bluuebunny/crossref_metadata_2025_split huggingface dataset:
2056. Retrospective Analysis of Intravenous Vancomycin Outcomes in Patients Discharged to Skilled Nursing Facilities
Authors: Gibson Heather D , Arnoczy Gretchen S , Kessell Andrew , Jawanda Jaspaul S 
Published: October 2019

Abstract

Background
Patients treated with intravenous (IV) vancomycin at skilled nursing facilities (SNFs) are at increased risk for adverse events.

Methods
Single-center, retrospective chart review to assess specific outcomes of patients receiving IV vancomycin discharged to an SNF from a single institution under the care of infectious diseases (ID) physicians. Population included all patients under the care of an ID provider between November 1, 2017 and October 31, 2018 with GFR > 30 who were discharged to an SNF on IV vancomycin for a minimum of 2 weeks. Patients with chronic kidney disease and patients younger than 18 years old were excluded. It was intended that all patients have weekly labs, including vancomycin troughs, communicated to the ID provider. Outcomes evaluated included complications related to vancomycin therapy, assessment of appropriate trough timing and sub-therapeutic troughs (defined as a trough less than 10), and assessment of communication to the prescribing physician. Complications were defined as vancomycin trough greater than 30, increase in serum creatinine greater than 0.5 above baseline, documented adverse events related to vancomycin, or hospital readmission during antibiotic therapy.

Results
25 patients who met inclusion criteria were admitted to 14 different SNFs. Osteomyelitis was the most common indication and MRSA was the most commonly isolated organism. 13 of 25 patients experienced the predefined complications; 5 of 25 patients had at least one trough value greater than 30. 13 of 25 patients had troughs drawn at inappropriate times in relation to doses and 15 of 25 patients had either absent or incomplete labs communicated to the prescriber. 4 of 25 patients had at least one trough value less than 10. Only 2 of 25 patients assessed had no complications, troughs appropriately drawn, and lab values communicated to the prescriber.

Conclusion
Patients discharged to SNFs on vancomycin had high rates of complications, low rates of appropriate laboratory monitoring, and poor communication between SNFs and the prescribing ID physician. Vancomycin administration at an SNF warrants careful monitoring for patient safety and demonstrates an area with significant opportunity for improvement.

Disclosures
All authors: No reported disclosures.
2058. Patient Satisfaction Not Impacted by Antibiotic Prescribing for Viral Upper Respiratory Infections
Authors: Ray Michael J , Tallman Gregory B , McCracken Caitlin M , Elman Miriam R , McGregor Jessina C 
Published: October 2019

Abstract

Background
Treating viral upper respiratory infections (URI) with antibiotics is a major contributor to the rise of antimicrobial resistance. Major drivers of unnecessary prescribing are a patient’s expectation to receive an antibiotic for acute illness and the physician’s desire to provide satisfactory care. Our objective was to determine whether receiving an antibiotic prescription for a URI is associated with increased patient satisfaction.

Methods
We identified emergency department (ED) and ambulatory visit (AC) visits with an acute URI diagnosis code between September 2015 and May 2016 that had an associated patient satisfaction survey. The survey queried patients’ overall satisfaction (“Overall rating of care received during your visit”) using a Likert-type scale ranging from 1 (Very Poor) to 5 (Very Good). We assessed survey responses among patients receiving and not receiving antibiotics using the Wilcoxon rank-sum test. Results from ED and AC visits were compared separately.

Results
We collected survey responses from 282 ED patients and 1306 AC patients with acute URI. Compared with non-recipients, ED respondents receiving an antibiotic were more likely to be female (67% vs. 55%) and on Medicare (28% vs. 21%); AC respondents receiving a prescription were more likely to be female (68% vs. 61%) and have private insurance (63% vs. 53%). Overall satisfaction was very high (Median = 5, IQR 4–5 for both groups). Median responses did not differ by antibiotic prescription status in either group (rank-sum P = 0.4 and 0.8 for ED and AC respectively). When dichotomizing the overall satisfaction score, more patients receiving an antibiotic reported satisfaction of good to very good than those not receiving an antibiotic (84% vs. 76%; Pearson’s Χ2P = 0.1) among ED patients, but not AC patients (95% vs. 94%; P = 0.5).

Conclusion
Patient satisfaction with their visit was not strongly associated with antibiotic receipt among ED and AC patients with URI in our study. This finding suggests that providers may limit the spread of antibiotic resistance by ceasing to unnecessarily prescribe antibiotics without jeopardizing patient satisfaction. Given low response rates to visit satisfaction surveys, further work is needed to verify the validity of this study and evaluate its generalizability.

Disclosures
All authors: No reported disclosures.
2085. Bedside Nurses Improve Antimicrobial Stewardship and Infection Prevention Outcomes: Results of a 3.5-Year Study in Three Hospital Telemetry Units
Authors: Ha David , Bette Forte Mary , Broberg Victoria , Olans Rita , Olans Richard , OYong Kelsey , Kullar Ravina , Catipon Nora , Ancheta Vickie , Desai Mamta , Khattak Yesenia , Okamoto Donna , Lira Donna , Chan Sarah , Mourani John , Gluckstein Daniel , McKinnell James 
Published: October 2019

Abstract

Background
Minimal literature exists to demonstrate the quantitative impact of bedside nurses in antimicrobial stewardship (AMS). We initiated bedside nurse-driven AMS and infection prevention (AMS/IP) rounds on three inpatient telemetry units of a community regional medical center. Rounds were nurse-driven, involved an infectious diseases (ID) pharmacist and infection preventionist, and were designed to complement traditional ID pharmacist and ID physician AMS rounds. Rounds were focused on use of antibiotics, urinary catheters (UCs), and central venous catheters (CVCs). Recommendations from rounds were communicated by the bedside nurse either directly to providers or to the ID pharmacist and ID physician for intervention.

Methods
This was an observational, multiple-group, quasi-experimental study conducted over 3.5 years (July 2015 to December 2018) to characterize the impact of bedside nurse-driven AMS/IP rounds on antibiotic, urinary catheter and CVC use, hospital-onset C. difficile infection (CDI), catheter-associated urinary tract infections (CAUTI), and central line-associated bloodstream infections (CLABSI). Outcomes were assessed in two cohorts based on time of AMS/IP rounds implementation (Cohort 1 implemented on one telemetry unit in July 2016, Cohort 2 implemented in two telemetry units in January 2018).

Results
A total of 2,273 patient therapy reviews occurred (Cohort 1: 1,736; Cohort 2: 537). Of these reviews, 1,209 (53%) were antibiotics, 879 (39%) were urinary catheters, and 185 (8%) were CVCs. Pre- vs. post-intervention, significant reductions were observed in both cohorts for mean monthly antibiotic days of therapy per 1,000 patient-days (Cohort 1: 791 vs. 688, P < 0.001; Cohort 2: 615 vs. 492, P < 0.001), UC days per patient day (Cohort 1: 0.25 vs. 0.16, P < 0.001; Cohort 2: 0.19 vs. 0.14, P < 0.001), CVC days per patient day (Cohort 1: 0.15 vs. 0.11, = 0.002; Cohort 2: 0.09 vs. 0.07, p = 0.005), and CDI per 10,000 patient-days (Cohort 1: 17.8 vs. 7.1, p = 0.035; Cohort 2: 19.1 vs. 5.4, p = 0.003). Numerical reductions were observed in CAUTI and CLABSI per 10,000 patient-days.

Conclusion
Bedside nurses can improve AMS and IP outcomes in a scalable fashion when supported by an interdisciplinary AMS/IP team and are complimentary to traditional AMS and IP practices.

Disclosures
All authors: No reported disclosures.
2091. Use of Telehealth to Expand Antimicrobial Stewardship Capacity Among Critical Access Hospitals in Washington State
Authors: Kvak Staci , Bryson-Cahn Chloe , D’Angeli Marisa A , Kassamali Zahra , Jain Rupali , Chan Jeannie D , Martinez-Paz Natalia , Pottinger Paul , Lynch John B , Lynch John B 
Published: October 2019

Abstract

Background
Critical access hospitals (CAH), defined as those with 25 or fewer beds and/or located in rural settings, may have difficulty implementing core elements of antimicrobial stewardship (CES) due to limited human resources, expertise, and funding. A 2015 National Healthcare Safety Network (NHSN) hospital survey found only 26% of CAH reported implementing all 7 CES compared with 50% of larger hospitals across the United States. The University of Washington Tele-Antimicrobial Stewardship Program (UW TASP) was developed through partnership with the University of Washington for hospitals lacking stewardship resources. The state department of health (DOH) provided funding to allow CAH to participate.

Methods
In January 2017, CAH were recruited to join UW TASP and participate in weekly 60 minute audiovisual conference calls led by an interdisciplinary team of infectious diseases physicians, pharmacists and microbiologists. Each session included a 15-minute didactic on stewardship topics followed by a discussion of case studies presented by participating hospitals. UW TASP faculty visited CAH to foster a collegial relationship between teams. Using hospital-reported metrics from the NHSN hospital survey reported in year 2016–2018 for years 2015–2017, we compared CES implementation by CAH participating in UW TASP (TASP CAH) in 2017 (n = 17) to those not participating (non-TASP CAH) (n = 22).

Results
TASP CAH reported increased implementation of all 7 CES from 29% (2015) to 59% (2016) before joining TASP to 76% (2017) after joining TASP (Figure 1). Non-TASP CAH reported implementation increased from 32% (2015) to 45% (2016) to 59% (2017). By the end of 2017, TASP CAH also succeeded in implementing individual CES to a greater degree than did non-TASP CAH (Table 1).

Conclusion
TASP CAH reported more successful implementation of CES than did non-TASP CAH. Improved CES implementation in TASP CAH may in part be due to differences in baseline hospital characteristics; however, expertise and support provided by UW TASP likely contributed. The use of telehealth mentoring increased antimicrobial stewardship in this resource-limited setting.

Disclosures
All authors: No reported disclosures.
2100. A Retrospective Chart Review of Emergent Antibiotic Use
Authors: Blyth Michelle , McNary James , Decano Arnold , Renson Audrey , Carey Jeanne 
Published: October 2019

Abstract

Background
The need for responsible antibiotic stewardship can be difficult to reconcile with the clinician’s task of quickly recognizing and treating sepsis. Empiric antibiotics are often given in patients with any suspicion of infection, yet antibiotics carry non-trivial risks including antibiotic resistance and susceptibility to other infections, such as Clostridium difficile.

Methods
This retrospective chart review includes 200 patients who were admitted to the hospital and administered antibiotics while in the Emergency Department (ED). From clinical documentation several clinical data points were gathered such as: changes to (including discontinuation of) antibiotics by the admitting team, final culture data, discharge diagnosis, vital signs and routine laboratory values.

Results
Our study finds that the majority of patients administered antibiotics in the ED of our academic community hospital were not diagnosed with sepsis (67%) and did not meet SIRS (62.5%) nor qSOFA (88%) criteria prior to administration of antibiotics. Vancomycin (39.7%) and piperacillin–tazobactam (22.2%) were the most frequent empiric antibiotics started. Antibiotics were stopped completely on admission by the admitting team in 22.2% of included patients. A wide variety of sources of infection were suspected, pneumonia (33%), cellulitis (15%), and cystitis (18%) being the most common. The overall mortality rate for this group during the admission was 4.5%, which was comparable to all-cause hospital mortality during the same time period. Infection was ruled out by discharge in 91 of the included 200 patients (45.5%). At least 37.5% of all included patients had received antibiotics within the last 3 months. Intriguingly, recent exposure was nearly twice as common (47.8%) among infected patients than in those without infections (24.7%), with a relative risk of 1.48 (CI 1.0993–2.0014).

Conclusion
These findings suggest that an opportunity exists for increased antibiotic stewardship in the emergency department in the management of suspected sepsis and/or infection. Stable patients in whom infection cannot be definitively ruled out may benefit more from prompt, thorough evaluation by an admitting team prior to the initiation of empiric antibiotics.

Disclosures
All authors: No reported disclosures.
2104. Susceptibility Trends in Antifungal Resistance (STAR) Study: Preliminary Data from A New Prospective Antifungal Surveillance Study
Authors: Ghannoum Mahmoud , Lisa Long , Sheriff Rania , Badal Erika , Lass-Flörl Cornelia , Hawser Stephen 
Published: October 2019

Abstract

Background
The development of new anti-infectives has increased rapidly over the past ten years. The need to support these important, life-saving products has increased as well. The STAR program was developed in 2018 to provide a repository of recent clinical fungal isolates with known susceptibility profiles and to monitor resistance trends over time. STAR reports the susceptibility patterns of the earliest STAR data concerning echinocandins, second-generation triazoles, and fluconazole against clinical Candida albicans and non-albicans strains including C. auris from worldwide sources.

Methods
Clinical isolates of Candida spp. (n = 203, from 2017–2018) from culture KOL investigator sites in the United States, Asia and the EU, were tested. Of these, 203 were isolated from blood or body tissues, and the remaining 11 from miscellaneous sources. Species distribution included mainly C. albicans, C. glabrata, C. krusei, C. lusitaniae, C. parapsilosis, C. tropicalis, and the emerging pathogen C. auris. Antifungals tested were amphotericin B (AMB), anidulafungin (ANID), fluconazole (FLU), isavuconazole (ISA), posaconazole (POS), and voriconazole (VOR). All testing was performed according to CLSI M27-A4 methodology.

Results
Overall, MIC50, MIC90, MIC range and percent susceptibility for each drug are listed in Table 1. Our data showed that for ANID, ISA and POS ≥ 93% of isolates were susceptible. While 84 and 88% were susceptible to FLU and VOR, respectively. Moreover, only 78% of isolates were susceptible to AMB. Interestingly, our data show that C. auris isolates were resistant to at least 1 antifungal with 15% of the C. auris strains (n = 40) showing multidrug resistance.

Conclusion
Ongoing antifungal resistance surveillance like STAR is of utmost importance in order to monitor the efficacy of traditional empirical therapy and for the development of novel antifungal agents. This repository and ongoing STAR study will provide a resource to better support the biopharmaceutical industry’s goals to develop new and more potent antifungal agents. STAR will continue to monitor yeasts and will also include more unusual fungi including Mucor, Rhizopus amongst others.

Disclosures
All authors: No reported disclosures.
2107. Azole Therapeutic Drug Monitoring (TDM) in a Multiracial Cohort with Varied Pharmacogenetics
Authors: Yvonne Zhou Peijun , Peng Lim Tze , Lin Sarah Tang Si , Liew Yixin , Grace Sy. Chua Nathalie , Lim Cheryl , Lee Winnie , Xuan Tan Si , fah Lai oi , Tong Tan Thuan , Hock Tan Ban , Chuan Wong Gee , Hoon Andrea Kwa Lay 
Published: October 2019

Abstract

Background
Voriconazole (VOR) and posaconazole (POS) exhibit wide pharmacokinetic variability. Various factors including race and genetic polymorphisms are at play and this may affect treatment response. We aim to evaluate the utility of VOR/POS TDM among Southeast Asians that are predominantly intermediate/poor VOR metabolizers.

Methods
All adults with VOR/POS TDM performed at our institution from 2015 to 2018 were included. We determined proportion of patients and doses required to achieve TDM targets [(2 – 5.5 mg/L (VOR) or ≥ 0.7 and ≥ 1.0 mg/L (POS prophylaxis and treatment respectively)], and correlate levels with treatment efficacy and safety.

Results
VOR/POS TDM was performed mostly among patients with hematological malignancy or solid-organ transplant (146/174, 83.9%). Less than half (32/70, 45.7%) of patients on VOR achieved target—18 (25.7%) were < 2 mg/L while 20 (28.5%) had levels > 5.5 mg/L. Doses required to achieve TDM target ranged from 1.9–11.4 mg/kg/day. Drug interactions, critically ill state and change in drug formulation were major causes of intra-patient variability. One-fifth (n = 14) experienced transaminitis; corresponding VOR trough levels were 0.5–> 7.5 mg/L. Neurotoxicity was also seen in 3 (4.3%) patients—all 3 had VOR trough ≥ 6.7 mg/L and saw symptom resolution upon dose reduction. There appears to be no association between the achievement of TDM targets and response rates. Majority (81/104, 77.9%) of patients on POS achieved TDM targets. Patients prescribed POS tablet were significantly more likely to attain targets compared with suspension 600 mg/day [19/26 (73.0%) vs. 27/62 (43.5%), P < 0.05] and 800 mg/day [17/26 (65.3%) vs. 4/16 (25.0%), P < 0.05)]. Of 23 with sub-therapeutic levels, 19 (82.6%) responded to dose increase and/or change in acid-reducing agents. Breakthrough infection occurred despite troughs ≥ 0.7 mg/L [5/42 (11.9%) vs. 2/40 (5.0%) when < 0.7 mg/L (P = 0.3)]. Treatment failure was observed in 2 patients (troughs > 1.0 mg/L).

Conclusion
VOR/POS TDM should be implemented in Southeast Asians due to significant unpredictability in dose exposure and potential to avoid need for switch to alternative anti-fungals due to intolerability. Higher POS trough cutoff may be required for effective anti-fungal prophylaxis.

Disclosures
All authors: No reported disclosures.
2118. Antifungal Susceptibility Testing of Clinical Isolates of Aspergillus in Mexico
Authors: Gonzalez-Lara María F , Valenzuela-Almada Maria O , Marina Román-Montes Carla , Piñon-Hernandez Viridiana , Rodriguez Jose , Ponce de Leon Alfredo , Sifuentes-Osornio José , Martinez-Gamboa Areli , Ostrosky-Zeichner Luis 
Published: October 2019

Abstract

Background
Invasive aspergillosis (IA) is a leading cause of morbidity and mortality in immunocompromised hosts. Triazole resistance in Aspergillus fumigatus is emerging globally. We performed antifungal susceptibility testing (AST) in Aspergillus isolates from Mexico and evaluated risk factors associated with 6 week mortality, including the MICs.

Methods
Aspergillus isolates from clinical samples were collected in a tertiary care center from 2014 to 2018. Species-level identification and broth microdilution following the CLSI M38 method were performed. MICs were interpreted according to epidemiological cutoff values. PCR and cyp51A gene sequencing were performed in A. fumigatus isolates with voriconazole (VRC) MIC >1 µg/mL. Data from the medical record were obtained to classify patients according to the MSG/EORTC criteria. The relationship between the MICs and 6-week mortality was described. Multivariate analysis of factors associated with six week mortality was performed.

Results
AST was performed on 85 Aspergillus isolates: 60/85 from patients with IA, 15/85 from patients with Aspergillus colonization, 2 patients with Aspergilloma, 1 with chronic otitis media and 1 with endophtalmitis. Information from 6 patients was unavailable. VRC MIC > 1 µg/mL was found in 3/38 (7.8%) A. fumigatus, from two patients with IA. Both had a TR34/L98H mutation in the cyp51A gene. Amphotericin B (AmB) MICs ≥ 2 were found in 16/49 (32%) A. fumigatus, 10/15 (66%) A. flavus and 1/14 (8%) A. niger. Forty-one patients with IA were treated: 29/41 (71%) with VRC or posaconazole, 7/41 (17%) with AmB and 5 with combination therapy. Overall, 6-week mortality was 30/49 (61.2%) among patients with IA; 2/2 (100%) when VRC MIC >1 µg/mL and 12/19 (63%) when AmB > 2 µg/mL, of which only 4 patients received initial treatment with AmB. Age older than 65 years (OR 11.8; 95% CI 1.14–123) and hepatic failure (OR 7.9; 95% CI 1.22–50.9) were independently associated with 6-week mortality in multivariate analysis.

Conclusion
We found a VRC MIC >1 µg/mL prevalence of 7.8% among A. fumigatus and a high prevalence of AmB MIC ≥ 2 among clinical isolates of Aspergillus in Mexico. Elevated mortality was seen in IA among older patients with hepatic failure. Larger epidemiological studies are warranted.

Disclosures
All authors: No reported disclosures.
2119. Matched-Paired Analysis of Patients Treated for Invasive Mucormycosis—Standard Treatment vs. Posaconazole New Formulations (MoveOn)
Authors: Salmanton-Garcia Jon , Seidel Danila , Koehler Philipp , Mellinghoff Sibylle , Wisplinghoff Hilmar , Vehreschild Jörg , Cornely Oliver , Vehreschild Maria 
Published: October 2019

Abstract

Background
Current first-line (first) antifungal treatment for invasive mucormycosis (IM) consists of liposomal amphotericin B (AMB). Salvage (SAL) treatment options are limited and often based on posaconazole oral suspension (POSsusp). However, with the approval of posaconazole new formulations (POSnew), patients could benefit from improved pharmacokinetics, safety and tolerability. Our aim was to assess the effectiveness of POSnew as first-line and SAL treatments for IM.

Methods
We performed a case-matched analysis with proven or probable IM patients from the FungiScope® Registry. 1st-POSnew and 1st-AMB+POSnew cases were matched with 1st-AMB-based treatment controls, and SAL-POSnew cases were matched with SAL-POSsusp controls. Each case was matched with up to three controls based on severity, hematological/oncological malignancy, surgery and/or renal dysfunction.

Results
Five patients receiving first-line POSnew alone, 18 receiving first-line POSnew combined with AMB, and 22 receiving salvage POSnew were identified. By day 42, favorable response was reported for 80.0% (n = 4/5) of patients receiving first-line POSnew, for 27.8% (n = 5/18) receiving first-line POSnew plus AMB, and for 50.0% (n = 11/22) receiving salvage POSnew. Day-42 all-cause mortality of patients receiving POSnew was lower compared with mortality in their respective controls (20.0% (n = 1/5) in 1st-POSnew vs. 53.3% (n = 8/15) in 1st-AMB; 33.3% (n = 6/18) in 1st-AMB+POSnew vs. 52.0% (n = 26/50) in 1st-AMB; 0.0% (n = 0/22) in SAL-POSnew vs. 4.4% (n = 2/45) in SAL-POSsusp).

Conclusion
In the observed patients, POSnew was effective in terms of treatment response and-associated mortality of IM. POSnew may be an alternative for the treatment of IM.

Disclosures
All authors: No reported disclosures.