bluuebunny/crossref_metadata_2025_split huggingface dataset:
784. Do Patients and Healthcare Professionals See Eye-to-Eye on the Usefulness of Strategies for Promoting HIV Care?
Authors: Felzien Gregory S , McIntosh Sean J , Taneva Ekaterina S , Simone Laura , Greene Laurence , Carter Jeffrey , Sapir Tamar 
Published: October 2019

Abstract

Background
Many studies have identified barriers to achieving goals for HIV care, thereby informing various intervention strategies. However, whether a given strategy can effectively overcome key barriers may depend on the extent to which patients and healthcare professionals (HCPs) agree that it is useful. To address this gap, we conducted a survey study to compare patients’ and HCPs’ perceptions of strategies for promoting HIV prevention, medication adherence, and care retention.

Methods
The survey was administered to patients and their HCPs as part of collaborative educational programs held in 12 community clinics in urban and suburban areas across 6 southeastern states. Participants included each clinic’s staff and their patients living with or at risk for HIV infection. The surveys listed 12 strategies for overcoming barriers to HIV prevention, adherence, and retention. Patients and HCPs rated the extent to which each strategy would be helpful for achieving desired goals (scale: 1 = very unhelpful to 5 = very helpful). We conducted χ 2 or Fisher’s exact tests to assess between-group differences in the frequency of pooled ratings of 4 (helpful) and 5 (very helpful).

Results
Surveys were completed by 224 patients (69% with HIV diagnosis, mean age 47 years, 42% women, 75% African American) and 39 HCPs (42% health educators/counselors, 31% nurse practitioners, 24% social workers, 3% physicians). Among other findings (Figures 1–3), similar percentages of patients and HCPs, respectively, gave ratings of 4 or 5 for taking pills (PrEP) that prevent HIV (83%, 80%); using a smartphone app with medication reminders (78%, 74%); and making it easier to get clinic appointments (90%, 85%). More discordant perceptions, all reflecting lower percentages of 4 or 5 ratings among patients than HCPs, were evident for talking with a counselor (82%, 90%); getting support from friends and family (82%, 92%); and improving relationships with clinic staff (85%, 100%).

Conclusion
These findings may inform interventions that are perceived by both patients and HCPs to be helpful for promoting HIV prevention, medication adherence, and retention. Effective interventions must address any discordance between patients and HCPs in the usefulness of selected strategies.

Disclosures
All authors: No reported disclosures.
788. Outcomes of Multidisciplinary Care Conferences for Patients with Substance Use Disorders Requiring Prolonged Antimicrobial Therapy for Severe Infections
Authors: Gore Sara J , Strnad Luke , Englander Honora , Gregg Jessica , Sikka Monica , Sikka Monica 
Published: October 2019

Abstract

Background
Infectious complications in people with substance use disorders (SUD) are rising, and while outpatient parenteral antimicrobial therapy (OPAT) is widely used in the general population, OPAT failure rates in SUD are high. Due to perceived PICC risks and OPAT safety, serious infections in people with SUD at our institution often resulted in hospitalization for the duration of treatment. Prolonged inpatient treatment is difficult to tolerate and increases healthcare costs. Our OPAT and addiction medicine teams initiated multidisciplinary discharge planning conferences (OPTIONS-DC) for inpatients with SUD requiring prolonged antimicrobials. The goal was to prioritize patient preferences regarding OPAT setting while incorporating harm-reduction principles. The goal of this study is to assess the impact and outcomes of the OPTIONS-DC.

Methods
We prospectively recorded comprehensive notes at OPTIONS-DC and retrospectively performed chart review for conferences held from February 2018 to March 2019.We performed a content analysis of OPTIONS-DC notes and patient records to identify ways that OPTIONS-DC modified care plans and prioritized patient preferences.

Results
Thirty-one conferences were held during the study period. Twenty-eight patients reported substance use within 90 days, 24 used intravenous substances, 12 were homeless, 24 had a mental health diagnosis, and 20 started medication-assisted treatment during hospitalization (Table 1). For 16 patients the conference altered the definitive treatment plan to align with patient preferences while emphasizing safety, and 13 of those were changed to an outpatient setting. A total of 10 patients had a decreased length of stay, with a total of 238 hospital days saved overall. OPAT was planned at discharge for 15 patients, 11 of whom completed their OPAT course. Overall, 21/31 (68%) completed their recommended antimicrobial course and 3 were lost to follow-up.

Conclusion
A multidisciplinary conference that prioritizes patient preferences and uses harm reduction strategies to optimize infection treatment plans is feasible and effective. The OPTIONS-DC model has potential to expand treatment options for infections in SUD, reduce hospital days, and may serve as an example for other institutions.

Disclosures
All authors: No reported disclosures.
1013. Electronic Assessment of Empiric Antibiotic Prescribing Using Diagnosis Codes
Authors: Dodds Ashley Elizabeth , Nelson Alicia , Johnson Melissa D , Jones Travis M , Davis Angelina , Dyer April , Moehring Rebekah W 
Published: October 2019

Abstract

Background
Antimicrobial stewardship programs (ASPs) must understand empiric choices for specific disease syndromes to assess adherence to local empiric treatment guidelines. Electronically-derived metrics to track empiric therapy choices would allow ASPs to target areas for intervention without significant data collection burden.

Methods
Admissions from 10 community hospitals between 7/2016 and December 2018 were reviewed to identify those with common infectious syndromes: pneumonia (PNA), urinary tract infection (UTI) and skin and soft-tissue infection (SSTI). Admissions with a syndrome of interest were identified using AHRQ clinical classifications software codes based on ICD-10 codes for infection at the time of discharge. Admissions were categorized as having the syndrome of interest with or without sepsis. Antibiotics received during the first 48 hours of inpatient admission were obtained from electronic medication administration records. The proportion of syndrome admissions receiving specific antibiotic agents was determined to evaluate initial treatment choices as compared with local empiric guidelines. Antibiotic categories were not mutually exclusive, admissions receiving combination therapy were included in the count for each individual agent as well as the combination group. The denominator was the count of admissions with the syndrome of interest. Distributions were tracked over time to observe the effects of ASP intervention.

Results
The analysis included 49,303 admissions. The most common diagnosis was UTI (30%) followed by PNA (23%). Empiric antibiotic use varied by syndrome (Figure 1). In general, patients with a targeted infectious diagnosis and sepsis received more broad-spectrum agents than those without sepsis. SSTI was an exception, but few patients admitted with SSTI did not also have presumed sepsis. Longitudinal analysis demonstrated shifts from less preferred agents to guideline-concordant choices. For example, for admissions with a diagnosis of PNA, we observed a steady year on year increase in ceftriaxone (preferred) while levofloxacin (avoided in local guidelines) declined. (Figure 2)

Conclusion
Syndrome-specific diagnosis codes were helpful in assessing empiric antibiotic selection and may assist ASPs in improving empiric guideline adherence.

Disclosures
All authors: No reported disclosures.
1018. Using prediction modeling to inform risk-adjustment strategy for hospital antimicrobial use: Can we predict who gets an inpatient antimicrobial?
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
Hospital antimicrobial stewardship program (ASP) assessments based on comparisons of antimicrobial use (AU) among multiple hospitals are difficult to interpret without risk-adjustment for patient case-mix. We aimed to determine whether variables of varying complexity, derived retrospectively from the electronic health record (EHR), were predictive of inpatient antimicrobial exposures.

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. We used Random Forests machine learning models on two antimicrobial exposure outcomes at the encounter level: binary (ever/never) exposure and days of therapy (DOT). Antimicrobial groups were defined by the NHSN AU Option 2017 baseline. Analyses were stratified by pediatric/adult, location type (ICU/ward), and antimicrobial group. Candidate variables were categorized into four tiers based on feasibility of measurement from the EHR. Tier 1 (easy) included demographics, season, location, while Tier 4 (hard) included all variables from Tier 1–3 and laboratory results, vital signs, and culture data. Data were split into 80/20 training and testing sets to measure model performance using area under the curve (AUC) for the binary outcomes and absolute error for DOT.

Results
The analysis dataset included 170,294 encounters and 204 candidate variables from three hospitals. A total of 80,190 (47%) encounters had antimicrobial exposure; 64,998 (38%) had 1–6 DOT, and 15,192 (9%) had 7 or greater DOT. Models strongly predicted the binary outcome, with AUCs ranging from 0.70 to 0.95 depending on the stratum (Figure A, B). The addition of more complex variables increased accuracy (Figure Model Tiers 1–4). Model performance varied based on location and antimicrobial group. Models for infrequently used groups performed better (Figure C, D). Models underestimated DOTs of encounters with extremely long lengths of stay.

Conclusion
Models utilizing EHR-derived variables strongly predicted antimicrobial exposure. Risk-adjustment strategies incorporating measures of patient mix may provide more informative benchmark comparisons for use in Antimicrobial Stewardship Program assessments.

Disclosures
All authors: No reported disclosures.
1020. Variations in inpatient and outpatient antibiotic use – opportunities for improvement and facility-level feedback
Authors: Goetz Matthew B , Graber Christopher J , Jones Makoto M , Madaras-Kelly Karl , Youn Sarah Y , Samore Matthew H , Glassman Peter A 
Published: October 2019

Abstract

Background
Participation in the Antibiotic Use (AU) option of the National Health Safety Network (NHSN), provides medical facilities with the Standardized Antibiotic Administration Ratio (SAAR), a normalized ratio of facility antibiotic use. However, the range of antibiotic use by similar facilities is not provided and thus the opportunity to “nudge” behavior by comparing use with “best facilities” is lost. We developed reports of variations of antibiotic use that allow comparisons of local antibiotic use with that of 107 other VA facilities.

Methods
Data for 2018 were extracted from the VA Corporate Data Warehouse. Antibiotic use in CY2018 on acute inpatient care units was assessed as days of therapy (using CDC-defined drug classes) per 1000 days-present. In addition, we assessed the proportion of patients with pneumonia, urinary tract infections or skin-soft-tissue infections (collectively, PUS) who received anti-MRSA therapy or ß-lactam therapy directed against multi-drug-resistant and hospital GNR (anti-MDRGNR) during hospital days 0–2 (CHOICE, a timeframe representing empiric therapy).

Results
Rates of total antibiotic use by VA facility varied over two-fold from 460 to 965 days of therapy (DOT)/1000 days-present (DP); anti-MRSA and anti-MDRGNR varied over four-fold, from 44 to 184 and, 55 to 262, respectively. Fluoroquinolone variation was even higher, ranging over 8-fold, from 17 to 145 DOT/1000 DP (Figure 1). Substantial variations were also observed in the frequency of administration of anti-MRSA and anti-MDRGNR therapy for PUS during CHOICE (14 to 49% and 15 to 65%, respectively; Figure 2).

Conclusion
The large variations in the use of total antibiotic therapy, anti-MRSA, anti-MDRGNR and fluoroquinolone therapies are greater than can be readily explained by known variations in antibiotic resistance or differences in case-mix within the VA. Efforts are underway in the VA to strengthen antimicrobial stewardship programs. In other work, we have shown improvements in antimicrobial use among sites that have access to reports that provide the data described herein and that participate in group collaboratives. Our group is now making these data available to all VA facilities.

Disclosures
All authors: No reported disclosures.
1023. Isavuconazonium Use at an Academic Transplant Center
Authors: Servais Abigail , Schoen John , Van Schooneveld Trevor C , Stohs Erica J , Bergman Scott 
Published: October 2019

Abstract

Background
Isavuconazonium is an appealing anti-fungal due to its broad spectrum of activity, predictable pharmacokinetics, oral bioavailability, and lack of QTc prolongation, but real-world experience with it is limited. At our academic medical center, isavuconazonium is restricted to the infectious diseases (ID) service for treatment of invasive fungal infections, including endemic mycoses due to high prevalence, and is recommended for patients intolerant of first-line agents. The purpose of this study was to describe isavuconazonium use at our institution and assess adherence to its formulary guidelines.

Methods
Inpatients with an order for isavuconazonium between June 2016 and November 2018 were analyzed via retrospective chart review. Prescribing team, indication, and rationale for use were evaluated.

Results
There were 97 inpatient encounters with an isavuconazonium order among 57 patients. Of those, 30 were solid-organ transplants and 9 had bone marrow transplants. Indications for isavuconazonium were: histoplasmosis 25%, high-risk fungal prophylaxis 21%, invasive aspergillosis 9%, candidiasis 2%, and other 44% (Table 1). Preceding anti-fungal therapy included: voriconazole 49%, posaconazole 12%, fluconazole 9%, micafungin 7%, amphotericin B 5%, itraconazole 4%, and none 35%. The rationale for the use of isavuconazonium is described in Table 2. ID consultation occurred in 79% of patients. Those without a consult had an indication of prophylaxis or were continuation of therapy started outpatient or at an outside hospital (OSH).

Conclusion
Histoplasmosis was the most common infection treated with isavuconazonium, despite limited data for that indication. Further investigation of the clinical course for these patients is warranted. Reasons for use most commonly centered on concern for QTc prolongation, clinical failure, and drug interactions. Over one-third of patients received no anti-fungal therapy prior to initiation. Adherence to required ID consultation was high. Patients on isavuconazonium for prophylaxis or as continuation therapy without a consult may still benefit from ID review to assess the appropriateness of therapy.

Disclosures
All authors: No reported disclosures.
1036. Clinical impact of an antibiotic time out initiative at an academic medical center
Authors: Taylor Amy P , Coe Kelci E , Stevenson Kurt , Wardlow Lynn , El Boghdadly Zeinab , Reed Erica E 
Published: October 2019

Abstract

Background
The Infectious Diseases Society of America’s guideline for implementing antibiotic (abx) stewardship recommends routine review of abx use. Several studies demonstrate antibiotic time out (ATO) programs result in de-escalation, but there is limited evidence of improved outcomes. The aim of this study was to evaluate the clinical impact of ATO.

Methods
This retrospective study included hospitalized patients at The Ohio State University Wexner Medical Center receiving abx and a documented ATO from 7/1/2017 to 6/30/2018. ATO patients were matched by infection type to abx-treated patients lacking an ATO note. Patients were excluded if they were identified as a protected population, were in the ICU at the time of ATO, had an ATO within 48 hours of discharge, cystic fibrosis, or febrile neutropenia. The primary objective was to evaluate abx optimization in patients with documented ATO vs. those without ATO. Abx optimization was defined as the selection of ideal abx based on guidelines, culture and susceptibility results, or expert opinion when undefined. Secondary outcomes included vancomycin-associated acute kidney injury (VAN-AKI), infection-related length of stay (LOS), all-cause 30-day readmission or mortality, abx days, and nosocomial C. difficile infection (CDI) rates. The Student t-test/Fisher’s exact test and Wilcoxon-rank sum were utilized as appropriate.

Results
One hundred ATO patients were compared with 100 non-ATO patients. Baseline characteristics and infection types were similar between groups. ATO resulted in improved optimization of abx selection (P = 0.05) and duration (P < 0.01), and reduced piperacillin/tazobactam (P/T) and vancomycin (VAN) utilization. No difference was observed in VAN-AKI (22 vs. 20%, P = 0.73), 30-day readmission (28 vs. 27%, P = 0.87), mortality (5 vs. 5%, P = 1), or CDI rates (6 vs. 5%, p = 0.76) in the ATO vs. non-ATO group. However, inpatient abx days (12 vs. 8, P = 0.004) and infection-related LOS (10 vs. 8, P = 0.0006) were shorter in the non-ATO group.

Conclusion
ATO improved optimization of abx selection and duration, and reduced P/T and VAN use. Despite this, clinical outcomes were not improved.

Disclosures
All authors: No reported disclosures.
1064. Antimicrobial Stewardship Program at a Large Academic Medical Center, Impact Over 12 Years
Authors: Kline Susan E , Boeser Kimberly , Houseman Jeana , Saunders Samantha , Johnson Shawnda , Helmin Derrek , Mason Joycelyn , Phelps Pamela 
Published: October 2019

Abstract

Background
The University of Minnesota Medical Center (UMMC) is a tertiary care facility, which has had a comprehensive antimicrobial stewardship program (ASP) for 12 years.

Methods
The antimicrobial stewardship team is comprised of a full-time PharmD and ID staff physicians. Recommendations are placed in the electronic medical record as a progress note. Verbal recommendations may also be made.

Results
There was a downward trend in Hospital-acquired (HA) C. difficile diarrhea from 2007 to 2014 from 1.2 to 0.5/1000 patient-days (pt day). Rates appear stable from 2014 to 2019 with adjustment for change to NHSN lab-based CDI surveillance (Figure 1). From 2009 to 2019 a decrease was seen in VRE hospital-acquired infections (HAI) from 0.53 to 0.21/1,000 patient-days and in MRSA HAIs from 0.2 to 0.14/1,000 patient-days. Newly acquired ESBL HAIs have remained relatively stable from 2009 to 2019 at 0.09 to 0.05/1,000 patient-days. CRE HAIs are low but stable rates at 0.02/1,000 patient-days (Figure 2). We track antimicrobial utilization for internal and national reporting (starting in July 2017). A SAAR for all Antibacterial agents (ICUs, wards, and oncology units) of 1.33 in 2018. Our top four agents average DOT; piperacillin/tazobactam (66.81), cefepime (34.40), oral levofloxacin (23.56) and intravenous meropenem (21.49). We demonstrate lower average DOT for our restricted antimicrobials (206.21) as compared with our nonrestricted antimicrobials (236.74) (Figure 3). Cost savings continued from year to year. After adjusting for inflation annually, our expected costs ($84.08) compared with actual costs ($40.12 ytd 2019), demonstrates effective cost management of antimicrobial agents. (Figure 4)

Conclusion
We observed a decrease in HAIs VRE and C. difficile infections after 3 years of operation, and MRSA after 5 years. This downward trend has continued. ESBL HAIs remain relatively stable and CRE are stable at low rates but remain emerging HAIs of concern. We are now focusing efforts on limiting unneeded fluoroquinolone and carbapenem use. We continue to analyze our SAAR data and internal DOT data to identify areas of opportunity to improve antimicrobial use. The ASP outcomes have continued to cost justify ongoing efforts. The effects of the program and the Infection Prevention Department appear to be synergistic.

Disclosures
All authors: No reported disclosures.
1066. Antimicrobial Stewardship Program: Audit and Feedback for Continued Improvement
Authors: Wang Joseph , Alexander Bryan , Bergman Scott , Ma Jihyun , Stohs Erica J , Van Schooneveld Trevor C , Marcelin Jasmine R , Marcelin Jasmine R 
Published: October 2019

Abstract

Background
Audit and feedback is a foundational approach used by antimicrobial stewardship programs (ASP) and has been our primary method for ASP intervention for over 7 years. We sought to evaluate and improve our ASP methods as well as identify barriers to effective antimicrobial management.

Methods
We distributed an online survey at our institution, to clinicians (prescribers and pharmacists). Results compared their perceptions of the ASP and barriers to antimicrobial stewardship. Descriptive statistics include counts and percentages for categorical variables. Fisher’s exact test was performed to describe the comparison groups for each survey response. We reviewed survey comments and categorized according to themes.

Results
We distributed the survey to 459 clinicians over 4 months with 110 surveys completed for a response rate of 24%. Prescribers comprised 77.3% of respondents. 74.5% of clinicians reported that antibiotic overuse is a problem at our institution. Prescribers were more likely to agree that conflicting priorities to core measures was a barrier to stewardship as well as disagree with current guidelines (P < 0.05) compared with pharmacists. Figure 1 demonstrates other barriers. Prescribers found ASP more helpful than pharmacists in antimicrobial dose adjustments (P < 0.05). Figure 2 demonstrates other scenarios where ASP provided input with varying degrees of perceived helpfulness. Pharmacists used the ASP website more than prescribers (P < 0.05). Text message and phone call were preferred methods of contact with prescribers favoring messages and pharmacists favoring phone calls. Clinicians infrequently used order-sets; Figure 3 demonstrates reasons for lack of use. 17.2% of participants commented about the ASP; of these, 42% were positive and 32% contained suggestions to improve communication and education. Comments are summarized in Figure 4.

Conclusion
Overall, clinicians agree that antimicrobial overuse is a concern at our institution. ASP is generally well received; however, after 7 years of operation, this survey shows that continued improvement is needed, notably in communication, education, and EMR order-sets. Results will be used to refine methods of effective communication and information delivery to nurture an effective relationship.

Disclosures
All authors: No reported disclosures.