bluuebunny/crossref_metadata_2025_split huggingface dataset:
1017. Scratching the Surface with NHSN Data: Defining High Impact Stewardship Targets in Critical Care
Authors: Cowman Kelsie , Chen Victor , Saraiya Nidhi , Guo Yi , Bartash Rachel , Nori Priya 
Published: October 2019

Abstract

Background
The National Healthcare Safety Network (NHSN) provides risk-adjusted Standardized Antimicrobial Administration Ratios (SAAR) as a benchmark for medical and surgical intensive care units (ICU). Antibiotic use (AU) data does not provide patient-level information (e.g., antibiotic appropriateness, indications, durations, etc.). However, we hypothesize that AU data can help define high impact stewardship targets, particularly in the context of critical care Clostridioides difficile rates.

Methods
Units with high rates of AU and hospital-onset (HO) C. difficile were selected for review. A monthly AU and C. difficile dashboard was created for ICU providers, inclusive of data from May 2018 onwards. We also performed chart audits for indication, duration, and location of initiation for all medical intensive care unit (MICU) patients receiving piperacillin/tazobactam (P/T) or vancomycin (Van) during February 2019 per request of ICU stakeholders. Data were used to obtain stewardship buy-in from local MICU champions.

Results
AU data indicated that (1) all 3 MICUs consistently had SAARs >1 for broad-spectrum categories and (2) Van and P/T were the highest volume agents on these units (Figure 1). Chart audit of 135 MICU patients showed that 17 patients received P/T, 34 Van, and 84 (62%) both agents; median duration was 2 days for Van and 3 days for P/T (Figure 2). Approximately half of initiations occurred in the emergency department (ED) (50% Van, 47% P/T); most common indications were “respiratory tract infection” and “severe sepsis/septic shock” for both P/T (77%) and Van (74%) (Figure 2). HO C. difficile in MICUs accounted for 6%, 13%, and 16% of total HO C. difficile cases in campuses A, B, and C, respectively during the time frame (Figure 1).

Conclusion
We feel that NHSN data scratches the surface of the deep-rooted challenges of ICU stewardship. However, it can identify AU trends and most frequently prescribed antibiotics in the context of unit-specific C. difficile rates. Intensive stewardship audit can further uncover areas for intervention, such as ED Van and P/T overprescribing. We suggest presenting clinical stakeholders with a quarterly “stewardship dashboard” combining AU rates, patient-level data, and C. difficile rates to maximize the impact of stewardship endeavors.

Disclosures
All authors: No reported disclosures.
1019. Defining electronic patient phenotypes to inform risk-adjustment strategies in hospital antimicrobial use comparisons
Authors: Moehring Rebekah W , Phelan Matthew , Lofgren Eric , Nelson Alicia , Neuhauser Melinda M , Hicks Lauri , Dodds Ashley Elizabeth , Anderson Deverick J , Goldstein Benjamin 
Published: October 2019

Abstract

Background
Comparison of antimicrobial use (AU) rates among hospitals can identify areas to intervene for antimicrobial stewardship. Hospital AU interpretation is difficult without risk-adjustment for patient mix. Identifying high- or low-risk patient characteristics, or “electronic phenotypes,” for receipt of antimicrobials using data from electronic health records (EHR) could help define risk-adjustment factors AU comparisons.

Methods
We performed a retrospective study of EHR-derived data from adult and pediatric inpatients within the Duke University Health System from October 2015 to September 2017. Encounters were included if the patient spent time in an inpatient location. The analysis aimed to identify subpopulations that were high- or low-risk for antimicrobial exposure based on EHR data summarized on the encounter level. Antimicrobial days of therapy (DOT) and days present, representing the length of stay (LOS), were defined as in the 2018 NHSN AU Option. Location exposures were defined in binary variables if patients were housed at least 1 day on a hospital unit type. We compared antimicrobial-exposed to unexposed patients as well as DOT among various factors including demographics, location, nonantimicrobial medications, labs, ICD-10 codes, and diagnosis-related groups (DRG).

Results
The EHR-derived dataset included 170,294 encounters and 204 variables in one academic and two community hospitals; 80,192 (47%) received at least one antimicrobial. Distributions of both LOS and DOT were zero-inflated and skewed by long outliers (figure). Encounters with >=7 DOT made up 63% of total DOT, but only 9% of inpatient encounters. Electronic phenotypes with highest DOT included those with long lengths of stay, older age, exposures to stem cell transplant, pulmonary, and critical care units, and DRG that included transplant, respiratory, or infectious diagnoses. Zero DOT phenotypes included those with short lengths of stay, exposure to labor and delivery wards, medical wards, and DRG that included birth and pregnancy.

Conclusion
Future work in defining risk-adjustment factors for hospital AU data comparisons should determine if factors associated with low- or high-risk electronic phenotypes assist in prediction of antibiotic use.

Disclosures
All authors: No reported disclosures.
1024. Evaluation of Atovaquone Prescribing for Pneumocystis jiroveci Pneumonia (PJP) Prophylaxis
Authors: Aleissa Muneerah , Kubiak David , Nauffal Mary , Sommer Jamie , Patterson Monica , Marty Francisco M , Pearson Jeffrey 
Published: October 2019

Abstract

Background
Trimethoprim-sulfamethoxazole (TMP-SMX) use for PJP prophylaxis has been associated with a variety of adverse reactions including myelosuppression, hypersensitivity reactions, acute kidney injury, and hyperkalemia. Atovaquone is used as an alternative drug, but it has several disadvantages, such as breakthrough PJP risk, dysgeusia, and higher cost compared with TMP-SMX. Indications for atovaquone prophylaxis at our institutions include severe cytopenias, hypersensitivity, renal impairment, or hyperkalemia. We evaluated atovaquone use and compliance with institutional PJP prophylaxis guidelines.

Methods
This was a retrospective study of inpatient atovaquone prescribing for PJP prophylaxis at Brigham and Women’s Hospital and Dana-Farber Cancer Institute from 7/1/18 to 9/30/18. We included adult patients who received ≥1 dose of atovaquone and ≥3 months of PJP prophylaxis with any agent. The primary endpoint of this study was the proportion of patients who could have been safely switched to TMP-SMX 3 months after atovaquone initiation. Other endpoints included the incidence of breakthrough PJP, reasons for TMP-SMX avoidance, and estimated cost savings.

Results
Two-hundred and eighteen patients were evaluated and 164 were included. Most common indications for atovaquone prophylaxis were bone marrow transplant (44.5%), solid-organ transplant (30.5%) and use of immunosuppressive agents (21.9%). Atovaquone was started in 145 patients (88.4%) according to institutional guidance. Three months after initiation, 89 patients (45.7%) could have been safely switched to TMP-SMX. Failure to timely change to TMP-SMX was associated with 1,615 additional patient-days of atovaquone therapy and $103,683 in excess costs within 3 months of initiation. Major reasons for TMP-SMX avoidance were thrombocytopenia (51.3%), neutropenia (35.4%), renal impairment (31.7%), allergy history (26.8%), and hyperkalemia (19.5%). No breakthrough PJP infections were observed while patients were on atovaquone.

Conclusion
Institutional-guideline compliance was high during atovaquone initiation. However, after 3 months, many patients who could have been safely transitioned to TMP-SMX continued to receive atovaquone. This resulted in excess costs and potentially sub-optimal therapy.

Disclosures
All authors: No reported disclosures.
1028. Dalbavancin Use in Complicated Infections and-associated Cost-Savings
Authors: Streifel Amber C , Sikka Monica , Sikka Monica , Lewis James 
Published: October 2019

Abstract

Background
Dalbavancin is a lipoglycopeptide antibiotic active against Gram-positive organisms with an extended half-life that allows for weekly dosing. Initially approved for treating skin and soft-tissue infections, use for more complicated infections provides several potential benefits, particularly in the outpatient setting when daily intravenous antibiotics are not practical due to social or financial issues.

Methods
We conducted a retrospective study to describe dalbavancin use at our institution and to estimate resulting cost avoidance. We identified all patients aged 18 years or older who received at least one dose of dalbavancin via medication records, regardless of setting.

Results
46 patients received dalbavancin between April of 2015 and March of 2019. The most commonly treated infections were bone and joint infections (41%), complicated bacteremias (24%), and skin and soft-tissue infections (20%). The most commonly treated organism was Staphylococcus aureus (55%). A variety of dosing regimens were used, 26 patients (57%) received a single dose to complete a treatment course. The majority of doses were administered in an outpatient infusion center (61%) although 28% of doses were administered in the inpatient setting prior to discharge. Reasons for dalbavancin selection included history of intravenous drug use (35%), contraindications to alternative antibiotics (30%), prior history of nonadherence or manipulation of PICC (18%), other social issues preventing PICC (11%), and limited outpatient daily infusion options due to lack of funding (9%). 4 patients (8.7%) were lost to follow-up. 11 (24%) patients were readmitted to the hospital within 30 days, 2 (4%) of these patients were readmitted with a concern related to their infection or an adverse effect of the dalbavancin infusion. Based on a calculation of equivalent dalbavancin therapy days for each patient, 774 hospital days were saved. In total, this is estimated to be $1,885,479 in overall cost avoidance and a mean cost avoidance of $40,988 per patient.

Conclusion
As data regarding the efficacy of dalbavancin for more complicated infections continue to emerge, it should be considered as a cost-effective alternative therapy when social and financial factors limit treatment options.

Disclosures
All authors: No reported disclosures.
1035. Implementation of an Antimicrobial Stewardship Program-Led, Multifactorial Pneumonia Diagnosis and Treatment Bundle
Authors: Cua Jefferson L , Crass Ryan L , Marshall Vince , Ateya Mohammad , Nagel Jerod , Eschenauer Gregory , Gandhi Tejal N , Kaye Keith S , Petty Lindsay A , Chenoweth Carol , Baang Ji , Lew Alison , Patel Twisha S 
Published: October 2019

Abstract

Background
Pneumonia remains a leading cause of hospitalization and accounts for significant antibiotic use. This study aims to evaluate the impact of bundled antimicrobial stewardship program (ASP) interventions, including procalcitonin and surveillance cultures, on broad-spectrum antimicrobial use in patients with suspected pneumonia.

Methods
This is a pre-post, quasi-experimental study conducted at Michigan Medicine. During the intervention period, an ASP member reviewed adult patients admitted to 3-floor medical services with antibiotics initiated for suspected pneumonia. The ASP member (1) recommended the use of procalcitonin when clinically appropriate, (2) used institutional guidelines to guide empiric antibiotic selection based on risk for drug-resistant pathogens, and (3) ordered a methicillin-resistant Staphylococcus aureus (MRSA) surveillance culture in patients receiving empiric anti-MRSA therapy. The primary endpoint was anti-MRSA and anti-pseudomonal (PSA) antibiotic use measured as days of therapy (DOT) per 1000 days-present on the services of interest. Antibiotic use and clinical data were extracted from an electronic database. Pneumonia diagnosis codes were used to identify the study population.

Results
A total of 549 patients were included: 310 in the pre-intervention (December 1/2017 - 3/31/2018) and 239 in the intervention (December 1/2018 - 3/31/2019) periods. Baseline demographics were similar between groups (Table 1). Less than 15% of patients had a microbiological diagnosis via respiratory culture in both study periods (Table 2). Respiratory cultures were ordered less commonly in the intervention period; however, the rate of culture positivity was higher (28% vs. 48%, P < 0.01). Process measures improved in the intervention period with an increase in the proportion of patients with MRSA surveillance cultures (13% vs. 39%, P < 0.01) and procalcitonin monitoring (77% vs. 83%, P = 0.07). Compared with the pre-intervention period, anti-MRSA antibiotic use decreased from 172 to 158 DOT per 1000 days-present (Δ -8%) and the use of anti-PSA antibiotics decreased from 348 to 316 DOT per 1000 days present (Δ -9%).

Conclusion
The implementation of an ASP-led pneumonia bundle led to reductions in anti-MRSA and anti-PSA antibiotic use.

Disclosures
All authors: No reported disclosures.
1039. Forty-eight-hour Antibiotic Time-out: Impact on Antibiotic Duration and Clinical Outcomes
Authors: Pettit Natasha N , Bhagat Palak , Nguyen Cynthia T , Konold Victoria J L , Kumar Madan , Choksi Anish , Pisano Jennifer 
Published: October 2019

Abstract

Background
A core element of the Centers for Disease Control and Prevention Antimicrobial Stewardship standard for the inpatient setting includes a 48-hour antibiotic time-out (ATO) process to reassess antibiotic indication. We implemented an automated alert in the electronic health record (EHR) that identifies patients that have received >=48hours of antibiotic therapy. The alert requires the clinician (physician or pharmacist) to note an indication for continuation or plan for discontinuation. Within the alert, a dashboard was developed to include relevant patient information (e.g., temperature, white blood cell count, microbiology, etc). We sought to evaluate the impact of the ATO alert on the duration of therapy (DOT) of cefepime (CFP), ceftazidime (CTZ) and vancomycin (VAN), for the treatment of pneumonia (PNA) and urinary tract infections (UTI) for adult and pediatric patients.

Methods
This quasi-experimental, retrospective analysis included adult and pediatric patients that received ≥48 hours of CFP, CTZ, or VAN for UTI or PNA between April 1, 2017 and July 31, 2017 (pre-48H ATO) and October 1, 2018–December 31, 2018 (post-48H ATO). Fields at order-entry to specify an antibiotic indication were not available prior to our EHR interventions. A randomized subset from the Pre-48Hr ATO group was selected for detailed analysis. The primary endpoint was to evaluate the average DOT of CFP/CTZ combined, VAN alone, and the combination of CFP/CTZ/VAN. We also evaluated length of stay (LOS), all-cause inpatient mortality, and 30-day readmissions.

Results
A total of 157 antibiotic orders (n = 94 patients) were evaluated in the pre-48h ATO group, and 2093 antibiotic orders (n = 521 patients) post-48H ATO group. Pre-48H ATO, 85 patients received CFP/CTZ and 72 VAN. Post-48H ATO, 322 patients received CFP/CTZ and 198 VAN. PNA was the most common indication pre- and post-48H ATO. DOT significantly decreased pre- vs. post-48H ATO (Figure 1). LOS was 2 days shorter (P = 0.01) in the post-48H ATO group, mortality and 30-day readmissions was similar between groups (Table 1).

Conclusion
Average antibiotic DOT for CFP/CTZ, and VAN significantly decreased following the implementation of the 48H ATO at our medical center. LOS was reduced by 2 days, while mortality and 30-day readmissions were similar before and after.

Disclosures
All authors: No reported disclosures.
1041. Staphylococcus aureus Bacteremia Bundle Adherence Pre- and Post-Implementation of Mandatory Infectious Diseases Consultation and Antimicrobial Stewardship Pharmacist Intervention
Authors: Arensman Kellie , Dela-Pena Jennifer , Miller Jessica , LaChance Erik , Beganovic Maya , Anderson Morgan , Wieczorkiewicz Sarah 
Published: October 2019

Abstract

Background
Infectious diseases consult (IDC) and antimicrobial stewardship (AMS) intervention independently demonstrate improved management of Staphylococcus aureus bacteremia (SAB). However, data supporting utilizing both strategies is limited. The objective of the current study is to assess evidence-based bundle adherence for SAB in the presence and absence of mandatory IDC and AMS pharmacist review in a multi-site health system.

Methods
This retrospective study included adult inpatients with SAB from January 2016 to December 2018 at seven hospitals. Outcomes were compared between three groups: pre-mandatory IDC and AMS review (group 1), post-mandatory IDC and pre-AMS review (group 2), and post-mandatory IDC and AMS review (group 3). The primary outcome was bundle adherence defined as: appropriate intravenous antimicrobial therapy, appropriate duration of therapy, 24–48-hour surveillance cultures until documented clearance, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary endpoints included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality.

Results
A total of 579 patients met the final inclusion criteria for analysis. Complete bundle adherence was achieved in 65% of patients for group 1 (n = 371), 54% for group 2 (n = 87), and 76% for group 3 (n = 121). Adherence to bundle elements was significantly higher in group 3 when compared with group 1 (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37–0.93), and group 2 (OR 0.37, 95% CI 0.20 – 0.67). No difference in bundle adherence was noted between groups 1 and 2. When comparing groups 1, 2 and 3, significant differences were seen in obtaining echocardiography (91% vs. 83% vs. 100%; P = 0.0378), and hospital LOS (10.5 vs. 8.85 vs. 12.0 days; P = 0.0149), respectively. Increased hospital LOS in group 3 may be due to nonsignificant higher rates of complicated bacteremia compared with groups 2 and 1 (32% vs. 44% vs. 43%, P = 0.09), respectively. No differences were noted for readmission or mortality.

Conclusion
The addition of AMS pharmacist review to mandatory IDC significantly improved quality care bundle adherence.

Disclosures
All authors: No reported disclosures.
1047. Impact of Indication for Antibiotic Orders on Pharmacist Interventions
Authors: Scardina Tonya , Sun Shan , Kotsonis-Chiampas Lori , Patel Avani , Patel Sameer 
Published: October 2019

Abstract

Background
Joint Commission mandates that prescribers document indication for antibiotics at the time of prescribing. Antibiotic indications may offer opportunities for pharmacists to optimize dosing and frequency or provide alternative therapeutic options. We examined the impact of antibiotic indications during order entry on frequency and type of pharmacist interventions, time to order verification, and time to administration of antibiotics.

Methods
Number of pharmacist interventions documented in EPIC from 4/28/17 through 4/28/18 (pre-intervention) were compared with interventions from 4/29/18 through 2/28/19 (post-intervention). All pharmacist interventions involving antibiotic orders were included. For antibiotic orders involving a pharmacist intervention, data collected included antibiotic prescribed, indication for antibiotic (post-intervention only) and reason for intervention. For administered antibiotics, data collected included order time, time of arrival of order in pharmacist queue, pharmacist verification time, patient administration time. Statistical analysis involved chi-squared test (compare the reason for intervention) and t-test (compare difference in time).

Results
There were 790 orders and 638 orders that involved a pharmacist’s interventions, pre-intervention and post-intervention, respectively (Tables 1 and 2). Pre-intervention, there were 200 antibiotic orders that had a documented pharmacist intervention and were administered. Post-intervention, there were 184 orders that had a documented pharmacist intervention and were administered. Abdominal/pelvic (29 orders, 16%), sepsis (19 orders, 10%), and surgical prophylaxis (18 orders, 9.7%) were the most frequent indications selected during order entry. Average time to order verification was 119 minutes pre-intervention and 123 minutes post-intervention (P =0.97). Average time to administration of antibiotics was 313 minutes and 360 minutes pre-intervention and post-intervention, respectively (P =0.45).

Conclusion
Inclusion of the selection of antibiotic indications during order entry did not significantly impact the number of pharmacist interventions, time to order verification nor time to administration.

Disclosures
All authors: No reported disclosures.
1052. Antimicrobial Stewardship: On Board with Lean Daily Management System
Authors: Monsees Elizabeth , Monsees Elizabeth , Wirtz Ann , Myers Angela , Myers Angela , Burns Alaina , Day Chris , El Feghaly Rana E , Lee Brian R , Purandare Amol , Weddle Gina , Goldman Jennifer 
Published: October 2019

Abstract

Background
Limited guidance exists on how to design and measure the efficiency and effectiveness of an antimicrobial stewardship program (ASP). Our established ASP sought to broaden interprofessional accountability and enhance our programmatic efficiency by employing Lean Daily Management System (DMS) procedures.

Methods
To improve ASP communication, a visual and systematic approach to identify, address, and resolve ASP projects while quantifying nontraditional metrics measuring the efficiency and effectiveness was developed. Through shared discussions, an interdisciplinary group of stakeholders produced the following deliverables: (a) established shared programming goals/metrics; (b) improved prioritization methods and project tracking through completion; (c) developed readiness and metric boards to display achievements, current activity, and metrics; (d) identified programming threats and strategies to strengthen our provided services.

Results
At 6 months following DMS adoption, our ASP has disbanded monthly meetings in lieu of weekly, 15 minute huddles utilizing the readiness and metric boards. We achieved consistent and interprofessional representation where each member is accountable for leading huddles, providing reports, and owning projects. Using a stoplight color system to indicate status, potential ASP influencers are tracked and reported: clinical workload/demands, organizational awareness, equipment/supplies, staffing, project updates, and announcements. The visual identification allows the team to address “quick hits” or escalate resource allocation to solve “big issues” (figure). Program metrics are codified under the domains of delivery, people, quality, safety, and financial stewardship. Administrative leadership has attended huddles and provided positive and constructive feedback to foster a process of continuous improvement.

Conclusion
Integration of Lean DMS huddles provides a collaborative, interactive and interdisciplinary approach to enhance shared awareness and to broaden the reach and efficiency of our ASP. With project tracking mechanisms in place, our team is refining our problem-solving abilities to ensure a congruent plan between issues raised and established program metrics.

Disclosures
All authors: No reported disclosures.