bluuebunny/crossref_metadata_2025 huggingface dataset:
2030. Impact of an Antimicrobial Stewardship Program on Carbapenem Susceptibility in a National Hospital in Bhutan
Authors: Chuki Pem , Bianchini Monica L , Tshering Thupten , Sharma Ragunath , Yangzom Pema , Dema Ugyen , Kenney Rachel , Maki Gina , Zervos Marcus
Published: October 2019

Background

The overuse of broad-spectrum antibiotics drives antimicrobial resistance (AMR), and the prevalence of highly-resistant Gram-negative infections is increasing across the world, especially in low- and middle-income countries (LMIC). Carbapenem resistance is of particular concern since these are often the last line agents. Antimicrobial restriction is an antimicrobial stewardship intervention (AMS) that aims to reduce the use of broad-spectrum antibiotics to preserve antimicrobial susceptibility.

Methods

This is retrospective, observational study of antibiotic consumption and prevalence of antibiotic resistance of bacterial isolates from inpatients at Jigme Dorji Wangchuck National Referral Hospital, a 350-bed multi-specialty hospital in Thimphu, Bhutan. Antibiotic consumption and antimicrobial susceptibility were monitored from January 2015 to December 2017 by the pharmacy department and the microbiology lab, respectively. Antibiotic consumption was measured using defined daily doses (DDD) and expressed as DDDs per 1,000 persons per day. The antibiotic susceptibility was determined using the Clinical Laboratory Standards Institute (CLSI) guideline. A hospital AMS program with multidisciplinary team and good hospital managerial/ leadership support were initiated in 2016 and interventions included antimicrobial restrictions, educations, guidelines for use, post prescription review, de-escalation, audit and feedback.

Results

From 2015 to 2016, the DDDs of carbapenems and piperacillin–tazobactam (PTZ) increased while ceftriaxone decreased (Figure 1). After the AMS program was implemented in 2016, the annual DDDs of carbapenems decreased while PTZ and ceftriaxone increased. Antimicrobial susceptibility of Klebsiella pneumoniae and Escheriachia coli blood isolates to carbapenems and ceftriaxone increased from 2016 to 2017: 50/61 (82%) vs. 45/49 (92%) and 24/91 (26%) vs. 31/92 (34%), respectively.

Conclusion

Implementing an AMS program that restricted the use of carbapenems resulted in a decrease in carbapenem use and increased antimicrobial susceptibility for carbapenems and ceftriaxone. AMS interventions can be successful to decrease carbapenem-resistance in LMIC.
2035. Clinical and Economic Outcomes in Patients with Complicated Urinary Tract Infection (cUTI) and Complicated Intra-Abdominal Infection (cIAI) in Perú: Impact of Gram-Negative Organisms (GNO) Resistant to Antibiotics
Authors: Hercilla Luis , Perez Giancarlo , Illescas Ricardo , Hidalgo Jose , Ramirez Eresvita , Moreno Vanesa , Galdos-Cardenas Gerson , Gutierrez-Rodriguez Raul , Rodriguez Lourdes , Carlos Orengo Juan , Monsanto Homero
Published: October 2019

Background

Delays in appropriate therapy of infections affect clinical outcomes. The aim of this study was to compare the clinical and economic outcomes of patients with cUTI and cIAI due to cephalosporin- and carbapenem-resistant GNOs to similar infections caused by nonresistant GNOs.

Methods

A retrospective cohort study of patients admitted to two tertiary care hospitals in Lima-Callao, Peru between January and December 2017. Patients with resistant strains were compared with those with nonresistant strains for the failure of initial antibiotic regimen (defined as worsened clinical status, change of initial antibiotic treatment, or in-hospital mortality), median length of stay (LOS), hospitalization ward cost and total hospitalization cost.

Results

A sample of 500 consecutive culture-positive patients were included: 429 (86%) with cUTI and 71 (14%) with cIAI (table).

Conclusion

cUTI caused by GNOs resistant to cephalosporins or carbapenems are associated with an incremental clinical and economic burden. The proportion of inappropriate therapy in patients with resistant infections is high. The cost of care for carbapenem-resistant cUTI was highest. The appropriate initial antibiotic choice may minimize the impact of GNO resistance on outcomes of patients with cIAI and cUTI.

Disclosures

All authors: No reported disclosures.
2036. A Quasi-Experimental Survey Study of Antimicrobial Stewardship Education for Registered Nurses
Authors: Santarossa Maressa , Walk Christina , Joyce Cara J , Albarillo Fritzie S
Published: October 2019

Background

Antimicrobial stewardship (AS) efforts have led to improved patient outcomes, reduction in unnecessary costs, and decrease in antimicrobial resistance (AR). Loyola University Medical Center (LUMC) is a quaternary care-system that has a comprehensive multidisciplinary Antimicrobial Stewardship Program (ASP). Registered nurses (RNs) have been shown to be a vital part of ASP; however their role and engagement in ASP should continue to be investigated and explored.

Methods

In February 2018, a voluntary online survey was created and disseminated to all RNs at LUMC to evaluate their baseline knowledge and perception of AS and AR, as well as to further investigate their role in AS at LUMC. Based on the results of the survey, our AS team implemented a multi-faceted education program. This included a series of lectures which were emailed to all RNs, as well as live education sessions by the AS team during nursing huddles. In March 2019, a second survey was distributed to all nurses with the primary goal of evaluating changes in the knowledge and perception of AS and AR after targeted education efforts. The secondary goal was to gather feedback to target further efforts of engaging RNs in AS.

Results

A total of 179 RNs completed the first survey and 117 completed the second survey. In both surveys, over 90% of RNs agree that they play an important role in AS, and that AS can decrease AR and adverse effects of antimicrobials. The majority in both surveys also agreed that AR can be caused by misuse/overuse of antimicrobials and this can be harmful to patients. Unfamiliarity with AS practices among RNs remains an issue, however this increased from 70% strongly agree/agree in the first survey to 74% in the second survey. Sixty-nine percent of RNs recalled reading the PowerPoint education slides, while only 38% recalled being educated in person by the AS team. A similar number of RNs (58% and 60%, respectively) prefer to be educated in person vs. through email.

Conclusion

Hospital-specific surveys on nurses’ perception and knowledge on AS and AR can be used to guide future ASP interventions, as well as to evaluate the effectiveness of these interventions. Our ASP at LUMC implemented strategies to improve nursing education and engagement in AS and evaluated this strategy using a pre-/post-survey.

Disclosures

All authors: No reported disclosures.
2044. An Assessment and Feedback Model Bringing Antimicrobial Stewardship Program Expertise to Long-Term Care Facilities
Authors: Chung Philip , Tyner Kate , Bergman Scott , Micheels Teresa , Rupp Mark E , Schwedhelm Michelle , Tierney Maureen , Van Schooneveld Trevor C , Ashraf M Salman
Published: October 2019

Background

Long-term care facilities (LTCF) often struggle with implementation of antimicrobial stewardship programs (ASP) that meet all CDC core elements (CE). The CDC recommends partnership with infectious diseases (ID)/ASP experts to guide ASP implementation. The Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) is an initiative funded by NE DHHS via a CDC grant to assist healthcare facilities with ASP implementation.

Methods

ASAP performed on-site baseline evaluation of ASP in 5 LTCF (42–293 beds) in the spring of 2017 using a 64-item questionnaire based on CDC CE. After interviewing ASP members, ASAP provided prioritized facility-specific recommendations for ASP implementation. LTCF were periodically contacted in the next 12 months to provide implementation support and evaluate progress. The number of CE met, recommendations implemented, antibiotic starts (AS) and days of therapy (DOT)/1000 resident-days (RD), and incidence of facility-onset Clostridioides difficile infections (FO-CDI) were compared 6 to 12 months before and after on-site visits. Paired t-test and Wilcoxon signed rank test were used for statistical analyses.

Results

Multidisciplinary ASP existed in all 5 facilities at baseline with medical directors (n = 2) or directors of nursing (n = 3) designated as team leads. Median CE implemented increased from 3 at baseline to 6 at the end of follow-up (P = 0.06). No LTCF had all 7 CE at baseline. By the end of one year, 2 facilities implemented all 7 CE with the remaining implementing 6 CE. LTCF not meeting all CE were only deficient in reporting ASP metrics to providers and staff. Among the 38 recommendations provided by ASAP, 82% were partially or fully implemented. Mean AS/1000 RD reduced by 19% from 10.1 at baseline to 8.2 post-intervention (P = 0.37) and DOT/1000 RD decreased by 21% from 91.7 to 72.5 (P = 0.20). The average incidence of FO-CDI decreased by 75% from 0.53 to 0.13 cases/10,000 RD (P = 0.25).

Conclusion

Assessment of LTCF ASP along with feedback for improvement by ID/ASP experts resulted in more programs meeting all 7 CE. Favorable reductions in antimicrobial use and CDI rates were also observed. Moving forward, the availability of these services should be expanded to all LTCFs struggling with ASP implementation.

Disclosures

All authors: No reported disclosures.
2051. Frequency of Inappropriate Antibiotic Prescribing in Nursing Homes
Authors: Kanchagar Chitra , Noble Brie N , Crnich Christopher , McGregor Jessina C , Bearden David T , Furuno Jon P
Published: October 2019

Background

Antibiotics are among the most prescribed medications in nursing homes (NHs). The increasing incidence of multidrug-resistant and C. Difficile infections due to antibiotic overuse has driven the requirement for NHs to establish antibiotic stewardship programs (ASPs). However, estimates of the frequency of inappropriate antibiotic prescribing in NHs have varied considerably between studies. We evaluated the frequency of inappropriate antibiotic prescribing in a multi-state sample of NHs.

Methods

We utilized a retrospective, (20%) random sample of residents of 17 for-profit NHs in Oregon, California, and Nevada who received antibiotics between January 1, 2017 and May 31, 2018. Study NHs ranged in size from 50 to 188 beds and offered services including subacute care, long-term care, ventilator care, and Alzheimer’s/memory care. Data were collected from residents’ electronic medical records. Antibiotic appropriateness was defined using Loeb Minimum Criteria for initiation of antibiotics for residents with indications for lower respiratory tract infection (LRTI), urinary tract infection (UTI) and skin and soft-tissue infection (SSTI). Residents with other types of infections were excluded from the study.

Results

Among 232 antibiotic prescriptions reviewed, 61% (141/232) were initiated in the NH. Of these, 65% were for female residents and 81% were for residents above the age of 65. Nearly 70% (98/141) of antibiotic prescriptions were for an indication of an LRTI, UTI, or SSTI of which 51% (57% of LRTIs, 52% of UTIs, and 35% of SSTIs) did not meet the Loeb Minimum Criteria and were determined to be inappropriate. Among antibiotics that did not meet the Loeb Minimum Criteria, more than half were cephalosporins (40%) or fluoroquinolones (14%) and the median (interquartile range) duration of therapy was 7 (5–10) days.

Conclusion

These data from a multi-state sample of NHs suggest the continued need for improvement in antibiotic prescribing practices and the importance of ASPs in NHs.

Disclosures

All authors: No reported disclosures.
2060. Evaluation of a Pharmacist’s Impact on Antimicrobial Prescribing in an Urgent Care Center
Authors: Fabian Amy , Linnertz Sara , Avery Lisa
Published: October 2019

Background

The urgent care center (UC) setting is an opportunity for pharmacists to promote antimicrobial stewardship (AS). The primary objective is to determine compliance with antibiotic prescribing recommendations for the treatment of urinary tract infections (UTIs), skin and soft-tissue infections (SSTIs), upper respiratory tract infections (URIs), and lower respiratory tract infections (LRTIs) before, during, and after the presence of an AS pharmacist in an UC.

Methods

Single-center, retrospective, observational, pre (December 10, 2018–January 6, 2019), intervention (January 7–February 3, 2019), and post-intervention (February 4–March 3, 2019) study. All non-pregnant, adult patients with a chief complaint consistent with UTI, SSTI, URI, or LRTI were included. Patients transferred to another facility, presented for a follow-up visit, with multiple sites of infection, or treated for a bite, wound, or surgical site infection were excluded. Noncompliance (NC) was a composite endpoint of non-guideline adherent antibiotic prescribing for viral infections, inappropriate empiric selection, duration, and/or dosage. Secondary outcomes include composite outcome components and subgroup analysis of disease states.

Results

A total of 1,930 patients were screened with 439,440, and 430 patients included in the pre, intervention, and post-intervention group. Demographics were similar between groups, except for age (P = 0.001) and influenza diagnoses (P < 0.001). NC decreased from 43.3% to 31.1% (P = 0.0002) pre-intervention to intervention and from 31.1% to 26.5% (P = 0.14) post-intervention. Pre-intervention to intervention resulted in a change in composite outcome components of non-compliant prescribing (18.9% to 13%, P = 0.02), empiric selection (8.7% to 5.9%, P = 0.12), duration (4.1% to 5.9%, P = 0.28), dosage (3.4% to 0.5%, P = 0.001), and multiple components for NC (8.2% to 6.4%, P = 0.3). Reductions in NC were seen for UTI (83.3% to 69.2%, P = 0.26), SSTI (45.7% to 42.9%, P = 1.0), URI (23.5% to 23.2%, P = 1.0), and LRTI (82.1% to 51.6%, P = 0.0004).

Conclusion

An AS pharmacist’s presence in a UC significantly reduced NC to antibiotic prescribing recommendations. The largest impact was in reducing antibiotic treatment of viral infections and optimizing antibiotic dosing.

Disclosures

All authors: No reported disclosures.
2073. Apples and Oranges: Comparing Toolkits to Track Antimicrobial Prescribing in Ambulatory Care Settings
Authors: Kassamali Zahra , Bryson-Cahn Chloe , Bouchard Todd , Min Lee Kyung , G. Lansang Jose Mari , Thomassen Scott , Lynch John B , Lynch John B , May Larissa , Kvak Staci , D’Angeli Marisa A
Published: October 2019

Background

Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one-third of this usage is considered unnecessary. Multiple tools have emerged to evaluate antibiotic prescribing in ambulatory settings. The toolkits, MITIGATE and Choosing Wisely, have been funded by the Centers for Disease Control and Prevention and promoted by the American Board of Internal Medicine, respectively, but use different reporting criteria. Notably, the target rate of antibiotic prescribing in the MITIGATE framework is zero, whereas the target rate for Choosing Wisely is not zero because it includes diagnoses for which an antibiotic may be appropriate. We compared both to evaluate prescribing in primary care and specialty clinics, urgent care, and the emergency department.

Methods

This was a single-center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. The primary outcome was rate of inappropriate antibiotic prescribing overall and in each of the individual settings.

Results

Between March 2018 and April 2019, 42,650 patient visits met MITIGATE inclusion criteria and 11% received an antibiotic unnecessarily. In the same time-period, 23,366 patient visits met Choosing Wisely inclusion criteria and 17% received an antibiotic unnecessarily. Within the MITIGATE framework, inappropriate prescribing was highest in the ED (17%), followed by primary care (12%), urgent care (10%), and specialty care (5%). Choosing Wisely, inappropriate prescribing was highest in primary care (23%), followed by urgent care (15%), and specialty care (8%). The ED was not included in the Choosing Wisely technical specifications. The top coded diagnosis in both frameworks was acute respiratory infection, unspecified.

Conclusion

Rates of inappropriate antibiotic prescribing varied widely depending upon the toolkit used. Inappropriate antibiotic prescribing in primary care by Choosing Wisely framework was double that of MITIGATE. Careful consideration of the differences and goals of using these toolkits is needed both on the local level for individual provider feedback and more broadly, when comparing prescribing rates between institutions.

Disclosures

All authors: No reported disclosures.
2080. Impact of an Emergency Department Post-discharge Blood Culture Follow-up Program
Authors: Vazquez Deida Axel , Salazar Veronica , Lee Lilly , Abbo Lilian
Published: October 2019

Background

Blood cultures are the gold standard in the identification of laboratory confirmed bloodstream infections (LCBI) but contamination can lead to unnecessary interventions. This study sought to assess the number of unwarranted admissions in patients with contaminated blood cultures post-discharge and at low risk for LCBI before and after the implementation of a multidisciplinary emergency department (ED) blood culture follow-up program.

Methods

This was a two-phase retrospective cohort study at a tertiary care, 1,550-bed, academic hospital and level I trauma center in southeast Florida. Phase 1 assessed interventions made on patients 18 years of age or older discharged from the ED or a hospital observation unit with a positive blood culture result post-discharge from March 2018 to July 2018. Phase 2 assessed interventions made from December 2018 to March 2019 post-implementation of the multidisciplinary follow-up program. The criteria for low risk of LCBI were lack of risk factors for infection and < 2 positive blood cultures with a commensal bacteria with no symptoms of fever or hypotension on the date of specimen collection and 3 days before or after such date.

Results

Among patients at low risk for LCBI (46% of 24 patients in phase 1 vs. 59% of 22 patients in phase 2), unwarranted admissions due to contaminated blood cultures occurred in 27.3% of patients in phase 1 vs. 0% of patients in phase 2 (P = 0.08). Phase 1 represented a period in which systematic reporting and evaluation of positive results and patient follow-up were not in place. Phase 2 consisted of daily pharmacist-led blood culture reviews with callback nurse follow-up and therapeutic care plan development with ED physicians. The number of contaminant isolates was relatively high (Figures 1 and 2). Pharmacist-led interventions were diverse (Figure 3). The program led to an estimated total cost avoidance of $16,410.80 in a median of 4.5 months due to unnecessary admissions.

Conclusion

Implementation of a multidisciplinary ED post-discharge blood culture follow-up program can be an effective strategy in improving patient care and avoiding unnecessary antibiotic therapy. Further interventions aimed at reducing blood culture contamination could have a direct impact on improving ED antimicrobial stewardship.

Disclosures

All authors: No reported disclosures.
2081. Low 30-Day Hospital Readmission Rates in Medicare Patients Receiving Outpatient Parenteral Antimicrobial Therapy (OPAT) in Physician Office Infusion Centers
Authors: Luu Quyen , Baker H Barry , Nathan Ramesh V , Hengel Richard L , Emmanuel. Bacon Alfred , Prokesch Richard C , Lo Carson T , Couch Kimberly A , Schroeder Claudia P , Van Anglen Lucinda J
Published: October 2019

Background

The Hospital Readmissions Reduction Program was established under the Affordable Care Act in 2012 to reduce payments to hospitals (hosp) with excess readmissions. Standardized readmission measures include all-cause unplanned readmissions within 30 days of hosp discharge, regardless of initial diagnosis. To avoid penalties, post-acute care, including OPAT, must have a neutral or favorable impact on 30-day hosp readmissions (30-dHR). We assessed 30-dHR for Medicare (MCR) patients receiving OPAT in ID physician office infusion centers (POICs).

Methods

All records of MCR patients were identified that were discharged from hosp to 15 national ID POICs. From those, 200 records were randomly selected and reviewed for unplanned 30-dHR. Additional data extracted were demographics, Charlson comorbidities index (CCI), infection diagnosis, therapy and reasons for readmission. The 30-dHR was compared with national average estimates obtained from the Medical Expenditure Panel Survey (MEPS) database. Multivariate logistic regression was performed with P < 0.05 being statistically significant.

Results

Mean pt age was 73.5 years (range: 65–97) with 56% males. Infections included bone and joint (34%), genitourinary (16%), complicated skin and skin structure (15%), bacteremia (13%), respiratory (10%), intra-abdominal (7%), endocarditis (2.5%), and central nervous system (2.5%) with a mean OPAT duration of 21 ± 18 days. Overall, 30-day HR rate was 11% (n = 22). Median days from initial hosp discharge to readmission was 13 (range 2–28). Reasons for 30-day HR included disease exacerbation unrelated to infection (n = 7, 32%), worsening infection (n = 6, 27%), adverse drug reaction (n = 5, 23%), new infection (n = 3, 14%), and line complication (n = 1, 4%). A logistic regression model (Table 1) indicates that 30-day HR rates reported in MEPS are significantly higher than observed for patients treated with OPAT in POICs after adjustment for age, gender, CCI and initial diagnosis (OR = 3.16, 95% CI: 1.89–5.28, P < 0.0001).

Conclusion

Patients receiving OPAT in POICs had significantly lower 30-day HRs compared with a national average, and in a more comorbid population. Our data suggest that continuous oversight of patients by ID physicians and infusion center staff in the POIC setting may prevent hospital readmissions.

Disclosures

All authors: No reported disclosures.
2083. A Targeted Remote Audit and Feedback Intervention Utilizing a Local Non-ID Trained Pharmacist
Authors: Khadem Tina , Kraft Jennifer , Bariola J Ryan
Published: October 2019

Background

Tele Stewardship (tASP) is a developing model for hospitals without local ID expertise. We report results of a tASP initiative using a hospital’s local non-ID trained pharmacist to conduct ertapenem (erta) audit and feedback (A&F).

Methods

Evaluation of erta use before and after implementation of a collaborative A&F process from October 2018 to March 2019. A central ID physician and ID pharmacist with EMR access reviewed charts of patients receiving erta Mon-Fri by phone with a local Critical Care trained pharmacist. Advice was given to the local pharmacist on when and how to intervene. The local pharmacist made all interventions. Acceptance rates and time involved were recorded. Usage was tracked as DOT/1,000 PD of inpatient usage. No other new local ASP interventions were undertaken during this time.

Results

120 erta orders were reviewed. Figure 1 reveals usage before and after implementation. Median usage dropped 55%. Median purchasing cost decreased by 73%. 51 unique patients received erta in the month prior to intervention, and 35 patients per month on average received erta afterwards. 30 providers ordered erta in the month prior to intervention, and 17 providers per month on average ordered erta afterwards. The overall intervention acceptance rate was 88%, and Figure 2 shows the breakdown of accepted interventions. Figure 3 describes the indications for use of erta orders after intervention started. Figure 4 shows changes in other antibiotics during this time. During this time, no patients were identified that later needed a carbapenem restarted or suffered harm due to this intervention. The average daily time required was 15 minutes for the central team and 22 minutes for the local pharmacist.

Conclusion

Using a remote collaboration with a local pharmacist, we showed a marked decrease in the use of one targeted antimicrobial. The time commitment was minimal, and no patient harm was identified. Tele-stewardship utilizing local non-ID trained pharmacists can be a significant tool for improving antimicrobial use in community hospitals. tASP’s should monitor for compensatory increase in other broad-spectrum antibiotics. Further local education regarding proper management of UTI’s and other common conditions may provide additional improvements in use of erta.

Disclosures

All authors: No reported disclosures.
2086. Antimicrobial Stewardship: Why Do Not Nurses Question the White Coat?
Authors: Sumner Sharon , Hanson Sandra F , Merrill Katreena C
Published: October 2019

Background

Resistance to antimicrobials has become a global issue. To combat this, registered nurses (RNs) need to be active participants with prescribers in an interdisciplinary approach to antimicrobial stewardship (AS). The prescriber role in AS has been well developed; however, more is needed to understand how RNs can contribute to AS efforts. The purpose of this study was to describe nurses comfort level with questioning providers about antimicrobials.

Methods

A survey was sent to point of care RNs in a healthcare system (approx. 4000). A total of 600 useable responses were received (Response rate = 15%). The survey included 4-items about antimicrobial delivery. (1) What percent of the time do you know why the patient is receiving an antimicrobial? (2) Would you feel comfortable raising concerns about antimicrobials to the treatment team? (3) In the last 30 days have you questioned the antimicrobial choice, dose, route or duration? (4) Have you ever given an antimicrobial you thought was inappropriate? Data were analyzed using descriptive statistics. Differences by demographics (age, gender, ethnicity, education level and location) were assessed using χ 2 statistics.

Results

Nurses reported that 84% of the time they knew “why” an antimicrobial was given. There was no difference by demographics. Over 80% of nurses also reported they felt comfortable raising concerns about antimicrobials. Nurses working in smaller hospitals reported being more comfortable raising concerns than nurses working in larger hospitals (P = 0.023). In the past 30 days, 19% of RNs questioned choice, 13% dose, 16% route, and 27% duration of antimicrobials. Nurses with Baccalaureate degree or higher were more likely to question antimicrobial dose (P = .023). However, 27% of RNs reported they had given an antimicrobial they thought was inappropriate. More RNs working in rural hospitals reported giving antimicrobials they thought were inappropriate compared with those working in larger hospitals (P = .013).

Conclusion

Providers as well as RNs need to collaborate to improve AS. Nurses in this study were not always comfortable raising concerns and administered antimicrobials they viewed as inappropriate. Providers may want to take steps to encourage collaboration with RNs about AS.

Disclosures

All authors: No reported disclosures.
2089. Effect of the Duke Antimicrobial Stewardship Outreach Network (DASON): A Multi-Center Time Series Analysis
Authors: Yarrington Michael E , Dodds Ashley Elizabeth , Johnson Melissa D , Davis Angelina , Dyer April , Jones Travis M , Sexton Daniel J , Anderson Deverick J , Moehring Rebekah W
Published: October 2019

Background

DASON is a 30-member, community hospital network in the southeastern United States that supports the development and growth of local antibiotic stewardship programs (ASPs). Collaborative activities include on-site visits from liaison clinical pharmacists, data sharing for routine feedback and benchmarking, and educational programs.

Methods

We performed a retrospective cohort analysis of antibiotic use (AU) in 17 hospitals that participated in DASON for a minimum of 42 months during 2013–2018. Segmented negative binomial regression models were used to estimate the change in facility-wide AU after an initial 1-year assessment, planning, and ASP intervention initiation period. Baseline AU trend (1 to 12 months) was compared against AU following the first year (13 to 42 months). Monthly AU rates were measured in days of therapy (DOT) per 1,000 patient-days (pd). Models assessed overall AU and specific antibiotic groups, as defined by the National Healthcare Safety Network AU option. The models controlled for hospital size, presence of a pre-existing formal ASP upon network entry, and year of network entry.

Results

Hospital data included a total of 2,988,930 pd over 5 years. Facility-wide AU was increasing during the first year of network entry and then began decreasing by 0.2% per month (P = 0.01, figure). Fluoroquinolone use was stagnant in year one and then decreased by 1.5% per month (P ≤ 0.001, figure). Antifungal agents were decreasing in year one and continued to decrease 0.7% per month thereafter (P = 0.03, figure). Agents predominantly used for resistant Gram-positive infections and broad-spectrum agents used for hospital-onset infections were increasing during year one and then attenuated afterward, though the slope change did not reach statistical significance. The presence of a pre-existing formal ASP was not a significant covariate in any model, while bed size and year of network entry significantly contributed to models of some antibiotic groups.

Conclusion

Participation in DASON was associated with a decline in total AU and fluoroquinolone use, and a trend toward attenuated use of other broad-spectrum agents in community hospitals. Collaborative network experiences can help local ASPs achieve reductions in AU.

Disclosures

All authors: No reported disclosures.
2103. Emergency Department (ED) Stewardship: Stratifying ED Sepsis Order Sets by Penicillin (PCN) Allergy Severity
Authors: Staicu Mary L , Laguio-Vila Maryrose R , Ramsey Allison , Conn Kelly M , Woodring Kristin
Published: October 2019

Background

The Surviving Sepsis Campaign Guidelines recommends administration of broad-spectrum antibiotics within 1 hour of sepsis diagnosis; electronic order sets drive antibiotic selection with pre-populated regimens based on the suspected infectious indication. Given the low rate of cephalosporin cross-reactivity in patients with a PCN allergy, we modified our ED sepsis order set (Images 1 and 2) to include cephalosporin options in patients with reported mild-to-moderate PCN reaction histories. This was a single-center, retrospective analysis evaluating the impact of this change on antibiotic prescribing and associated outcomes.

Methods

An electronic medical record (EMR) report identified patients ≥18 years of age with a documented PCN allergy that received antibiotics via the ED sepsis order set from December 30, 2012 to September 28, 2013 (pre-intervention) and January 3, 2014 to July 18, 2015 (post-intervention). The primary objective was to compare antibiotic days of therapy (DOT) and length of therapy (LOT) between the pre- and post-groups. The secondary objectives included 30-day readmission and mortality, hospital length of stay (LOS), incidence of C. difficile within 6 months and documented hypersensitivity reactions. Bivariate analyses, with chi-square, Mann–Whitney U, and Poisson means test, were used.

Results

A total of 180 patients (90 pre- and 90 post-intervention) were included. Demographics were similar between groups, with the exception of congestive heart failure (CHF) which was more prevalent in the post-intervention group (P = 0.039). Aztreonam, vancomycin, aminoglycoside, and fluoroquinolone DOTs were significantly reduced (P < 0.001) while cephalosporin DOTs significantly increased (P < 0.001) in the post-intervention group. There were no statistical differences in antibiotic LOT, 30-day readmission and mortality, hospital LOS, or incidence of C. difficile infection. For those patients that received cephalosporin antibiotics, there were no hypersensitivity reactions documented in the EMR.

Conclusion

Stratifying ED sepsis order sets by PCN allergy history severity is a safe and effective intervention that reduces second-line antibiotics in PCN allergic patients presenting to the ED with suspected sepsis.

Disclosures

All authors: No reported disclosures.
2105. Liposomal Amphotericin B Use Before and After Implementation of Voriconazole Prophylaxis in Cancer Patients
Authors: Shams Madeeha , Heil Emily , Oni Ibukunolupo , Morales Megan K , Bork Jacqueline
Published: October 2019

Background

Invasive fungal infections (IFI) are life-threatening complications of prolonged neutropenia in hematologic cancer or after hematopoietic stem cell transplantation (HSCT). Guidelines recommend mold prophylaxis (ppx) for patients at high risk of IFI. Patients receiving ppx with new signs of infection are often escalated to Liposomal Amphotericin B (L-AmB) for concerns of breakthrough mold infections. We describe the impact of implementing voriconazole (VZL) ppx in cancer patients.

Methods

We performed a quasi-experimental study of all adult patients prescribed L-AmB for ≥1 dose in Cancer Center at the University of Maryland Medical Center. VZL ppx was implemented for patients with hematologic cancer with anticipated prolonged neutropenia (≥ 7 days) in 4/2017. HSCT patients routinely received posaconazole ppx for ≥ 1 year during study period. Comparisons were made pre (November 2015–June 2017) and post (July 2017–December 2018) implementation of VZL ppx allowing for 3-month wash-in period. Cancer center-specific L-AmB days of therapy (DOT) per 1,000 patient-days (PD) were compared using segmented regression and Student t-test. Comparison of patient characteristics, mortality, nephrotoxicity and hospital length of stay (LOS) among patients receiving L-AmB in pre vs. post periods was done using Χ 2 and Student t-test.

Results

There were 87 (24 pre, 63 post) unique patients included in the analysis, translating to a total of 17.6 L-AmB DOT per 1,000 PD for the study period. Mean L-AmB utilization in cancer center was 9.9 and 24.4 DOT per 1,000 PD (P = 0.0037) for pre and post-implementation, respectively. There was an average 16% increase of L-Amb quarterly (P = 0.93). Among patients receiving L-AmB, most had acute myelogenous leukemia (63% vs. 60%) with lung source (71% vs. 73%, P = 0.8). More patients had proven IFI pre-implementation (42% vs. 29%, P = 0.3). Nephrotoxicity (46% vs. 48%, P = 0.9), median LOS (17 vs. 28, P = 0.4) and inpatient mortality (30 % vs. 38%, p = 0.5) all increased without statistical significance.

Conclusion

After implementation of VZL ppx there was a significant increase in L-AmB use, and associated non-significant increases in LOS, mortality and nephrotoxicity for those receiving L-AmB. Larger, robust longitudinal studies are needed to better understand the implications of VZL ppx on this population.

Disclosures

All authors: No reported disclosures.
2106. Evaluation of Isavuconazole for the Prophylaxis and Treatment of Invasive Fungal Infections at a Large Academic Medical Center
Authors: Vu Christine , Rana Meenakshi , Saunders-Hao Patricia
Published: October 2019

Background

Isavuconazole is an azole antifungal with in vitro activity against various fungi, including Candida spp, Aspergillus, and Mucormycetes. Currently, isavuconazole is FDA approved for the treatment of invasive aspergillosis and mucormycosis; however, there remains limited data to support prophylaxis use. Compared with other first-line azoles, isavuconazole’s broad spectrum of activity, favorable safety profile, and oral bioavailability makes it an attractive antifungal option. In July 2017, isavuconazole was added to our hospital formulary as a restricted antimicrobial. Since then, we have seen increased use for both prophylaxis and treatment of invasive fungal infections.

Methods

A single-center, retrospective chart review was conducted on adult patients who received at least 1 dose of isavuconazole at The Mount Sinai Hospital between July 1, 2017 and December 31, 2018. The electronic medical record was utilized to collect information on therapeutic indication, dosing, formulation, duration, reasons for switching to isavuconazole, prior antifungals, and proven or probable breakthrough invasive fungal infections (bIFIs) based on EORTG/MTG definitions.

Results

54 patients received 61 courses of isavuconazole. Reasons for switching to isavuconazole are described in Table 1. Eleven patients received inappropriate intravenous formulations and 14% of orders were prescribed isavuconazole without a loading dose (Table 2). We identified 4 proven/probable bIFIs, representing 7.4% of patients and 6.6% of courses (Table 3). All patients died within 60 days of bIFI onset.

Conclusion

Since its addition to hospital formulary, we have observed varying isavuconazole prescribing practices, highlighting the need for improved antifungal stewardship. Rates of bIFIs on isavuconazole were lower than previously reported studies. Additional studies are needed to provide guidance on isavuconazole use and determine its role as prophylaxis therapy.

Disclosures

All authors: No reported disclosures.
2108. Comparison of Voriconazole vs. Itraconazole in the Treatment of Histoplasmosis – A Retrospective Analysis
Authors: Hendrix Michael J , Larson Lindsey , Rutjanawech Sasinuch , Franklin Alexander , Spec Andrej
Published: October 2019

Background

The guideline-preferred azole for histoplasmosis (HP) is itraconazole (IC). While voriconazole (VC) has shown success in in-vitro and in retrospective analyses, there has not been enough data to include newer generation azoles as first-line treatment for infections with Histoplasma capsulatum.

Methods

We conducted a single-center retrospective cohort study of adult patients diagnosed with HP from 2002 through 2017. Data included demographics, clinical features and sites of infection, immune status, treatments, and mortality. Patients were categorized into two groups based on initial choice of azole (IC or VC) and mortality was compared between these two groups. The treatment groups were defined based on the first azole received, either IC or VC, as initial or as step-down therapy from amphotericin. Patients initiated on other azoles were excluded.

Results

We identified 263 cases of HP from 2002 to 2017. After excluding patients initiated on other azoles, 194 patients remained. 175 (90%) patients were started on IC and 19 (10%) were started on VC, either as stepdown or initial choice of antifungal. There were no significant demographic differences between patients receiving IC compared with VC as their initial azole treatment. Patients with hematologic malignancies tended to be prescribed VC more frequently but this was not statistically significant (OR 3.1 [0.77–12.4]). Death occurred in 40 (23%) patients from the IC and 5 (26%) patients from the VC group. The hazard ratio for mortality with the use of VC was 1.21 (CI 0.4–3.6, P = 0.73).

Conclusion

IC is the mainstay in the treatment for HP. It appears that VC has comparable outcomes to IC and can be considered an alternative treatment option for HP, at least for patients with contraindications to IC treatment.

Disclosures

All authors: No reported disclosures.
2127. Parental Acceptance of Over-the-Counter (OTC) Testing for Streptococcal Pharyngitis
Authors: Szigeti Aviva , Tena Meseret , Jose Temitope , Hammerschlag Margaret
Published: October 2019

Background

Group A Streptococcus (GAS), is currently diagnosed by throat culture or rapid antigen detection test (RADT) by a healthcare provider (HP), usually in an outpatient (OP) setting. There is current interest in expanding OTC diagnostics (FDA approved for HIV and hepatitis C) to other infectious diseases such as GAS pharyngitis. There are no data on parental acceptance of such a test. Our aim was to determine parental acceptance of expanding OTC diagnostic availability for GAS pharyngitis testing.

Methods

Caregivers of 3–18 years old in OP primary care pediatric clinics were given a questionnaire: data included demographics (excluding all patient identifiers), interest in buying/using an OTC GAS test, education level, type of health insurance (HI), comfort level swabbing their child, interest in available support/free hotline with the test. Statistical analysis included Mann–Whitney U test for non-continuous and T-test for continuous variables.

Results

90 questionnaires were collected, 14 duplicates excluded. 34 (45%) parents indicated they would buy an OTC GAS test, 35 (46%) would not, 4 (5%) were unsure, 3 (4%) did not respond. There was no correlation between interest in OTC test and age (P = NS), or education level (P = NS). There was a trend of OTC test interest among those with private HI vs. Medicaid (P = 0.067). There was a statistically significant association between interest in buying an OTC GAS test and the following variables: high self-swab comfort level and availability of support (P = 0.009 and 0.001, respectively). The majority of participants [73/76 (96%)] did not respond to questions about acceptable pricing.

Conclusion

There was mixed interest in OTC GAS testing among respondents. Neither age nor educational level affected interest. Surprisingly, 96% of respondents declined to select a price they would pay for an OTC GAS test. Greater interest in OTC GAS testing among respondents with private HI suggests those parents are more likely to purchase the kits to avoid an HP visit (and co-payment). Since most respondents were comfortable self-swabbing or unsure, further education including swab tutorial and support availability may lead to greater comfort level with such testing.

Disclosures

All authors: No reported disclosures.
2130. Detection of Carbapenemase-Producing Organisms and Impact on Antimicrobial Utilization for Carbapenem-Resistant Enterobacteriaceae (CRE) Infections
Authors: Minor Sarah Brooks , Alexander Jose
Published: October 2019

Background

CREs are feared pathogens with resistance occurring through the production of carbapenemases. Identification of carbapenemase-producing (CP) organisms assists with proper antimicrobial selection of commonly used agents, such as ceftazidime/avibactam (CA), meropenem/vaborbactam (MV), and tigecycline (TG). AdventHealth Orlando implemented a CRE screening method based on meropenem (MER) and a confirmatory CRE PCR testing in March 2018. Prior to implementing this test, patients were deemed to have CRE infections (CREI) if the organism demonstrated resistance to any carbapenem. The objective of this study was to evaluate the impact of this testing on the utilization of anti-CRE antibiotics.

Methods

This was a retrospective pre (March 2017–February 2018)- and post (March 2018–February 2019)-implementation study examining the impact of CRE PCR testing. Outcomes included the number of antibiotic days saved, average duration of therapy (DOT), median length of stay (LOS), and change in CP-CRE prevalence. The intervention consisted of the implementation of CRE PCR testing and included inpatients > 18 years old who received either CA, MV, or TG for the treatment of a CREI.

Results

Post-implementation, 30 unique patients were identified as having a positive K. pneumoniae carbapenemase gene by PCR, indicating a CP-CRE and received CA, MV, or TG; whereas, 42 patients in the pre-implementation group had a CREI and received CA, MV, or TG. Testing to identify CP-CREs led to a 50% reduction in the number of antibiotic days for CA, MV, and TG (575 vs. 287 days, P < 0.0001). Additionally, the average DOT decreased by 2.5 days in the post-implementation group (10.5 days vs. 8 days, P = 0.18) along with a 3.5-day shorter median LOS (15 days vs. 11.5 days, P = 0.48). The CRE prevalence based on resistance only to MER is 0.27%, compared with the previously reported rate of 2.5% that included resistance to ertapenem or MER.

Conclusion

Implementing CRE PCR testing to identify CP-CRE organisms resulted in a significant reduction in utilization of anti-CRE agents for CREIs. Additionally, the testing algorithm allowed for accurate reporting of our local CRE prevalence. By avoiding CA, MV, or TG in patients without CP-CREs, this has the potential to optimize therapy while reducing collateral damage associated with broad-spectrum agents.

Disclosures

All authors: No reported disclosures.
2132. Multicenter Evaluation of Eravacycline MIC Results for Enterobacteriaceae Using MicroScan Dried Gram-Negative MIC Panels
Authors: Traczewski Maria M , Beasley Denise , Harrington Amanda , DesJarlais Sharon , Garner Omai , Hastey Christine , Brookman Regina , Lockett Zabrina , Chau Jennifer , Zimmer Barbara
Published: October 2019

Background

A multicenter study was performed to evaluate the accuracy of eravacycline on a MicroScan Dried Gram-negative MIC (MSDGN) Panel when compared with a frozen CLSI broth microdilution reference panel.

Methods

For efficacy, an evaluation was conducted at three sites by comparing MIC values obtained using the MSDGN to MICs using a CLSI broth microdilution reference panel. A total of 414 Enterobacteriaceae clinical isolates were tested using the turbidity and Prompt®* methods of inoculation. For challenge, 79 Enterobacteriaceae isolates were tested on MSDGN panels at one site. For reproducibility, a subset of 11 organisms was tested on MSDGN panels at each site. MSDGN panels were incubated at 35 ± 2°C and read on the WalkAway System, the autoSCAN-4 instrument, and read visually. Read times for the MSDGN panels were at 16–20 hours. Frozen reference panels, prepared according to CLSI/ISO methodology, were inoculated using the turbidity inoculation method. All frozen reference panels were incubated at 35 ± 2°C and read visually. Frozen reference panels were read at 16–20 hours. FDA breakpoints (µg/mL) used for interpretation of MIC results were: Enterobacteriaceae ≤ 0.5 S. Potential major and very major errors were calculated using the NS result in place of resistant (R).

Results

When compared with frozen reference panel results, essential and categorical agreements for isolates tested in the Efficacy and Challenge are as follows (see table). Reproducibility among the three sites were greater than 95% for all read methods for both the turbidity and Prompt inoculation methods.

Conclusion

This multicenter study showed that eravacycline MIC results for Enterobacteriaceae obtained with the MSDGN panel correlate well with MICs obtained using frozen reference panels using FDA interpretive criteria. * PROMPT® is a registered trademark of 3M Company, St. Paul, MN USA. Beckman Coulter, the stylized logo and the Beckman Coulter product and service marks mentioned herein are trademarks or registered trademarks of Beckman Coulter, Inc. in the United States and other countries. Xerava™ (Eravacycline) is a registered trademark of Tetraphase Pharmaceuticals, Inc.

Disclosures

All authors: No reported disclosures.