bluuebunny/crossref_metadata_2025_split huggingface dataset:
1025. Inappropriate Aztreonam Usage – Antimicrobial Stewardship Strikes Back
Authors: Smith Brandon J , Batykefer Bridget , Andrzejewski Christina , Yassin Mohamed , Arbulu Ricardo 
Published: October 2019

Abstract

Background
Several studies have demonstrated that patients with reportedly β-lactam allergies (BLA) receive less efficacious and more toxic alternative antibiotics. A previous study at our institution utilizing aztreonam as a surrogate marker for BLA demonstrated nearly 50% of patients receiving aztreonam had previously tolerated an alternative β-lactam (BL). In response to those results, our Antimicrobial Stewardship Program (ASP) provided dedicated hospitalist, medical resident and pharmacist education on appropriate utilization of aztreonam and BLA. Additionally, members of the ASP team began receiving real-time clinical surveillance alerts for all aztreonam orders.

Methods
A retrospective chart review of inpatients >18 years old who received at least one dose of aztreonam between July 1, 2018 – December 31, 2018. Patients were excluded if they did not have a documented BLA or if they received aztreonam as de-escalation therapy. Cost of aztreonam therapy was compared with the cost of alternative BL agents based on prior and subsequently tolerated classes of BLs. Comparator agents included: piperacillin/tazobactam (penicillin), cefepime (cephalosporin) and meropenem (carbapenem). Comparisons of total number of aztreonam patients and doses, cost of aztreonam, and cost of alternative therapy were compared with the index population from 2017

Results
Similar to our prior study, 43.7% (48.5% in 2017) had prior BL tolerance with an additional 31.3% (19.4% in 2017) demonstrated subsequent BL tolerance following aztreonam administration. Following the ASP interventions, orders, doses and cost of aztreonam was reduced. Forty-eight patients during the 6-month period received aztreonam, a 26.7% reduction. There was a 38.5% reduction in the number of aztreonam doses (P = 0.001), which yielded a cost savings of $14,067.67 (extrapolated to 1 year). Median aztreonam cost in 2017 $382.40 vs. $191.20 in 2018 (P = 0.004). In 2018, 41.7% of patient’s allergy profiles were appropriately updated compared with 3.3% in 2017.

Conclusion
Our study demonstrates that ASP interventions including increased education, allergy documentation and clinical surveillance alerts targeted at reducing aztreonam utilization can reduce pharmaceutical expenditures.

Disclosures
All authors: No reported disclosures.
1027. Vancomycin Use in Community-Acquired Pneumonia: Assessing Inappropriate Therapy
Authors: Shan Timothy , Gore Sara J , McCracken Caitlin M , Tallman Gregory B , Holmer Haley K , Bearden David T , McGregor Jessina C 
Published: October 2019

Abstract

Background
Current Infectious Disease Society of America guidelines recommend anti-methicillin-resistant Staphylococcus aureus(MRSA) agents for treatment of community-acquired pneumonia (CAP) only in specific high-risk patients. There are limited data on duration of vancomycin use that is appropriate in hospitalized patients with CAP. The objective of this study was to evaluate the use of vancomycin for CAP among inpatients.

Methods
We conducted a retrospective cohort study of inpatients at Oregon Health and Science University Hospital from August 1st, 2017 to July 31st, 2018 who received IV vancomycin and had a pneumonia encounter ICD-9 diagnosis code. Patients with hospital or ventilator-associated pneumonia were excluded. Appropriate therapy was defined as empiric therapy with known risk-factors, concordant therapy with no de-escalation option, or concurrent sepsis or febrile neutropenia. Vancomycin appropriateness was assessed based on medical history and microbiology for both empiric and definitive therapy. We characterized patients receiving inappropriate therapy and calculated the proportion of inappropriate days of therapy (DOT).

Results
We identified 52 patients with CAP who were treated with vancomycin for a median of 2 DOT (Interquartile Range (IQR): 1–3). Approximately 21% (11/52) of patients had risk factors warranting vancomycin empiric therapy and 42% (22/52) had concurrent sepsis. Nine CAP patients received inappropriate courses of vancomycin, median of 1 day (IQR: 1–2.25) of inappropriate therapy. The most common reason for classifying use as inappropriate was a positive culture for organisms other than MRSA. Patients receiving inappropriate therapy were more frequently transferred from another hospital (44% vs. 30%, P = 0.22). Overall, 16% (20/125) of vancomycin DOT were inappropriate.

Conclusion
In our study,CAP patients accounted for a small number of pneumonia patients who received vancomycin. The median inappropriate DOT was relatively short, possibly indicating that identification and de-escalation was performed quickly. Further work is required to determine the impact of these findings on patients.

Disclosures
All authors: No reported disclosures.
1030. Analysis of a Novel Mortality Prediction Rule for Organizing and Guiding Antimicrobial Stewardship Team Activities
Authors: Collins Curtis D , Scheidel Caleb , Dietzel Christopher J , Leeman Lauren R , Morrin Cheryl A , Malani Anurag N 
Published: October 2019

Abstract

Background
Antimicrobial stewardship team (AST) surveillance at our hospital is facilitated by an internally-developed database. In 2013, the database was expanded to incorporate a validated internally-developed prediction rule for patient mortality within 30 days of hospital admission. AST prospective audit and feedback expanded to include all antimicrobials prescribed in patients with the highest risk for mortality determined by risk score. This study describes the impact of an expanded AST review in patients at the highest risk for mortality.

Methods
This retrospective, observational study analyzed all adult patients with the highest mortality risk score who received antimicrobials not historically captured via AST review. Patients were identified through administrative and AST databases. Study periods were defined as 2011 – Q3 2013 (historical group) and Q4 2013 – 2018 (intervention group). Primary and secondary outcomes were assessed for confounders including demographic data and infection-related diagnoses. Outcomes were assessed using both unweighted and propensity score weighted versions of the t-test or Wilcoxon rank-sum test for continuous variables and the chi-squared test or Fisher’s Exact test for discrete variables.

Results
A total of 2,852 and 5,460 patients were included in the historical and intervention groups, respectively. After adjusting for demographic and clinical characteristics, there were significant reductions in median antimicrobial duration (5 vs. 4, P = 0.002), antimicrobial days of therapy (7 vs. 7, P = 0.001), length of stay (LOS) (6 vs. 5 days, P = 0.001), intensive care unit (ICU) LOS (3 vs. 2 days, P < 0.001), and total hospital cost ($11,017 vs. $9,134, P < 0.001) in the intervention cohort. There were no significant differences observed in 30-day mortality or 30-day readmissions. Secondary analyses showed significant decreases in fluroquinolone and intravenous vancomycin utilization between cohorts.

Conclusion
Reductions in antimicrobial use, inpatient and ICU length of stay, and total hospital costs were observed in a cohort of patients following incorporation of a novel mortality prediction rule to guide AST surveillance.

Disclosures
All authors: No reported disclosures.
1050. Impact of Weekend Infectious Diseases and Antimicrobial Stewardship Pharmacy Services
Authors: Bohn Brian C , Neuner Elizabeth A , Athans Vasilios , Rivard Kaitlyn R , Riffle Allison R , Richter Sandra S , Fraser Thomas G , Gordon Steven M 
Published: October 2019

Abstract

Background
In September 2018, pharmacy antimicrobial stewardship services were expanded to include weekends at Cleveland Clinic. Activities performed by antimicrobial stewardship (AMS) pharmacists on the weekend include blood culture rapid diagnostic (RDT) review, antiretroviral therapy (ART) review, prospective audit and feedback (PAF) utilizing clinical decision support, vancomycin dosing, and operational support. The purpose of this study was to assess the operational and clinical impact of these expanded AMS services.

Methods
This single-center, the quasi-experimental study included data from 13 weekends before (9/2017 – November 2017) and after (9/2018 – November 2018) implementation of weekend services. The primary outcome was the number of reviews relating to each stewardship activity. Secondary outcomes were time to AMS opportunity resolution, time to escalation or de-escalation following PAF or RDT alert, time to resolution of other AMS-related opportunities, length of stay (LOS), and antimicrobial use outcomes. Patients were included in time to resolution outcomes if they had an RDT, ART, or select PAF review requiring intervention. Time to opportunity resolution was defined as the time from AMS alert to implementation of the recommendation in the electronic health record.

Results
During the post-intervention period 1261 reviews were conducted, averaging 97/weekend. This included 187 RDT, 432 PAF, 124 ART, 331 vancomycin dosing notes and 187 other. Inclusion criteria for time to resolution outcomes were met by 72 patients pre-intervention compared with 59 patients post. No significant differences were seen in baseline characteristics between groups with 43% of patients requiring ID consultation and 58% requiring ICU admission. The median time to opportunity resolution improved significantly overall (P < 0.01), with de-escalation (P = 0.03), and with time to other AMS opportunity (P = 0.01) (Figure 1). A numerical reduction was seen with time to escalation (P = 0.1). LOS was a median of 13 and 14 days pre- and post-intervention, respectively (P = 0.4). No differences were seen in antimicrobial use outcomes.

Conclusion
Presence of pharmacist-driven weekend AMS services significantly reduced time to resolution of AMS interventions. These data support the value of weekend AMS services.

Disclosures
All authors: No reported disclosures.
1062. Provider-Based Survey to Determine the Relative Importance of Clinical Factors Used to Make Empiric Antibiotic Decisions
Authors: Kim Casey J , Szymczak Julia E , Herman David J , Kennedy Leigh A , Talati Naasha J , Akhter Shafinaz N , Schnellinger Erin M , Hamilton Keith W 
Published: October 2019

Abstract

Background
Despite advances in rapid organism identification, clinicians must make empiric antibiotic decisions prior to knowing the causative organism. Though many risk factors and patient characteristics have been studied and incorporated into predictive clinical decision support tools for empiric antibiotic prescription, little evidence exists on the relative importance of these factors in clinician judgment. The purpose of this study was to establish how providers evaluate patient and clinical risk factors when making empiric antimicrobial decisions.

Methods
An anonymous survey tool was distributed in February 2019 to medical providers who routinely prescribe antibiotics in 4 acute care hospitals throughout the University of Pennsylvania Health System. Providers were asked to rank the importance of 12 clinical factors using a 5-point scale from not important at all (1) to extremely important (5) in 3 unique clinical scenarios: uncomplicated cystitis, septic shock of unknown etiology, and uncomplicated pneumonia.

Results
Response rate was 30% (217/732). The importance of each factor varied among different clinical scenarios except for prior antibiotic exposure, local resistance patterns, drug-drug interactions, and treatment guidelines. However, the absolute difference varied by the factor and clinical scenario. Presence of indwelling catheter(s) had the largest absolute variation (median difference of 2 between septic shock and pneumonia, P < 0.001), and it was one of the top 5 most important factors for septic shock, but the least important factor for pneumonia.

Conclusion
The importance of clinicians place on clinical factors varies in different clinical scenarios. A better understanding of clinical decision-making in empiric antibiotic prescribing has the potential to guide stewardship efforts and clinical decision support.

Disclosures
All authors: No reported disclosures.
1067. Variation of Antimicrobial Stewardship Programs’ Membership and Organization Within a Single Health System
Authors: Bariola J Ryan , Khadem Tina 
Published: October 2019

Abstract

Background
Antimicrobial stewardship programs (ASPs) vary in terms of members and administrative (admin) structure. Joint Commission (TJC) has member requirements, but little is known about adherence or how ASP’s fit into hospitals’ admin structures. We reviewed the makeup and organization of ASP’s within a single healthcare system.

Methods
Survey of pharmacy directors or ASP pharmacists at 14 system hospitals in January 2019.

Results
All hospitals responded. All are TJC accredited. Thirteen (92%) had a local stewardship committee. Of these 13, 6 (42%) met quarterly, 4 (30%) monthly, and 3 (21%) every other month. 9 (69%) were a subcommittee of Pharmacy and Therapeutics, and 1 (11%) was a separate committee. 3 (23%) had no clearly defined reporting structure. Figure 1 shows ASP committee compositions. 9 (69%) had all TJC required members, if ID physician is considered a required member. All had pharmacy representation but only 4 (30%) had a pharmacist with ID training. Most had representation from ID physicians (10), Infection Prevention (12), other practitioners (11), and microbiology lab (9). Less than half had hospital admin members, and only 2 had nursing members. None had Information Technology (IT) representation. 12 (92%) created minutes, but only 4 (30%) forwarded minutes for review by hospital admin. Tables 1–3 describe relationships between hospitals based on bed size, if they submitted minutes for review, and if they had both an ID pharmacist and ID physician as members. No hospital indicated citations during a TJC visit about membership or organization.

Conclusion
ASPs within even a single health system vary as to membership and organizational structure. Some did not have all TJC required members. With few having admin representation or submitting minutes for admin review, it raises the concern of ASPs being ignored and possible noncompliance with TJC requirements regarding leadership support. ASP’s should actively work with hospital admins to ensure they have all needed representation and develop reporting mechanisms that keep hospital admins aware of their successes and needs. Lack of involvement from pharmacists with ID expertise, nursing, and IT are issues also. Larger evaluations are needed to determine whether membership and administrative structure can impact antimicrobial usage.

Disclosures
All authors: No reported disclosures.
1070. Handshake Antimicrobial Stewardship as a Model to Prevent Patient Safety Incidents and Recognize Diagnostic Errors
Authors: Searns Justin B , Williams Manon , MacBrayne Christine , Wirtz Ann , Parker Sarah , Grubenhoff Joseph A 
Published: October 2019

Abstract

Background
Patient safety incidents (PSIs), such as diagnostic errors, are common events that may lead to significant patient harm. Few studies describe the impact that antimicrobial stewardship programs (ASPs) have preventing PSIs and recognizing diagnostic errors. Handshake Stewardship has emerged as a specific ASP model that involves prospective review of hospital-wide antimicrobial ordering with a compressed “second look” of relevant clinical and historical patient data. In person recommendations are then provided directly to the medical team. The objective of this project was to evaluate the potential impact that Handshake Stewardship has on preventing PSIs and recognizing diagnostic errors.

Methods
Following Children’s Hospital Colorado (CHCO) ASP’s implementation of the Handshake Stewardship model in October 2013, the CHCO ASP team began prospectively self-labeling interventions as “Great Catches” (GCs). These GCs were defined as any ASP intervention that “notably changed the trajectory of patient care.” Patient charts for all GCs from October 2014 through May 2018 were retrospectively reviewed and each intervention was assigned one or more descriptive category labels including: administration error, de-escalation/escalation of therapy, bug-drug mismatch, inappropriate dose/duration, potential adverse effect, alternative diagnosis, additional testing, prevent hospital admission, and epidemiology alerts. In addition, each intervention was scored using the previously validated “Safer Dx Instrument” to determine which GCs intervened on a potential diagnostic error.

Results
From October 2014 through May 2018 there were 87,322 admissions to CHCO. Our ASP team intervened on 6,735/87,322 (7.7%) of these admissions. Of these, 174/6,735 (2.6%) were prospectively labeled by ASP providers as GCs, of which 44/174 (25%) resulted in new infectious disease consultations.

Conclusion
Given the frequency and significance of PSIs including diagnostic error, systems are needed to help recognize and prevent patient harm. The Handshake Stewardship model may help prevent PSIs and recognize diagnostic errors among hospitalized children.

Disclosures
All authors: No reported disclosures.
1071. Implementation and Impact of an Antimicrobial Tier Structure Along with Prospective Audit and Feedback at a Large Health System: Collaborations for Care Transformation
Authors: Minor Sarah Brooks , Rafferty Kelly D , Rutkowski Julia , Allison Steven , Herrera Victor 
Published: October 2019

Abstract

Background
Antibiotic overuse continues to be a challenge in the acute care setting. At AdventHealth Orlando (AHO), pharmacy-led prospective audit with feedback (PAAF) has been the primary stewardship tool. Despite PAAF and criteria for use, overall utilization of high-cost, broad-spectrum agents continues to increase. Recently, the Antimicrobial Stewardship Awareness Program (ASAP) employed transformation medical directors (TMDs) and, along with the pharmacy team, developed a novel concept using an antimicrobial tier structure, in addition to historical PAAF. The purpose was to assess the impact of the tier structure, along with PAAF performed by the pharmacists and TMDs, compared with PAAF alone.

Methods
This retrospective pre (March–August 2018)- and post (October 2018–March 2019) implementation study was conducted at AHO. The ASAP team developed a hospital-wide policy listing antimicrobials based on a tier system (Figure 1), with higher priority agents falling in tiers 3 (T3) and 4 (T4). Education was completed in September 2018 and the process was implemented in October 2018. Criteria for use was evaluated at the point of order entry, followed by PAAF by the pharmacist and TMD. The primary outcome was impact on T3 and T4 antimicrobial utilization, measured in days of therapy (DOT) per 1,000 days present (DP). Secondary outcomes included T3 and T4 antimicrobial cost/adjusted patient-days and rates of hospital-acquired C. difficile infections (CDI).

Results
During the post-implementation period, the average DOT per 1,000 DP for T3 and T4 agents decreased by 21.3% (89 vs. 70, P = 0.001) compared with the pre-implementation period (Figure 2). Average T3 and T4 antimicrobial costs decreased by 26% during the post-implementation period ($9.83 vs. $7.27, P < 0.001). Additionally, rates of hospital-acquired CDI decreased by 14% (P = 0.41) during the post-implementation period.

Conclusion
The tier concept, along with PAAF collaborations between the pharmacists and TMD, allowed for a greater impact on antimicrobial utilization, compared with pharmacist-led PAAF alone. In addition to significant decrease in antimicrobial utilization, substantial cost-savings were demonstrated. A nonsignificant declining trend in the incidence of hospital-acquired CDI was also noted during the post-implementation period.

Disclosures
All authors: No reported disclosures.
1111. Characterization of Antibiotic Ordering in Patients with Mental Status Changes and Presumed Urinary Tract Infection in Patients 65 and Older
Authors: Harrington Nicole , Leri Jessica , Shoop Scott 
Published: October 2019

Abstract

Background
Altered mental status (AMS) is the most common diagnosis among those 65 and older who present to the emergency department (ED). Urinary tract infections (UTIs) account for 15.5% of hospitalizations in this population. The purpose of this study was to determine the incidence of initiation of antibiotics in the ED in patients 65 years and older with mental status changes and asymptomatic bacteriuria or negative urine cultures.

Methods
A retrospective chart review was performed to evaluate patients aged 65 and older from January 2017 through June 2018 who presented to the ED from home with AMS, a urinalysis that reflexed to culture, and were admitted to an internal medicine unit. The primary outcome was defined as the percentage of patients with AMS who received antibiotics in the ED with asymptomatic bacteriuria or negative urine cultures. Secondary outcomes included adherence to the CCHS UTI antibiotic guideline, incidence of early discontinuation of antibiotics, culture sensitivity to ordered antibiotic, and disposition after discharge.

Results
A total of 91 patients were included in this study. Seventy-five patients had asymptomatic bacteriuria and antibiotics were started in the ED in 63 (84%) of these patients. Fourteen patients had no growth on culture and seven of these patients (50%) had antibiotics initiated in the ED. Of those who received antibiotics (n = 82), there was 81.7% adherence to the Christiana Care UTI antibiotic selection guideline. Sensitivities were available for 41 isolates and 65.9% were sensitive to the initial antibiotic administered. Antibiotics were discontinued early in 29/82 (35.4%) of patients. Thirty-one patients (33.7%) were discharged to a skilled nursing facility.

Conclusion
These results indicate that the majority of patients aged 65 and older who presented to the emergency department with altered mental status and no other UTI symptoms such as dysuria, urinary frequency, or urgency were treated with antibiotics. When antibiotics are initiated the majority of providers are adhering to organizational guidelines for antibiotic selection and duration. The results will be shared with Emergency Department and Internal Medicine leadership to foster practice change.

Disclosures
All authors: No reported disclosures.