bluuebunny/crossref_metadata_2025 huggingface dataset:
2425. Correlating Use of High-Risk Antimicrobials and the Incidence of Hospital-Onset Clostridium difficile Infection: Targeting Prescribing Trends for Antimicrobial Stewardship
Authors: Thottacherry Elizabeth , Whitfield Philip L , Steuber Taylor D , Li Chao , Sawyer Adam J , Edwards Jonathan , Hassoun Ali
Published: October 2019

Background

Hospital-onset Clostridium difficile infection (HO-CDI) has a significant morbidity and mortality risk. It also poses increasing financial strain on the healthcare system. Certain antibiotics have been associated with increased HO-CDI incidence and novel strategies are needed to determine what modifiable risk factors exist. Choices of antibiotic have changed overtime time to overcome potential side effects, leading to a possibility that changed prescribing trends could be linked to significant differences in the rate of HO-CDI.

Methods

This study took place at a 971-bed community hospital from January 2016 to January 2018. Monthly utilization (grams) of 11 antimicrobials considered high risk of HO-CDI was collected, along with monthly HO-CDI rate. Antimicrobials included cephalosporins, carbapenems, fluoroquinolones and clindamycin. Correlational (Pearson’s) and logistic regression analyses were completed to identify association with HO-CDI. A P-value of < 0.05 was considered statistically significant.

Results

215 cases of HO-CDI were identified during the study period with 30 being classified as severe. The average HO-CDI rate was 4.3 cases/1000 patient-days. There were no significant correlations identified for any antimicrobials and HO-CDI rate (p> 0.05 for all interactions). Pearson’s correlation coefficients were not significant for any antimicrobial. The multivariable logistic regression model including all antimicrobials, indicated that only ceftazidime had a statistically significant positive effect on the HO-CDI rate. Bearing in mind that only a small number of ceftazidime was prescribed, additional univariate analysis was performed indicating that there was no significant linear association between the HO-CDI rate and ceftazidime utilization (P = 0.3527).

Conclusion

Our study shows that there is no significant correlation between specific antimicrobial use and HO-CDI rates, even though there has been a general increase in HO-CDI rates. Additional analysis involving control groups of antibiotic use in patients without HO-CDI as well as incidence of HO-CDI in patients without antibiotic use at all is required to further assess possible modifiable risk factors in the inpatient population.

Disclosures

All authors: No reported disclosures.
139. The Morbidity and Financial Burden of Infective Endocarditis in Persons Who Inject Drugs in the Deep South
Authors: deMontigny Danielle , Lee Rachael A , Radney Joshua , Eaton Ellen
Published: October 2019

Background

In the context of the opioid epidemic, infective endocarditis (IE) poses an economic challenge in Alabama. The objective of this proposal is to analyze the outcomes and financial burden of IE in persons who inject drugs (PWID) at The University of Alabama at Birmingham (UAB) Hospital, the largest tertiary referral center in this rural, Southern state. We hypothesized that those with the most severe substance use disorder would be most costly.

Methods

This is a retrospective study of PWID receiving care for IE at UAB Hospital from October 1, 2016 to March 1, 2019. IE was defined by Infectious Diseases consultation. Clinical data were obtained from the electronic medical record (EMR). Deaths were obtained from both the EMR and the regional medical examiner. Hospital costs (direct costs, overall charges) were obtained from financial accounts. To stratify patients by severity of substance use disorder, we used a 9-item risk assessment for PWID (see table). We then evaluated the association between clinical factors and outcomes (death, cost) using parametric and nonparametric tests when appropriate. A P-value < 0.05 was considered significant.

Results

A total of 69 persons met criteria (Table 1). The average length of stay was 30.8 days. Thirty-four (52%) had documentation of antibiotic completion (in or outpatient). Seventeen received surgery: 16 with valve replacement and one device removal. Overall, 14 (20%) died over the study period. There was no significant association between antibiotic completion or 9-item risk and death. When stratified into low risk (<4 items) vs. high risk (≥5), there was no difference in overall direct costs, LOS, or whether patients received surgery.

Conclusion

PWID with IE at a hospital serving a rural, Southern population have a greater length of stay, discharges against advice, surgical interventions, and costs than other regions, relative to existing literature. The lack of association between 9-item risk and outcomes suggests that death and high costs are attributable to factors beyond substance use. Costs of providing care for this population are exorbitant and likely devastating for rural county hospitals within the context of the current public health and payment framework, including Medicaid non-expansion.

Disclosures

All authors: No reported disclosures.
141. Use of Rapid Diagnostic Testing in Gram-negative Bloodstream Infections with and without Antimicrobial Stewardship
Authors: Claeys Kimberly C , Heil Emily , Loughry Nora , Chainani Sanjay , Kristie Johnson J , Leekha Surbhi
Published: October 2019

Background

Verigene Blood Culture Gram-Negative (VBC-GN) is a rapid diagnostic test (RDT) that can detect key GNs and resistance within hours from Gram-stain. Numerous studies have shown that RDTs in BSIs improve clinical outcomes, particularly with active antimicrobial stewardship (AMS) intervention. Little is known regarding outcomes in GN BSI without vs. with AMS intervention.

Methods

A retrospective three-part quasi-experimental study of adult patients with GN BSI from December 2014 to April 2018. VBC-GN was introduced September 2015 and AMS review was implemented October 2017. Antibiotics were appropriate if active in vitro against isolated GN. Optimal antibiotics were not overly broad, accounted for resistance, source of infection, and other infecting organisms. Comparisons were made using Chi-squared for nominal variables and Kaplan–Meier with log-rank for time to event analysis.

Results

In total, 772 patients met inclusion. The most common source was urinary (30.1%) and E. coli was the most common GN (37.9%). Infectious Disease consults increased with each group (50.6% vs. 67.9% vs. 81.8%, P < 0.001). More patients pre-RDT (37.36%) and RDT+AMS (35.6%) compared with RDT only (24.6%) were critically ill, P = 0.001. Optimal therapy was achieved in more patients in RDT-only (79%) and RDT+AMS (86%) groups compared with pre-RDT (66%), P < 0.001. More patients in the pre-RDT group (44.7%) were appropriately de-escalated compared with RDT only (31.6%) and RDT + AMS (38.7%), P = 0.026. Appropriate escalation occurred most often in the RDT-only group (39.3%) vs. pre-RDT (15.2%) and RDT + AMS (14.2%), P = 0.019. Median post-BSI length of stay (8.2 vs. 7.1 vs. 8.5 days, P = 0.226) and inpatient mortality (10.8% vs. 14.3% vs. 11.4%, P = 0.493) were similar.

Conclusion

With the implementation of VBC-GN RDT there was a significantly decreased time to optimal therapy, mainly based on necessary antibiotic escalation. Antibiotic de-escalation remained a challenge, even with active AMS review.

Disclosures

All authors: No reported disclosures.
2490. Longer-Term Safety and Efficacy of Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Alafenamide in Virologically Suppressed Adults Living With HIV and End-Stage Renal Disease on Chronic Hemodialysis
Authors: Eron Joseph J , Lelievre Jean-Daniel , Kalayjian Robert , Slim Jihad , Wurapa Anson K , Stephens Jeffrey L , McDonald Cheryl , Cua Eric , Wilkin Arjun , McKellar Mehri , Cox Stephanie , Majeed Sophia , Blair Christiana , Carter Christoph C , SenGupta Devi , Brainard Diana M , Das Moupali
Published: October 2019

Background

HIV treatment for individuals with end-stage renal disease (ESRD) on hemodialysis (HD) has previously required complex dose-adjusted regimens. We evaluated the safety and efficacy of single-tablet, once-daily elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) in people living with HIV (PLH) and ESRD on chronic HD.

Methods

Virologically suppressed adult PLH with ESRD on chronic HD for ≥ 6 months were switched to open-label E/C/F/TAF 150/150/200/10 mg once daily for 96 weeks. Efficacy was assessed as the proportion of participants who maintained virologic suppression (HIV RNA < 50 copies/mL) using the snapshot algorithm. Safety and participant satisfaction were assessed throughout the study.

Results

We enrolled 55 participants with median age 51 years (range 23–64) with median time on HD 6 years (range 1–17). In the per protocol analysis set, virologic suppression was maintained in 30 of 31 participants (96.8%, 95% CI [83.3%, 99.9%]) at week 96. In the full analysis set, virologic suppression was maintained in 30 of 55 participants (54.5%; 95% CI [40.6%, 68.0%]); one discontinued therapy due to lack of efficacy, and W96 data were unavailable for 24. Of the 24 participants lacking W96 data, 17 discontinued study drug early and 7 had missing data while on study drug; all had HIV RNA < 50 copies/mL at the last pre-week 96 check. Treatment-emergent AEs occurred in 53 (96.4%) participants, and study-drug-related AEs occurred in 7 (12.7%). Treatment-emergent AEs leading to premature study drug discontinuation occurred in 4 (7.3%) participants; two were considered study-drug-related (allergic pruritus and peripheral neuropathy in one participant each). No study-drug-related serious AEs were observed. 85.7% (30/35) of responding participants reported they were ‘much more satisfied’ with their regimen.

Conclusion

Single-tablet, once-daily E/C/F/TAF was effective in maintaining virologic suppression in PLH on chronic HD over 96 weeks of follow-up. E/C/F/TAF was well tolerated and was associated with improved participant satisfaction. These data demonstrate that E/C/F/TAF is a safe and effective alternative to more complicated regimens in PLH on chronic HD, with the potential to improve patient satisfaction and quality of life.

Disclosures

All authors: No reported disclosures.
2492. Differences between Individuals Currently Taking Integrase Inhibitor (INSTI)-based Therapy and Those Not Taking INSTIs in the Era of INSTIs as Recommended First-line Therapy
Authors: Monroe Anne K , Levy Matthew E , Greenberg Alan E , Moore Richard , Keruly Jeanne , Horberg Michael A , Mohanraj Bernadine , Kumar Princy , Castel Amanda
Published: October 2019

Background

Agents from the integrase inhibitor (INSTI) therapeutic class only are recommended as initial therapy for most patients with HIV. Clinicians now face a decision when treating ART-experienced patients on non-INSTI regimens: continue current therapy or switch to INSTI. Multiple factors may be considered in this decision: clinician/patient preference, comorbidities, tolerability, and resistance history. The objective of this analysis was to examine patient factors associated with currently taking an INSTI-based regimen.

Methods

We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants in the sample had ≥ 1 encounter between 4/1/17 and 3/1/18, were aged ≥ 18 years and were ART experienced. Participants were classified as currently, previously, or never on an INSTI. Independent variables included demographics, clinical characteristics, alcohol/tobacco use, HBV/HCV status and HIV-related variables (recent CD4 and HIV RNA, presence of resistance mutations). Multivariable multinomial logistic regression was used to identify factors associated with INSTI use status.

Results

Among 4584 participants (58.2% aged 50+ years; 69.4% male; 2.5% transgender; 80.3% Black; 36% MSM), most (65.0%) were current INSTI users; however, a sizeable proportion (28.3%) were never users and 6.7% were former users. Current and previous INSTI users were more likely to have a major NRTI, NNRTI or PI mutation compared with never users (see Table 1). Transgender participants (compared with males), were less likely to be current (vs. never) users (adjusted odds ratio (aOR) 0.48, 95% CI 0.32, 0.72). Younger participants (18–24 vs 50+ years) were more likely current users (aOR 1.90, 95% CI 1.18, 3.06), as were Hispanic participants (aOR 1.39, 95% CI 1.05, 1.84).

Conclusion

The majority of active DC Cohort participants were using INSTI-based therapy. Transgender and older individuals were less likely to be on INSTIs, indicating that they are more likely to be on PI-based or NNRTI-based therapy or not on therapy. Further research should explore whether this is detrimental for long-term HIV outcomes in these patient groups. Additionally, these results suggest resistance history as an important driver of INSTI prescription.

Disclosures

All authors: No reported disclosures.
2498. Perceptions of Injectable Antiretrovirals in an Urban HIV Clinic
Authors: Koren David E , Fedkiv Volodymyra , Zhao Huaqing , Bettiker Robert , Tedaldi Ellen , Samuel Rafik
Published: October 2019

Background

Although new injectable antiretrovirals (ARV) for HIV may soon be available, there is little research on patient preferences. We examined perceptions of injectable ARV among persons living with HIV (PLWH).

Methods

This cross-sectional study was conducted among PLWH presenting for an appointment at TempleHealth in Philadelphia, PA between March 11 and April 18, 2019. Respondents completed a self-administered survey comprising 29 questions about socio-demographic data, current ARV, and preferences regarding injectable ARV therapies. Responses were recorded on a 10-point Likert scale, on which responses in the 1–5 range were defined as unlikely and 6–10 range as likely to choose injectable ARV. The primary endpoint was to describe factors associated with likely vs. unlikely uptake of injectable ARV. Responses between groups were compared with Chi-square or Wilcoxon rank-sum tests.

Results

171 patients completed a survey with a 56% response rate. Demographics were 60% male, 70% African American, 33% LGBQ-identifying, 2% transgender, with a mean age of 48 ± 13 years. Percentages of likely uptake (55%, n = 94) and unlikely uptake (45%, n = 77) were similar. Median likelihood was 7 (IQR 7–10) and varied from likely (10, IQR 8–10) and unlikely (1, IQR 1–5) cohorts. There were no differences in overall likelihood based on current number of pills or pill frequency (P > 0.05). A likelihood trend was found among patients who missed one or more doses per week, however current adherence was not significant (p = 0.06). Likelihood of uptake means increased as the frequency of administration decreased: 1-week (5.7 ± 3.7), 2-week (5.9 ± 3.7), 1-month (7.3 ± 3.5), 2-month (7.3 ± 3.6), and 3-month (7.7 ± 3.4). Likelihood of uptake decreased as duration of a potential injection site reaction increased: 1 day (6.2 ± 3.5), 2–3 days (4.6 ± 3.3), 4–6 days (3.6 ± 3.1), 7 days or longer (3.0 ± 3.2). Respondents preferred their doctor’s office (60%) over self-injection (23%), assisted injection at home (11%), pharmacy (4%), or special injection center (2%) for administration setting.

Conclusion

Our study indicates that availability of injectable administration has potential to find acceptance among PLWH.

Disclosures

All authors: No reported disclosures.
2511. Characterization of Patient Pill Preferences from a Prospective Placebo vs. Placebo Ease of Swallowability Study
Authors: Osborn Zachary F , Acosta Tommy J Parraga , Lee Jean C , McNicholl Ian , McKinnon John E
Published: October 2019

Background

HIV therapy has been moving toward smaller size, once a day regimens in hopes of improved adherence. Surprisingly, few publications characterize HIV patient’s pill preferences. To evaluate HIV-negative or treatment-naïve pill preference, we conducted a prospective randomized study at the Infectious Diseases Clinic at Henry Ford Hospital in Detroit, MI.

Methods

Fifty patients were recruited, receiving questionnaires regarding factors influencing the ease of swallowability, medication habits, pill preferences and adherence while being randomized to receive placebo pills representing currently FDA approved combination antiretrovirals DTG/ABC/3TC and BIC/FTC/TAF. Statistical analyses presented are descriptive.

Results

Patients preferred pills or tablets (84%) as their preferred form of medication. Patient’s ideal pill length size was reported between 4–9 millimeters (96%), with no responses > 13 mm. The most important factors for ease of swallowability were stated as size (40%) and smoothness (38%). Interestingly, 80% of participants then reported that size and shape of the pills was only “some or less” important to them for their pills; however, 32% of participants stated that size, and shape (16%), could make them not want to take a pill daily. When offered the choice of regimens, patients preferred taking more, smaller pills (42%) vs. fewer larger pills (36%) or liquids (14%). Three most common factors indicated as making medication adherence difficult included taking multiple doses daily (38%), large pills (16%), and multiple pills per dose (14%). When given free response, pills having a smooth coating was reinforced by 10 of the 25 (40%) participants who commented.

Conclusion

Patient preferences for medications are varied and nuanced, but carry implications on patients self-reported likelihood to remain adherent to a regimen. Care should be taken in a clinical setting, such as HIV, to take pill characteristics into account when selecting antiretroviral regimens for patients.

Disclosures

All authors: No reported disclosures.
2514. Real-time Antiretroviral Electronic Adherence Monitoring In Young African American Men Who Have Sex With Men
Authors: Dworkin Mark S , Panchal Palak , Jimenez Antonio , Garofalo Robert , Haberer Jessica , Wiebel Wayne
Published: October 2019

Background

Antiretroviral therapy adherence remains a challenge, particularly for young African American men who have sex with men (YAAMSM). We enrolled 40 YAAMSM for 3 months of electronic adherence monitoring (EAM). These data may be useful in developing an antiretroviral EAM intervention that responds to missed doses with real-time text messages.

Methods

YAAMSM (age 18–34 years) living with HIV and taking ART participated in a quantitative and qualitative study that included ART adherence monitoring with a Wisepill electronic monitoring device for up to 3 months. Interviews were performed during April 2017–April 2019 at baseline and follow-up. Monitoring data were reviewed to determine timing and patterns of missing their first true adjudicated miss for durations of 1 dose, 3 consecutive days, and 7 consecutive days. Follow-up qualitative interviews included exploring acceptability of monitoring.

Results

The median age was 28 years and median participant observation time was 90 days (interquartile range 88–90 days) (n = 40 participants). Among those with at least 2 weeks follow-up and adjudication (n = 32), 100% missed at least 1 day. Most (82%) of these participants were <80% adherent in at least one of their monitored months. One dose and 3-day misses did not cluster (e.g., no disproportion on weekends). Most (88%) first missed doses occurred during the first 9 days monitored and most (69%) of the 13 who missed 3 consecutive days missed within the first monitored month. Four participants missed 7 consecutive days. Among 31 with a follow-up interview, 28 (90%) felt receiving a text because of device monitoring would affect their medication taking in the future. Illustrative quotes included, “It made me more responsible” and “…it makes you want to do it right.”

Conclusion

Most YAAMSM living with HIV in this study had adherence below the target threshold of >80%. These data support development of a text message responsive real-time electronic adherence monitoring intervention approach.

Disclosures

All authors: No reported disclosures.
145. Liver Steatosis as a Risk Factor for Invasive Group B Streptococcus Infection in Non-Pregnant Adults
Authors: Papic Neven , Gjurasin Branimir , Vince Adriana
Published: October 2019

Background

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease associated with metabolic syndrome and systemic changes in immune response. However, the impact of NAFLD on bacterial infections is unknown. Group B Streptococcus (GBS) infection is a significant cause of invasive disease among adult non-pregnant patients with high mortality rates, associated with diabetes mellitus and obesity as the most common underlying conditions. The aim of this study was to analyze the association of liver steatosis with invasive GBS disease outcomes.

Methods

A retrospective, cohort study of all non-pregnant adult patients diagnosed with invasive GBS infection (GBS isolated from the normally sterile site) was conducted at the University Hospital for Infectious Diseases Zagreb during a 14-year period.

Results

Of the 127 patients with invasive GBS, 90 had complete data and were included in the study. Disease primarily presented as bacteremia without focus (34; 37.8%), cellulitis/erysipelas (27; 30.0%), pneumonia (11; 12.2%) and endocarditis (8; 8.9%). The most common co-morbidities were diabetes (36; 40.0%), dyslipidemia (35; 38.9%), cardiovascular (32; 35.6%), peripheral vascular disease (18; 20.0%) and malignancy (16; 17.8%). Based upon the results of abdominal US the patients were divided into two groups: with steatosis (39; 43.3%) and without steatosis (51; 56.6%). The patients with liver steatosis were younger (63 ± 13 vs. 71 ± 14 years, P = 0.01), had higher AST (45.0; IQR 30–71 vs. 28.5; IQR 20–71, P = 0.047) and ALT (38; 25.5–55.5 vs. 21.5; 14–40, P = 0.009). There were no differences in clinical presentation and comorbidities between groups. The in-hospital mortality was 43.5% in patients with steatosis (17/39) and 17.6% (9/51) in control group (P = 0.009). Logistic regression analysis showed that endocarditis (OR 200.8; 95% CI 11.5–3512.5), primary bacteremia (6.5; 1.7–25.0), qSOFA ≥2 (20.2; 4.2–97.6) and liver steatosis (8.4; 2.0–35.1) were associated with in-hospital mortality.

Conclusion

Our findings showed that invasive GBS disease has significant mortality, which is independently associated with liver steatosis.

Disclosures

All authors: No reported disclosures.
146. Infective Endocarditis in South Korea: a 12-year Single-Center Experience of 419 Patients
Authors: Ho Kim Jung , Jae Lee Hi , Ji Lee Woon , Seong Hye , young Ahn Jin , Jin Jeong Su , Su Ku Nam , Hyun Lee Seung , Yong Choi Jun , Yeom Joon-Sup , Goo Song Young
Published: October 2019

Background

Infective endocarditis (IE) is a potentially lethal disease that has undergone constant changes in epidemiology and pathogen. Treatment of IE has become more complex with today’s myriad healthcare-associated factors as well as regional differences in causative organisms. Therefore, it is necessary to investigate the overall trends, microbiological features, clinical characteristics and outcomes of IE in South Korea.

Methods

We performed a retrospective cohort study of patients with the diagnosis of probable or definite IE according to the modified Duke Criteria admitted to a tertiary care center in South Korea between November 2005 and August 2017. Poisson log-linear regression was used to estimate time trends of IE incidence rate and mortality rate. Risk factors for in-hospital mortality were evaluated by multivariate logistic regression analysis including an interaction term.

Results

There were 419 IE patients (275 male vs. 144 female) during the study period. The median age of the patients was 56 years. The annual incidence rate of IE of our institution was significantly increased. (RR 1.05; 95% CI, 1.02–1.08; P = 0.006) The mortality rate showed trends toward down, but not statistically significant (P = 0.875). IE was related to a prosthetic valve in 15.0% and 21.7% patients developed IE during hospitalization. The mitral valve was the most commonly affected valve (61.3%). Causative microorganisms were identified in 309 patients (73.7%) and included streptococci (34.6%), followed by Staphylococcus aureus (15.8%) and enterococci (7.9%). The in-hospital mortality rate was 14.6%. Logistic regression analysis found aortic valve endocarditis (OR 3.18; P = 0.001), IE caused by staphylococcus aureus (OR 2.32; P = 0.026), a presence of central nervous system embolic complication (OR 1.98; P = 0.031), a high SOFA score (OR 1.22; P = 0.023) and a high Charlson’s comorbidity index (OR 1.11; P = 0.019) as predictors of in-hospital mortality. On the other hand, surgical intervention for IE was found to be a protective factor against mortality. (OR 0.25, P < 0.001)

Conclusion

Although IE has been increasing, the mortality rate has not yet reduced significantly. Studies on causative organisms of IE and risk factors for mortality are warranted in improving prognosis.

Disclosures

All authors: No reported disclosures.
2533. HIV Training Pathways in Residency: A National Survey of Curricula and Outcomes
Authors: Budak Jehan , Sears David , Wood Brian , Dhanireddy Shireesha , Dhanireddy Shireesha , Teherani Arianne , Schwartz Brian , Schwartz Brian
Published: October 2019

Background

Despite dramatic advances in the care of people with HIV (PWH), the shortage of HIV providers is worsening. An approach to this workforce shortage has been integration of robust HIV training into residency. We created a national survey to describe curricula and outcomes of formal HIV training pathways and how this may impact the HIV workforce shortage.

Methods

We designed a cross-sectional study of Internal Medicine (IM) and Family Medicine (FM) Residency HIV pathways in the United States. We identified programs via literature review, internet search, and snowball sampling. A draft survey was piloted with two pathway directors, and in January 2019, the final survey was sent via email to all pathway directors. This survey included 33-items, predominantly quantitative, and focused on program organization, curricular content, graduate outcomes, and challenges. We used descriptive statistics to summarize numeric responses.

Results

Twenty-five residency programs with dedicated HIV pathways were identified; 11 IM and 15 FM. The majority of the programs are in the West and Northeast United States. Twenty-four (96%) of programs have completed the survey. Since the first program was established in 2006, 228 residents have graduated from HIV pathways in the United States (151 IM, 77 FM). Programs have varying goals, application procedures, clinical requirements, didactic structures, graduation requirements, and assessments of competency. Of graduates, 108 (47%) have American Academy of HIV Medicine (AAHIVM) certification. Ninety-two (42%) of graduates are reported as currently providing primary care to ≥ 20 PWH (the majority in the West and Northeast United States). The most commonly cited reported barrier to graduates finding jobs caring for PWH are lack of job opportunities in their geographic area.

Conclusion

HIV pathways in IM and FM programs are heterogenous in their structure and curricula. Less than 50% of pathway graduates remain in the HIV provider workforce, and the majority of those work in the West and Northeast United States. The impact of these programs might be enhanced by interventions to increase graduate retention in this workforce and to launch pathways in the areas of greatest need, such as the Southern United States.

Disclosures

All authors: No reported disclosures.
2535. The Stairway to Antibiotic Heaven: Evaluating a Scaffolded Video Series on Empiric Antibiotic Selection
Authors: Larnard Jeffrey , Zucker Jason , Gordon Rachel
Published: October 2019

Background

Inappropriate antibiotic use and spread of resistance is a well-known problem. In academic settings, house staff often make initial decisions regarding antibiotic use. Recently, there has been increasing interest in using “whiteboard animations” as a way of delivering educational content. We introduced a supplemental series of short whiteboard animation videos on empiric antibiotic selection during a blended transition to residency course for fourth year medical students. Our aim was to determine whether the videos were an effective learning resource.

Methods

A total of eight whiteboard animation videos on empiric antibiotic selection were created using Camtasia. Learning was scaffolded using a pneumonia case and an antibiotic “ladder” to provide context for the antibiotics discussed. Questions were interspersed throughout the videos. Students completed an eight question pretest and then an eight question post-test after completing the modules. Qualtrics was used to randomly select questions for the pre- and post-tests from a common question bank. After each individual video module, students were also offered a post-module survey with Likert scaled questions evaluating student perception of the module. All tests and surveys were anonymous. Scores of pre- and post-tests were compared with unpaired t-tests.

Results

We received a total of 37 pre-tests and 14 post-tests. The average score on the pre-test was 66% compared with 93% on the post-test (P < 0.0001). We also received seventy-four post-module surveys across the eight videos. When asked whether the particular video module was an effective way to learn about antibiotic coverage, 98% of responses responded “agree” or “strongly agree.” 90% of responses also answered “agree” or “strongly agree” when asked if they were more likely to remember the spectrum of activity of the presented antibiotics after watching the module.

Conclusion

While further studies are needed our results suggest that whiteboard animation videos may be an effective way to teach empiric antibiotic selection to medical students preparing for internship.

Disclosures

All authors: No reported disclosures.
2536. Evaluation of Anticipatory Guidance Provided by Internal Medicine Residents for the Care of Patients with Fever
Authors: Rubio Luis , Abdoler Emily , Schwartz Brian , Schwartz Brian
Published: October 2019

Background

Overnight fever is common in hospitalized patients. Past work has analyzed cross-covering resident practices regarding overnight fever, but little is known about how residents provide anticipatory guidance for overnight fever. We aimed to further our understanding of resident sign-out practices for overnight fever by analyzing the specific content of the guidance they provide and evaluating whether the presence of infection impacts the guidance provided.

Methods

We performed a cross-sectional study of resident sign-outs on an inpatient Internal Medicine service between September 2018 and April 2019 using a data collection tool we developed. Data collected included patient’s primary reason for hospitalization, whether fever was an anticipated problem, whether a differential diagnosis for fever was included, evaluation and management instructions for fever, and any rationale provided for the instructions. We analyzed the data using descriptive statistics and chi-squared analysis.

Results

Among 216 sign-outs reviewed, 38% indicated infection was the primary hospital diagnosis. Fever was an anticipated issue in 169 (78%) of sign-outs (Table 1). Of sign-outs recommending fever evaluation, 79% specified at least one diagnostic test but 34% still utilized a nonspecific phrase such as “full fever work-up” (Table 2). Only 62% of fever sign-outs included antibiotic guidance. In addition, rationales were provided for evaluation or management guidance in only 41% and 61% of sign-outs, respectively (Table 3). Chi-squared analysis did not show a statistically significant association between primary hospital problem and the sign-out including fever anticipatory guidance (P = 0.78), recommending in-person assessment (P = 0.11), or providing antibiotic guidance (P = 0.15).

Conclusion

Fever anticipatory guidance is commonly included in resident-written sign-out regardless of primary hospital problem. Specific evaluation instructions for fever are used more commonly than nonspecific fever work-up terms, but rationales for testing are given uncommonly. Future educational interventions around signing-out and evaluating fever overnight may lead to more effective anticipatory guidance and rationale testing and treatment.

Disclosures

All authors: No reported disclosures.
2538. Directed Educational Intervention and Resident Physician Outpatient Antimicrobial Prescribing
Authors: Andrews Shannon L , Beaudoin Amanda , Rothenberger Meghan , Drekonja Dimitri M
Published: October 2019

Background

Antimicrobial stewardship is the coordinated approach to optimal use of antimicrobials. Directed stewardship may benefit resident physicians and improve outpatient antimicrobial prescribing.

Methods

Internal medicine residents as of July 1, 2017 (n = 37) with continuity clinic at the Minneapolis Veterans Affairs Health Care System were eligible. Antimicrobial prescriptions and number of patient visits per month were extracted from the Computerized Patient Record System. Antimicrobial rate was calculated for 9 baseline months (July 1, 2017–March 31, 2018) and 12 intervention months (April 1, 2018–March 31, 2019). Residents were divided into high and low prescribing groups based on baseline antimicrobial rate. The low prescribing group received one email with links to antimicrobial stewardship resources. The high prescribing group received the same email and one in person meeting with an infectious disease fellow to discuss antimicrobial prescribing.

Results

Prescription and visit data were available for 37 residents. The low and high prescribing interventions were administered to 17/17 (100%) and 12/20 (60%) participants, respectively. Remaining high prescribing participants (8, 40%) graduated and did not complete the intervention. During the intervention period, there were a total of 171 prescriptions and 4,018 visits, for an average antimicrobial rate of 43 prescriptions/1,000 visits compared with baseline rate of 51 (P = 0.09). Antimicrobial rate per month is shown in Figure 1.

Conclusion

An educational intervention did not significantly change antimicrobial prescribing rates in a VA resident clinic. Antimicrobial prescribing rates were much lower than expected, suggesting that weekly continuity clinic may not be an optimal setting for learning how to manage outpatient antimicrobials. Our study was small and conducted at a single site without evaluation of antimicrobial appropriateness. Further studies should explore the optimal setting for residents to gain outpatient antimicrobial prescribing experience.

Disclosures

All authors: No reported disclosures.
2539. Characterization of Infectious Diseases Advanced Pharmacy Practice Experiences at United States Colleges of Pharmacy
Authors: Cho Jonathan C , Kufel Wesley D , Jeffres Meghan N , Chahine Elias
Published: October 2019

Background

Antimicrobial resistance is a public health crisis. Experiential education about the appropriate use of antimicrobials is necessary to prevent the post-antibiotic era. The purpose of this study was to describe the learning experiences during infectious diseases (ID) advanced pharmacy practice experiences (APPEs) offered by ID pharmacy faculty.

Methods

A 18-item, cross-sectional, multi-center, electronic survey was distributed via e-mail to ID pharmacy faculty at 124 schools and colleges of pharmacy in the United States. Programs were identified via the Accreditation Council for Pharmacy Education directory. Data related to student learning experiences, preceptor credentials, and teaching opportunities offered to pharmacy students were collected.

Results

Seventy-two (58%) ID faculty responded to the survey and 64 (89%) offered an ID APPE. Forty-three (67%) preceptors completed a PGY-2 ID pharmacy residency and 17 (27%) completed an ID pharmacy fellowship. ID physicians served as co-preceptors for 52% of rotations but only 34% had other ID pharmacists as co-preceptors. Of the 64 APPEs offered, 45% were at an academic medical center. The majority of students participated in antimicrobial stewardship activities (84%) and ID consults (80%) in adults. Greater than 90% of APPEs included learning experiences related to bone and joint, cardiovascular, central nervous system, Clostridioides difficile, fungal, intra-abdominal, lower respiratory, skin and soft-tissue, and urologic infections. Viral hepatitis (39%), travel medicine (13%), ophthalmologic (39%), parasitic (33%), and rickettsial (31%) infections were less commonly offered. Most students were required to present patient cases (92%), lead topic discussions (91%), present journal clubs (89%), conduct medication use evaluations (56%) and work on research projects (53%).

Conclusion

Pharmacy ID APPEs provide students with a broad range of experiences, particularly in adult populations. Students commonly participated in the management of core infectious syndromes. ID APPEs provide students additional training on the appropriate use of antimicrobials.

Disclosures

All authors: No reported disclosures.
2540. Targeting ID Education for Advanced Practice Providers: A Growing Learning Group in Academic Medical Centers
Authors: Lee Matthew S L , Stead Wendy
Published: October 2019

Background

Advanced Practice Providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs), increasingly provide patient care in inpatient settings at academic medical centers. However, little is known about their medical education. We sought to describe current APP educational experiences at our institution and to implement and evaluate an educational intervention aimed at decreasing inappropriate antimicrobial use for asymptomatic bacteriuria (ASB) amongst this group.

Methods

33 inpatient-based APPs participated in the educational intervention consisting of in-person sessions and an online video reviewing diagnosis and management of ASB. Pre- and post-intervention surveys assessed knowledge before and after the intervention. Surveys also assessed APP’s educational background, opportunities, and barriers.

Results

17 APPs completed the pre-intervention survey. 59% estimated less than 10 hours of antimicrobial education during their training. 88% reported that the majority of their current learning is independent. All APPs reported desiring more educational opportunities. 76% felt current opportunities are designed for medical students or housestaff. Commonly reported barriers included patient care, rounding obligations, and lack of protected time. 8 APPs attended the in-person sessions and there were 21 views of the online video. 10 APPs completed the post-intervention survey. All reported interest in similar sessions in the future. 70% planned to prescribe fewer antimicrobials for ASB; however, the same number also reported “Attending or fellow decision” as the main barrier to decreasing prescriptions. Mean knowledge scores significantly increased after the intervention from 2.5 to 4.125 (P < 0.05).

Conclusion

APPs within an academic medical center have unique educational backgrounds and needs. APPs identified current educational opportunities as student/resident directed and incompatible with their work schedules. More APPs utilized the video session than attended in-person lectures. This intervention improved immediate knowledge acquisition; however, retention and impact on clinical outcomes are still being evaluated.

Disclosures

All authors: No reported disclosures.
2551. Optimizing Rounding Efficiency on the Infectious Diseases Inpatient Service: A Multi-Generational Conversation
Authors: Clark Eva , Kulkarni Prathit A , Mohajer Mayar Al , Rose Stacey , Serpa Jose , Singhal Geeta , Giordano Thomas
Published: October 2019

Background

To optimize faculty and trainee wellness without compromising patient care and trainee education, it is important to develop efficient team rounding strategies. This quality improvement project describes rounding practices and suggestions for optimizing rounding efficiency on Infectious Diseases (ID) inpatient consult services at a large academic institution.

Methods

An anonymous survey on rounding strategies was distributed to the ID Section at Baylor College of Medicine in February 2019 as part of a facilitated discussion on optimizing clinical education for fellows.

Results

Twenty-seven members of the ID section completed the survey (17 faculty, 10 fellows). Fellows reported rounding for a median of 4 hours per day (range 3–5), while faculty reported 4.5 hours (range 2–5.5). When asked what time fellows should start their workday, the median response was 7:30 am from both fellows (range 6:30–8 am) and faculty (range 7–8 am). When asked what time fellows should end their work day, the median response was 5:30 pm from both fellows (range 5–6 pm) and faculty (range 5–7 pm). Fellows reported signing their last note at 5:30 pm (range 5–9 pm), vs. 9 pm for faculty (range 6–11 pm). Regarding rounding method, most respondents (100% of fellows and 77% of faculty) preferred a combination of traditional rounding at patient bedside and “table” rounds. Regarding teaching method, most faculty (64%) preferred bedside teaching, while most fellows (60%) preferred teaching presentations in the work room (P = 0.011, Fisher’s exact). Both fellows and faculty had many suggestions for optimizing rounding efficiency; the most common was to avoid having fellows see all patients twice daily (“double rounding,” suggested by 80% of fellows and 30% of faculty).

Conclusion

Overall, the reported behaviors of fellows regarding the structure of their days on inpatient ID services coincided with faculty expectations, although preferences differed between fellows and faculty regarding teaching methods. Avoiding “double rounding” was the most common suggestion to optimize efficiency. Larger studies are needed to better understand rounding behavior and strategies that will optimize the efficiency and effectiveness of inpatient ID consult teams.

Disclosures

All authors: No reported disclosures.
148. Retrospective Evaluation of Acute Cholangitis and Clinical Implication and Management of Secondary Bacteremia
Authors: Hamdi Ahmed , Yetmar Zachary A , Miller Alexander T , Diaz Mark , Fida Madiha , Beam Elena
Published: October 2019

Background

Optimum duration of antimicrobial therapy for acute bacteremic cholangitis is not well established; however, 4–7 days is recommended by the 2018 Tokyo guidelines in those without Gram-positive bacteremia.

Methods

A retrospective study performed at Mayo Clinic - Rochester, Florida and Arizona sites was conducted, reviewing all adult patients with the first episode of acute cholangitis secondary to biliary stone obstruction, between January 1, 2012 and December 31, 2017. We reviewed the duration of prescribed antimicrobials.

Results

Among 331 included cases, 197(60%) were men, 66 (20%) were immuno-compromised. Presenting symptoms included fever in 202 (61.5%), abdominal pain in 289 (87%), jaundice 128(38.7%), and altered mentation in 49 (15%). Among these, 256 (77%) were classified as “definite” and 38 (11.5%) were “suspected” using the 2018 Tokyo guideline classification. Cholangitis grade was grade III in 134 (40.5%); grade II in 115 (34.7%); and grade I in 82 (24.8%). Majority of cases, 321 (97%), underwent source control—most commonly 309 (96%) achieved by endoscopic retrograde cholangiopancreatography (ERCP). Source control occurred within 24 hr of presentation in 197 (61.4%) of the cases. Bacteremia was documented in 131/277 (47%). Majority of bacteremias were due to Gram-negative organisms in 119 (91%). Mean duration of antibiotic therapy following “source control” was 9.6 days (SD 7.0). Cases with bacteremia, resulted in longer treatment duration, mean of 13 days (SD 5.6), regardless of the isolated organism. Overall 30 day mortality was 14/331 (4.2%). No mortality difference was noted in patients who underwent early (within 12 hours) vs. later source control (4.55% Vs. 4.53%), nor in those who received more or less than 6 days of antibiotic therapy after source control (4.7% Vs. 3.9%, P = 0.76). No difference in mortality was observed in those with or without bacteremia.

Conclusion

Our results note the use of longer courses of antimicrobials for management of bacteremic cholangitis, regardless of the organism type. This population could be a prime target for an antimicrobial stewardship intervention, to decrease the duration of prescribed antimicrobials in accordance with recent guidelines.

Disclosures

All authors: No reported disclosures.
2556. Does a Brief Education Intervention Affect Perceptions and Knowledge Regarding HIV Pre-Exposure Prophylaxis Among Medical Trainees?
Authors: Myers Michaela , Weissman Sharon , Tavakoli Abbas , Sanasi-Bhola Kamla
Published: October 2019

Background

HIV Pre-Exposure Prophylaxis (PrEP) has been shown to be 90–92% effective in preventing HIV, but uptake in the South is the lowest in the country. Expanded implementation into clinical practice requires systemic efforts to improve education among providers early in their careers.

Methods

The objectives were to investigate medical trainees’ perceptions, knowledge, and attitudes regarding PrEP and to improve knowledge with a brief interventional education session. Trainees were affiliated with the University Of South Carolina and received a ten-minute, 23-question survey starting June 2018. This was followed by the intervention and then a post intervention survey.

Results

157 trainees (31 residents, 86 medical students and 40 others) responded to survey and attended the intervention. Post intervention survey was completed by 43 trainees. Prior to intervention 83% of trainees (n = 131) had heard about PrEP and 80% (n = 125) knew of PrEP for HIV prevention. Half, mainly medical students and residents, had formal PrEP education as part of their curriculum but only 38% identified the appropriate regimen (n = 60). Trainees’ concerns included non-adherence (n = 96, 61%), side effects (n = 91, 58%), development of resistance (n = 81, 52%) and poor risk reduction practices (n = 55, 35%). 33% (n = 52) felt confident evaluating patient’s eligibility for PrEP and 47% (n = 74) felt comfortable recommending PrEP. Post intervention 91% (n = 39) of trainees who responded identified the appropriate regimen. No statistically significant changes in trainees’ perceptions regarding SE, adherence development of resistance and risk reduction practices were observed. 93% (n = 40) felt confident evaluating patient’s eligibility for PrEP and 98% (n = 42) felt comfortable recommending PrEP (P < 0.0001). 95% (n = 41) felt that the intervention was beneficial and 98% (n = 42) would recommend the education intervention to other trainees.

Conclusion

After a brief intervention medical trainees’ knowledge and comfort with prescribing PrEP improved. Modifications to the intervention are needed to improve perception regarding safety and efficacy. Improving PrEP uptake in the South will need continued formal PrEP education in the curriculum to advance perceptions and knowledge.

Disclosures

All authors: No reported disclosures.