in Outpatient Clinics and an Emergency Department
Authors: Fatima. de Lima Corvino Daniela , Gauthier Timothy , Virginia Romero Alvarez Maria , Madaras-Kelly Karl , Lichtenberger Paola
Published: October 2019

Background

Acute Respiratory tract infections (ARI) are infections involving the upper respiratory tract. Most ARIs are viral in nature and self-limited in which most of the times antibiotic treatment is unnecessary. A recent VA medication utilization evaluation conducted in 28 medical centers identified high rates of unnecessary antibiotic prescribing for ARI. Based on these analyses the VA National Academic Detailing Service (VANADS) created the ARI campaign, providing materials for VA systems to employ as the seek to improve ARI management. Our project consists of implementation of the ARI Campaign in a South Florida Veteran Affairs HealthCare System (Miami VAHS).

Methods

We utilized VANADS resources for our campaign. Activities included assessing ARI prescribing patterns, garnering stakeholder support, identifying pharmacist and physician champions, providing targeted academic detailing, handing out provider ARI guidance documents (in paper and electronically), disseminating provider-specific feedback with peer comparison, order-set development with advertisement, promoting appropriate coding, and reporting to the Miami VAHS antimicrobial stewardship program (ASP) subcommittee. Campaign activities were initiated in October 2017. The ARI Campaign was selected as the priority item for FY-2019, from our annual ASP risk assessment with a goal of reducing antibiotic prescribing for ARI diagnosis to below 40%. We present the data up to March 2019.

Results

Baseline data from October 2015 through September 2017 revealed an antibiotic was prescribed to 1,651 of 2,843 (58%) encounters in which an ARI diagnosis was made in our system. In the months following ARI Campaign initiation, a decline in antibiotic prescribing for ARI diagnosis was found. In the most recent quarter (January–March 2019), the prescribing rate was 39%. Figure 1 shows system-wide vs. Florida region prescribing rates. Table 1 provides data by major site and for the top 10 priority providers we identified.

Conclusion

Implementation of a multifaceted ARI Campaign at a single-center resulted in a substantial reduction in antibiotic prescriptions. Future work is warranted investigating which activities are most impactful for reducing unnecessary antibiotic prescribing for ARI.

Disclosures

All authors: No reported disclosures.
2077. Fluoroquinolone Usage Reduction in the Outpatient Setting
Authors: Lin Kevin , Zahlanie Yorgo , Ortwine Jessica , Mang Norman , Wei Wenjing , Prokesch Bonnie C
Published: October 2019

Background

Fluoroquinolones (FQs) are the third most commonly prescribed outpatient antibiotic due to ease of dosing, broad spectrum of activity, and favorable pharmacokinetics. However, since 2016, the Food and Drug Administration (FDA) has released warnings about adverse effects, concluding that risks outweigh benefits especially for uncomplicated sinusitis, bronchitis, and cystitis. In fall 2016, our antimicrobial stewardship team began an initiative to decrease outpatient FQ usage involving provider education, addition of FDA warnings to oral FQ orders in Epic, and suppression of FQ susceptibilities. This evaluated the effectiveness of these initiatives in decreasing inappropriate outpatient FQ usage.

Methods

Retrospective chart review of FQ prescription was performed on all outpatient clinic, emergency department (ED), and urgent care emergency center (UCEC) visits during October 2016, 2017, and 2018. Inappropriate use was defined as an indication for cystitis, bronchitis, or sinusitis without a history of Pseudomonas aeruginosa or other multi-drug-resistant organism, or drug allergies precluding the use of non-FQs.

Results

1,033 outpatient FQ prescriptions were reviewed. Total FQ prescribing decreased 34% from 405 in October 2016 to 267 in October 2018, with the proportion of inappropriate FQ use decreasing from 53% to 34%. Over 90% of the inappropriate FQ use was for cystitis. Inappropriate prescribing for cystitis and sinusitis decreased by 58% and 33%, respectively, but increased for bronchitis by 25%. The outpatient clinics, ED, and UCEC saw declines in the percentage of inappropriate FQ use of 10%, 15% and 22%, respectively, from October 2016 to October 2018. Despite these decreases, rates of inappropriate FQ utilization for the outpatient clinics, ED, and UCEC were 64%, 25%, and 31%, respectively, at the end of the last study period.

Conclusion

A multi-modal FQ stewardship initiative effectively reduced the volume of outpatient FQ utilization and inappropriate FQ usage. Continued efforts to educate providers about the risks of FQ use and implement system-level initiatives are likely necessary to improve the rates of appropriate use and sustain the effects demonstrated in this study, especially for primary care providers in the outpatient setting.

Disclosures

All authors: No reported disclosures.
2079. Outpatient Antimicrobial Stewardship Initiative to Reduce Unnecessary Use of Antibiotics in Patients with Upper Respiratory Infections: Findings Shared by a Metropolitan Community Hospital in NYC
Authors: Shah Jilan , Izaguirre-Anariba Dora , Rao Hariprasad , Patel Yash , Zin Win Kyaw , Akande Olawale Samuel , Ward Laurie , Badem Olga
Published: October 2019

Background

Antibiotic-resistant infections are one of the greatest public health issues with more than 2 million infections and 23,000 deaths per year in the United States. Reducing inappropriate antibiotic use is essential to reduce both antibiotic resistance and adverse events. The most important modifiable risk factor for antibiotic resistance is inappropriate prescribing of antibiotics. At least 30% of outpatient antibiotic prescriptions in the United States are unnecessary. We aimed to pilot our outpatient antimicrobial stewardship initiative to track and reduce antibiotic prescriptions among adult patients presenting with common acute respiratory infections in our hospital’s outpatient primary care settings.

Methods

A retrospective and prospective cohort study from October, 2017 to March, 2019. Implemented a robust outpatient antimicrobial stewardship initiative with a dedicated team and data analyst based on CDC core elements for outpatient antimicrobial stewardship and a prior UHF initiative. Data of common respiratory tract infections and the respective rates of antibiotic prescriptions from 3 adult primary care sites were collected from the EHR. Serials of educational interventions were performed between June, 2018 to September, 2018. We disseminated resources from the CDC and DOH like brochures, posters, viral prescription pads, pocket guidelines, grand rounds and electronic lectures for providers and periodic provider feedback reports.

Results

Our findings revealed that the physician compliance rate of antibiotics not prescribed for common respiratory tract infections remarkably improved from 72% to 85% after implementing our interventions (Figure 1). The chi-square test showed 40, and P value is 0.000034 which is less than 0.05. Thus, we are 95% confident that there is a significant association between our interventions and reduction of inappropriate antibiotic use (Figure 2).

Conclusion

Introduction of a robust and multifaceted Outpatient Antimicrobial Stewardship initiative with a dedicated team can substantially decrease outpatient antibiotic prescription rates for respiratory tract infections in metropolitan community hospital-based primary care settings.

Disclosures

All authors: No reported disclosures.
2094. Acceptability of Antibiotic Substitutions for Fluoroquinolones and Third and Fourth-generation Cephalosporins: A Report from the VA-CDC Practice-Based Research Network (PBRN)
Authors: Goetz Matthew B , Hockett Sherlock Stacey , Goedken Cassie , Balkenende Erin C , Evans Charlesnika T , Perencevich Eli , Echevarria Kelly , Reddy Sujan , Neuhauser Melinda M , Reisinger Heather , Suda Katie J
Published: October 2019

Background

Studies suggest fluoroquinolones (FQ), and third (3C) and fourth (4C) generation cephalosporins, agents often used for empiric therapy, place patients at higher risk for C. difficile infection. Substituting alternative antibiotics for empiric therapy might reduce risk. We surveyed inpatient physician (MD) and pharmacist (PharmD) antimicrobial stewardship champions to evaluate their preferred FQ, 3C and 4C substitutions for empiric therapy.

Methods

Semi-structured interviews were conducted with the antimicrobial stewardship MD and the PharmD champion from each of the 15 VA-CDC Practice Based Research Network (PBRN) sites. Interviewees were asked what empiric antibiotics for pneumonia and urinary tract infections would be recommended in local guidelines if all 3C, 4C and FQ were restricted. Respondents could list multiple antibiotics. Templated data collection and analysis were used to assist in rapid analysis of interviews.

Results

Narrow β-lactams were identified as appropriate options for CAP by 8 MD and 9 PharmD (table). Piperacillin/tazobactam was the preferred choice by MDs and PharmDs for HCAP (7 and 12, respectively) and HAP (10 and 12, respectively). For community-onset urinary tract infections (cUTI), numerous alternatives to FQ, 3C and 4C were identified. For hospital-onset (hUTI), piperacillin/tazobactam was most frequently mentioned by MD and PharmDs (7 and 9, respectively). 4 of 5 MDs and 5 of 7 PharmDs who chose 3C for CAP indicated that 3C were preferred over all other choices for CAP, few stewards indicated that 3C were the sole preferred agents for other conditions.

Conclusion

Antimicrobial stewardship MD and PharmD champions were readily able to find FQ substitutions for all indications; 3C and 4C substitutions were found for all indications with a notable exception of treatment of CAP. These results suggest considerable opportunity to reduce use of these antibiotic classes. Future studies should examine the appropriateness and acceptability of the substitutions identified by stewardship champions to providers and the impact of restriction of FQ, 3C and 4C on clinical outcomes.

Disclosures

All authors: No reported disclosures.
2116. Comparative Effectiveness of Amphotericin B, Azoles, and Echinocandins in the Treatment of Candidemia and Invasive Candidiasis: A Systematic Review and Network Meta-Analysis
Authors: Demir Koray K , Butler-Laporte Guillaume , Lee Todd C , Cheng Matthew P
Published: October 2019

Background

Current guidelines recommend the use of echinocandins, amphotericin B or fluconazole for the treatment of invasive candidiasis and candidemia. The objective of our study was to compare these agents through a systematic review of the literature and network meta-analysis of randomized controlled trials.

Methods

Three electronic databases (Medline, PubMed, and the Cochrane Database of Systematic Reviews) were searched from database inception to January 1 2019. Randomized controlled trials that compared triazoles, echinocandins and/or amphotericin B (either in lipid formulation or deoxycholate form) for the treatment of invasive candidiasis or candidemia were included. Among included studies, treatment success was collected as the primary outcome and was assessed by a random effect network meta-analysis using Bayesian estimation methods. A sensitivity analysis was performed for all patients with candidemia.

Results

Eleven randomized controlled trials met the study inclusion criteria. Of the 2,475 patients included from these trials, 684 received an echinocandin, 855 received amphotericin B and 936 received a triazole. Echinocandins were associated with the highest rate of treatment success when compared with amphotericin B (OR 1.40, 95% CI 1.02–1.93) and the triazoles (OR 1.80, 95% CI 1.32–2.51). Similarly, in the pre-specified analysis of candidemic patients, echinocandins were also more effective overall than amphotericin B (OR 1.25, 95% CI 0.84–1.87) and triazoles (OR 1.66, 95% CI 1.16–2.44). Patients treated with triazoles had a lower rate of treatment success than amphotericin B in the overall (OR 0.78, 95% CI 0.60–1.01) and candidemia sensitivity analyses (OR 0.76, 95% CI 0.56–1.01) Rank probability analysis favored echinocandins as the most effective treatment choice 98% of the time.

Conclusion

In our meta-analysis comparing treatment strategies for severe Candida infections, the echinocandins had the highest rate of treatment success compared with both amphotericin B and triazoles. Echinocandins should be considered as first-line agents in the treatment of invasive candidiasis and candidemia. Further research is needed to determine the minimum duration of echinocandin treatment prior to using step-down therapy.

Disclosures

All authors: No reported disclosures.