bluuebunny/crossref_metadata_2025_split huggingface dataset:
1140. Evaluation of Neonatal Sepsis Guidelines in a Neonatal Intensive Care Unit
Authors: Patel Priya V , Nash Colleen B , Vu Betty N 
Published: October 2019

Abstract

Background
Clinical practice surrounding neonatal sepsis varies significantly among physicians. In efforts to confront the challenge of inappropriate and overuse of antimicrobials in our Neonatal Intensive Care Unit (NICU), a multidisciplinary team developed a guideline for the evaluation and management of suspected and proven sepsis within the NICU in preterm infants. We evaluated the antimicrobial utilization before and after the implementation of our guideline, developed in July 2018.

Methods
All infants <37 gestational weeks born in July and August of 2016, 2017, and 2018 were retrospectively reviewed and compared before and after implementation of the guideline. The primary outcome was the percentage of antibiotic-free days per admission. Secondary outcomes include percentage of directive treatment courses and percentage of antibiotic days for culture-negative sepsis. Chi-square and Mann–Whitney U tests were performed, as appropriate.

Results
A total of 75 and 37 patients were included for preliminary data analysis in the pre- and post-implementation periods, respectively. Chi-square and Mann–Whitney U tests were performed, as appropriate. The percentage of antibiotic-free days per admission per patient born in the pre-implementation period was lower (84.4% vs. 86.5%, P = 0.028). There is no statistical difference in the percentage of directive treatment between the two groups. The percentages of culture-negative antibiotic days were not statistically significant (69.2% vs. 80.5%, P = 0.296). The average birth weights were lower (1,719.7 grams vs. 1,420.7 grams, P = 0.02) and gestational ages were younger (31.4 weeks vs. 29 weeks, P = 0.001) in the post-implementation period.

Conclusion
Our preliminary data did not show a significant decline in the percentage of antibiotic-free days or culture-negative antibiotic days after the implementation of our guideline; however, this may be confounded by the differences noted in our patient populations and is based on preliminary data. Implementation of this guideline is feasible and may reduce the inappropriate use of antimicrobials. Further data collection is ongoing to fully assess the impact of this guideline.

Disclosures
All authors: No reported disclosures.
1141. Implementation of a Pediatric Handshake Antimicrobial Stewardship Program to Improve Antimicrobial Utilization
Authors: Hughes Amanda P , Beganovic Maya , Oram Ronda , Wieczorkiewicz Sarah , Chiang Anthony 
Published: October 2019

Abstract

Background
Antimicrobial stewardship (AMS) programs emerged in response to rising rates of resistance and adverse effects associated with inappropriate antimicrobial utilization. Optimal metrics and strategies (e.g., preauthorization, prospective audit and feedback) for AMS remain to be elucidated. This study evaluated the impact of a multidisciplinary, rounding-based AMS strategy (i.e., Handshake Stewardship) on antimicrobial utilization and prescribing practices at a pediatric hospital.

Methods
This was a single-center, retrospective quality improvement study at a community, teaching children’s hospital. All pediatric and neonatal inpatients with active antimicrobial orders between July 2018 and March 2019 were included in the study, and endpoints were compared with data from July 2017- March 2018. Antimicrobial courses were prospectively audited by a multidisciplinary AMS team, and feedback was provided to the primary teams during Handshake Stewardship rounds. The primary endpoint was a number of interventions made and the corresponding acceptance rates. The secondary endpoint was days of therapy (DOT) per 1000 patient-days. Descriptive statistics were performed on all continuous and categorical data as appropriate.

Results
Of 2238 antimicrobial courses reviewed, 710 (32%) required intervention, and 86% of the interventions made were accepted. The top 3 indications evaluated were respiratory (n = 522, 23%), sepsis/bacteremia (n = 351, 16%), and surgical prophylaxis (n = 266, 12%). Of the respiratory courses reviewed, there were 228 opportunities for antimicrobial optimization. The most common interventions were: bug-drug optimization (n = 208, 29%), discontinuation of anti-infective (n = 136, 19%), and dose optimization (n = 120, 17%). No significant difference was observed for overall, ceftriaxone, meropenem, and vancomycin DOT pre- and post-implementation of Handshake Stewardship. However, a statistically significant reduction in DOTs was observed for piperacillin–tazobactam (15.2 vs. 7.4, P = 0.004) and a nonsignificant reduction in meropenem (9.5 vs. 6.2).

Conclusion
Rounding-based, Handshake AMS was associated with overall high intervention acceptance rates and a reduction in commonly utilized broad-spectrum antimicrobials.

Disclosures
All authors: No reported disclosures.
1144. Evaluation of Nafcillin vs. Vancomycin as Empiric Therapy for Late-Onset Sepsis in the Neonatal Intensive Care Unit
Authors: Magers Jacqueline , Prusakov Pavel , Sanchez Pablo J 
Published: October 2019

Abstract

Background
Empiric therapy for possible late-onset sepsis (LOS) due to Gram-positive bacteria in the neonatal intensive care unit (NICU) has included vancomycin to cover, among other pathogens, coagulase-negative staphylococci (CoNS) which are the most frequent cause of bloodstream infections (BSI). In 2015, Nationwide Children’s Hospital (NCH) neonatal antimicrobial stewardship (nASP) team recommended nafcillin rather than vancomycin, in combination with gentamicin, as the preferred agent for empiric therapy of LOS in infants not colonized with methicillin-resistant Staphylococcus aureus, irrespective of presence of a central venous catheter. The NCH nASP team provides oversight for 6 Columbus NICUs, and Our objective was to evaluate the impact of the vancomycin reduction program, with secondary objectives including duration of therapy, recurrence of BSI within 14 days of completion of therapy, and mortality.

Methods
The pharmacy database at NCH was queried with respect to all nafcillin and vancomycin use from 2013–2018. Pertinent clinical and laboratory data were obtained from the electronic health record (EHR) on all infants who had nafcillin or vancomycin therapy initiated, with each initiation defined as an antibiotic “course.”

Results
From 1/2013 to December 2014 (pre-vancomycin reduction), there was an average of 112 vancomycin and 42 nafcillin courses provided to infants each year. From 1/2015 to December 2018, the use of nafcillin increased to an average of 90 courses while vancomycin decreased to 55 courses per year (P < 0.01). Since the institution of the vancomycin reduction program, preliminary EHR review of 50 infants has shown that 9 had a positive blood culture (7 CoNS; 2 methicillin-susceptible S. aureus; 1 Escherichia coli). All CoNS isolates were resistant to nafcillin, and all infants sterilized the blood culture within 24 hours of vancomycin. The overall median length of therapy was 3 days with nafcillin or vancomycin. However, when excluding rule outs, the median duration of therapy was 9.5 days. There was no BSI recurrence or infection-related death.

Conclusion
An empiric antibiotic regimen that includes nafcillin rather than vancomycin for possible LOS in high-risk infants in the NICU effectively and safely reduced overall vancomycin use.

Disclosures
All authors: No reported disclosures.
1150. Evaluating the Impact of Antibiotic Prophylaxis on the Microbiology and Incidence of Ventriculitis in Patients with External Ventricular Drains
Authors: McCormick Jack , McManus Dayna , Ammar Abdalla A , Topal Jeffrey E 
Published: October 2019

Abstract

Background
External ventricular drains (EVDs) are frequently used in acute brain injuries for continuous intracranial pressure monitoring and cerebrospinal (CSF) fluid diversion. EVDs are associated with a 0–22% risk of ventriculitis. The evidence for antibiotic prophylaxis (AP) for ventriculitis prevention is not robust. This study aimed to delineate the incidence of EVD-related ventriculitis and causative organisms in patients receiving AP.

Methods
A retrospective chart review from 2013 to 2018 at Yale New Haven Hospital was performed. Patients were included if ≥18 years of age, admitted to the neurosciences intensive care unit (ICU), and had AP with cefazolin, vancomycin, sulfamethoxazole/trimethoprim, or clindamycin. Patients were excluded if they had a diagnosis of meningitis or ventriculitis prior to EVD placement, on multiple agents for AP, on antibiotics for indications other than AP, CSF leak, or skull fracture. The primary endpoint was the incidence of ventriculitis per 1,000 EVD-days. Secondary endpoints were causative organisms of ventriculitis, EVD duration, ICU length of stay (LOS), hospital LOS, and 30-day mortality.

Results
Five hundred ninety-nine patients were reviewed and 249 patients were included. Baseline demographics are noted in Table 1. Cefazolin was the most common agent for AP (98%). There were 7 cases of ventriculitis with an incidence rate of 2.8% (4 infections per 1000 EVD-days). All of the causative organisms were resistant to the prophylactic agents administered (Table 2). Patients with ventriculitis had a significantly longer duration of EVD placement (10 ± 3 vs. 7 ± 6 days, P = 0.03), hospital LOS (30 ± 19 days vs. 15 ± 12, P = 0.04), ICU LOS (22 ± 14 vs. 10 ± 7, P = 0.03). Two patients with ventriculitis (28%) died within 30 days of admission compared with 46 patients without ventriculitis (19%, P = 0.53) (Table 3).

Conclusion
The rate of ventriculitis in our study was similar to previous studies that did not utilize AP. All of the causative organisms were resistant to the prophylactic agent. Patients who had ventriculitis had a longer duration of EVD placement, hospital LOS, and ICU LOS; however, 30-day mortality was not impacted. Based on our findings, the use of AP to prevent EVD-related ventriculitis should be reconsidered.

Disclosures
All authors: No reported disclosures.
1160. CAUTIs are the Most Common Type of Healthcare-Associated Infection. In an Effort to Decrease CAUTI Rates Through Proactive Prevention, We Sought to Develop a Weighted Model of CAUTI Risk Factors. The Final Set of Risk Factors Jointly Predicting CAUTI Were ADL Dependent, CVA, Catheter Replacement Within 7 days, and Catheterization Duration ≥5. We Have Defined Contemporary Weighted Risk Factors for CAUTI and Intend to Utilize These to Deploy a Tiered Approach Where Patients with Risk Factors Will Receive Advanced in Addition to Basic Preventive Efforts
Authors: Nanda Neha , Aleksanyan Meline 
Published: October 2019

Abstract

Background
Catheter-associated urinary tract infections (CAUTI) are the most common type of healthcare-associated infection. In an effort to decrease CAUTI rates through proactive prevention, we sought to develop a weighted model of CAUTI risk factors in our patient population.

Methods
A retrospective case–control study was conducted to identify potential CAUTI risk factors in a 401-bed, acute care, tertiary academic facility. Data were collected through chart review of CAUTI cases between January 2014 and June 2018. Controls were catheterized patients who did not develop a CAUTI, and were selected based on the corresponding case event date (±7 days) and location. The case to control ratio was 1:2. A multivariable logistic regression was used to identify CAUTI risk factors by stepwise selection. All tests were 2-sided at a 0.05 significance level. All statistical analyses were performed using SAS 9.4.

Results
We reviewed 501 patients. The mean age was 62.7 years and 51% were female. The most common organisms in CAUTI cases (n = 167) were Escherichia coli (28.7%) and Pseudomonas aeruginosa (18.6%). Median catheterization duration for cases and controls was 8 and 5 days, respectively. Univariate logistic regression analyses revealed the following statistically significant risk factors: female, catheterization duration ≥5 days, ADL-dependent, cerebrovascular disease (CVA), nonoperating room procedure, catheter placement in operating room and history of malignancy. The final set of risk factors jointly predicting CAUTI included ADL-dependent (OR 1.69), CVA (OR 7.3), catheter replacement within 7 days (OR 1.85), and catheterization duration ≥5 (OR 2.1). The final model’s AUC was 0.72. Risk factors were scored using β coefficient from the final model. The highest score attainable was 20 with CVA receiving the maximum weight. The risk score’s ability to classify infection was measured by AUC of 0.60.

Conclusion
In our study, we have defined contemporary weighted risk factors associated with CAUTI. We intend to utilize these findings to deploy a tiered approach where patients with risk factors will receive ‘advanced’ in addition to ‘basic’ preventive efforts. Additionally, our risk score model will allow for prioritizing efforts.

Disclosures
All authors: No reported disclosures.
1164. In vitro Antimicrobial Efficacy of Novel Antimicrobial Dacron Vascular Grafts in the Inhibition of Multidrug-Resistant Gram-Negative Biofilm
Authors: Vargas-Cruz Nylev , Rosenblatt Joel , Reitzel Ruth A , Khalil Kamal , Raad Issam I 
Published: October 2019

Abstract

Background
Vascular graft infections can be a devastating complication in vascular reconstructive surgery. Management of these infections is highly invasive and includes excision of the graft, debridement of infected material, and in situ reconstruction. There is a need for additional strategies for infection prevention in graft surgeries. The minocycline + rifampin + chlorhexidine (MRCH) triple combination had been previously demonstrated to be effective against biofilm formation in central venous catheters. In this study, we evaluated in vitro effectiveness and durability of MRCH coated Dacron vascular grafts in inhibiting multidrug-resistant Gram-negative biofilm formation.

Methods
Dacron vascular grafts were coated with MRCH based on a proprietary method. Antimicrobial efficacy at baseline and 3-week durability was assessed using a well-established in vitro biofilm colonization model. Multidrug-resistant Gram-negative pathogens tested include CRE Escherichia coli (EC), MDR Pseudomonas aeruginosa (PS) and CRE Klebsiella pneumoniae (KB). Antimicrobial durability was assessed for grafts that had been eluting in serum for 3 weeks prior to testing. Baseline and 3-week grafts were quantitatively culture to enumerate any biofilm viable biofilm colonization. Uncoated Dacron grafts were used as controls.

Results
At baseline and 3 weeks MRCH vascular grafts completely inhibited biofilm formation resulting in an 8-log10 reduction in bacterial colonization compared with uncoated grafts.

Conclusion
MRCH coated Dacron vascular grafts demonstrated in vitro effectiveness for at least 3 weeks in preventing biofilm colonization by multidrug-resistant Gram-negative pathogens. Further in vivo testing is warranted.

Disclosures
All authors: No reported disclosures.
1170. A Quality Improvement Study to Assess the Effectiveness of a Meaningful Use Protocol in the Reduction of PICC Line Use and Complications
Authors: Dillon William P , Szpunar Susan , Sharma Mamta 
Published: October 2019

Abstract

Background
The use of peripherally-inserted central catheters (PICC) has grown substantially over time because of their ease of insertion, cost-effectiveness and relative safety. With increased use; however, there are increased complications including catheter-related bloodstream infections (CLABSI) and PICC line-associated deep vein thrombosis (DVT). To help decrease complications a meaningful use protocol was implemented based on the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) to define appropriate indications for PICC line use. The objectives of this study were (1) to determine the rate of PICC line use at our hospital; (2) to determine rates of complications associated with PICC lines, including CLABSI and DVT; and (3) to compare the metrics listed above before and after implementation of the meaningful use protocol.

Methods
We performed a retrospective chart review of all inpatient admissions before (June 1, 2017 to September 1, 2017) and after the implementation of the meaningful use protocol (June 1, 2018 to September 1, 2018). Patients who had a PICC line inserted at another institution or in the outpatient setting were excluded. We compared the rate of insertion, patient demographics, characteristics of the use of PICC lines and complications from the two periods. Data were analyzed using the chi-squared test, Student’s t-test, the Mann–Whitney U test and the z test for proportions.

Results
We reviewed 281 patient charts, 166 before the implementation of the meaningful use protocol and 115 after implementation. Overall, the mean age was 55.8 ± 17.9 years, 58.7% male and 54.1% white. There were no significant differences between groups with respect to demographics, comorbidities, source of admission, or complications. Post-implementation there was a significant reduction in lines used for unknown reasons as well as lines used for multiple blood draws (P <0.0001). The overall rate of PICC line use decreased from 23 per 1,000 admissions to 17.2 per 1,000 admissions after the intervention (P = 0.007).

Conclusion
Implementation of a meaningful use protocol reduced the rate of PICC line use at our institution by 25%. The proportion of lines used for unknown reasons decreased as well. Widespread implementation could have a significant impact on the reduction of PICC line use.

Disclosures
All authors: No reported disclosures.
1178. Cardiac Device Infection: Do We Follow the Guidelines?
Authors: Nagarakanti Sandhya , Bishburg Eliahu , Bapat Anita 
Published: October 2019

Abstract

Background
Cardiovascular implantable electronic device (CIED) such as pacemaker (PPM) and automated implantable cardiac defibrillator (AICD) are commonly utilized in clinical practice. Definitions of device infection (DI) and guidelines for the work up and device extraction (DE) have been published by the American Heart Association and the Infectious Disease Society of America. Our objective was to evaluate whether the work up of DI as recommended was followed, and whether the device was extracted according to guidelines.

Methods
A retrospective review in a 680-bed tertiary care hospital. Adult patients (patients) >18 years. who were diagnosed as having a DI and had the device extracted between 2008 and 2017 were included. Data were collected on demographics, device duration, blood culture (BC), echocardiogram utilization, lead cultures (LC) and device pocket cultures, appropriateness of extraction as per guidelines.

Results
Ninety-five patients were included. Mean age 68 years (range 23–90). 67 (70%) were male. Devices included: AICD in 75 (79%), PPM in 20(21%). CIED was present <1 year prior to infection in 24(24%). Compliance with guidelines recommendation to draw blood cultures, obtain an echocardiogram and send lead cultures and device pocket cultures were seen in 100%, 90.5% and 49.4% and 67.7%, respectively. Criteria for extraction was met in 65/95 (69%); reason for extraction was a pocket infection in 16/65(24.6%), bacteremia in 49/65 (75%), infective endocarditis in 38/65(58%). Thirty (31.5%) had device extracted without meeting guidelines recommendation, in 17 a diagnosis of pocket infection but without microbiological criteria or clinical diagnosis. In 9 patients lead vegetations were seen but no cultures to support extraction. Mortality was seen in 4 patients, one during the extraction procedure.

Conclusion
In our institution, 1/3 of the patients diagnosed with DI had no indication for DE. Guidelines recommendation for CIED extraction should be followed as extraction could be associated with significant complications. In this study, overall compliance with guidelines work up recommendations were not consistently followed, especially LC and device pocket cultures.

Disclosures
All authors: No reported disclosures.
1185. Impact of Utilizing Drug Resistance in Pneumonia (DRIP) Score on Management of Pneumonia
Authors: Sandhu Avnish , Goldman Erin , Polistico Jordan , Polistico Sarah , Oudeif Ahmed , Aranha Anil , Murray Kyle P , Zhao Jing , Mynatt Ryan , Pogue Jason M , Dhar Sorabh 
Published: October 2019

Abstract

Background
Pneumonia is a leading cause of infection-related admissions and death. It is imperative that appropriate antibiotic therapy is selected. Traditional scoring systems for identifying at-risk persons for drug-resistant pathogens– i.e., Healthcare-associated pneumonia (HCAP), have been inaccurate and often lead to inappropriate antibiotic selection. A novel pneumonia scoring system –“Drug Resistance in Pneumonia (DRIP)” was implemented at the Detroit Medical Center (DMC) in January 2018. The objective of this study was to evaluate the effectiveness of the DRIP score in reducing the use of broad-spectrum antibiotics and the impact on key outcomes in patients treated for pneumonia.

Methods
A retrospective chart review of 89 patients admitted to the DMC for treatment of pneumonia was conducted—45 patients prior to and 44 patients post-implementation of the DRIP score. Basic demographics, signs and symptoms, antibiotics data, pneumonia severity score (CURB – 65), Charlson co-morbidity score, and outcome measures were compared. DRIP scores and HCAP risk factors were calculated for all patients. The definitions of broad-spectrum antibiotics (BSA) were consistent with DMC guidelines for the treatment of pneumonia (antibiotics targeting nosocomial Gram-negative organisms and/or methicillin-resistant Staphylococcus aureus).

Results
Demographics are shown in Table 1. 18 (40%) of the pre-implementation cohort had risk factors for resistance (HCAP risk factors) compared with 14 (32%) in the post. Conversely, 15 (33%) of the pre-implementation cohort had risk factors for resistance (DRIP ≥4) compared with 8 (18%) in the post-implementation period (Table 2). A difference in BSA prescribing was seen in patients previously characterized as having a high risk of resistance (HCAP) but with DRIP score <4 [5/7 (72%) vs.1/7 (16%) (Table 2)]. BSA use was 24 (53%) in the pre-implementation cohort and 12 (27%) in post-implementation cohort, P = 0.03. Durations of antibiotics were 8.3 days vs. 9.8 days respectively, P = 0.04. Readmission with pneumonia at 30 days was 3 (7.5%) for both groups.

Conclusion
The implementation of a novel DRIP scoring system resulted in improved prescribing patterns and a significant reduction of broad-spectrum antibiotics by 26% as compared with traditional HCAP score.

Disclosures
All authors: No reported disclosures.