bluuebunny/crossref_metadata_2025_split huggingface dataset:
763. 30 Day Readmission Outcomes in Patients Over 80 Years of Age Enrolled in an Outpatient Parenteral Antibiotic Therapy (OPAT) Program
Authors: Sheridan Kathleen R , Wingfield Joshua , McKibben Lauren , Clouse Natalie 
Published: October 2019

Abstract

Background
OPAT is a well-established model of care for the monitoring of patients requiring long-term IV antibiotics1. We have previously reported a reduction in the 30-day readmission rate to our facility for patients managed in our OPAT program. However, little has been published to date regarding outcomes in OPAT patients over 80 years of age 2–3. Our OPAT program was established in 2013. Patients can be discharged to a facility or home to complete their course of antibiotics.

Methods
We conducted a retrospective chart review of all OPAT patients discharged from our facility from 2015 to 2018. Patients were divided into two groups based on age, <80 (n = 4618) and >80 (n = 562).

Results
Patient demographics are listed in Table 1. The overall 30-day readmission rate for patients older than 80 was 27.8%. For patients over 80 that had a follow-up ID clinic appointment, the 30-day readmission rate decreased to 15.7%. For patients younger than 80, the 30-day readmission rate was 36.0% with a decrease to 16.2% if patients were evaluated in the outpatient clinic. Figure 1. Staphylococcus Aureus was the predominant organism in both age categories. Vancomycin was the most common antibiotic used in both age groups followed by β lactams.

Conclusion
In general, patients aged over 80 years were more likely to be discharged to a facility to complete their antibiotic course than younger patients. These patients also were more likely to have other comorbidities. The 30-day readmission rate in each age group was relatively similar. OPAT in patients over age 80 can have similar 30-day readmission rates as for patients less than 80 years of age

Disclosures
All authors: No reported disclosures.
764. Patients with Substance Use Disorder Discharged from Safety Net Hospital to Skilled Nursing Facility for OPAT: Baseline Characteristics and Clinical Outcomes
Authors: Bird Cylaina , Collins Ryan , Mang Norman , Nijhawan Ank E , Nijhawan Ank E , Bhavan Kavita 
Published: October 2019

Abstract

Background
Self-administered Outpatient Parenteral Antimicrobial Therapy (S-OPAT) is offered at Parkland Memorial Hospital for uninsured patients requiring an extended course of intravenous (IV) antibiotics to complete treatment at home.1 At Parkland, S-OPAT has been demonstrated to be safe and effective with >70,000 inpatient bed days avoided to date, lower 30-day readmission rates, and significant cost savings.1 Patients with a history of substance use are not eligible for S-OPAT and are discharged to skilled nursing facilities (SNF) to complete IV antibiotic therapy. This study aims to describe clinical outcomes of a patient population with history of substance use discharged to SNF for OPAT.

Methods
The electronic medical record was used to identify patients with substance use discharged to an SNF for OPAT between January 1, 2017 and April 30, 2018. Data were retrospectively reviewed for demographics, substance use history, treatment plan and clinical outcomes.

Results
76 patients with history of substance use were discharged to SNFs for OPAT in the study period. 62% of patients reported non-IV drug use and 38% reported IV drug use (IVDU). The mean age for patients with non-IV drug use was 47 (83% male) vs. 43 years for patients with IVDU (86% male). Of patients with non-IV drug use, 30% reported cocaine use, 11% methamphetamine use and 59% polysubstance use or other. Of patients with IVDU, 38% reported heroin use, 10% methamphetamine use and 52% polysubstance use or other. When comparing outcomes of IVDU vs. non-IV drug use patients, 34% vs. 21% did not complete the prescribed treatment course, 28% vs. 11% left against medical advice (AMA), and 20% vs. 15% were readmitted to the hospital within 30 days.

Conclusion
The majority of patients with substance use, 74%, completed their prescribed IV antibiotic course when sent to an SNF. However, a subset of these patients is at risk for poor clinical outcomes. A greater proportion of patients with prior IVDU compared with patients with prior non-IV drug use left treatment AMA and were readmitted to our hospital within 30 days of discharge. Future efforts to identify patients with substance use disorder who may be appropriate for S-OPAT with integration of addiction medicine services may improve clinical outcomes.

Disclosures
Ank E. Nijhawan, MD, MPH, Gilead Sciences, Inc.: Research Grant.
771. A Quality Improvement Initiative to Reduce 30-days Sepsis-Related Readmissions by Internal Medicine Residents
Authors: Ahmed Mahmoud , Khalid Nida , Ahmad Faran 
Published: October 2019

Abstract

Background
Early readmissions after sepsis treatment are associated with an increased cost of care and poor outcome. Based on nationwide Medicare data, one-third of sepsis survivors get readmitted and wide variation exists between hospitals. Internal medicine residents aimed to determine the most common factors associated with readmission after hospitalization for sepsis at Rochester General Hospital and Unity Hospital in Rochester, New York.

Methods
This quality improvement (QI) project involved a retrospective chart review of 30 days sepsis-related readmissions from January to July 2017. We used Rochester General Hospital and Unity Hospital electronic database of the admitted patients with ICD 9/ICD 10 diagnoses for sepsis at admission or during the hospital course. This data were used for interpreting predominant risk factors for readmission. Based on the specific determinants, a “readmission alert” is being implemented in the electronic medical record to address the specific area of concern with relevant interventions. In the next phase of the performance improvement, six-monthly follow-up retrospective chart review will be carried out to look for the outcome.

Results
Of 2,221 patients admitted with a sepsis diagnosis from January to July 2017, 462 (20.8%) were readmitted within 30 days of discharge of which the majority were older than 65 years (66.4%). 66 (16.6%) patients had a septic shock on readmission and 19.3% died within 30-days of discharge after readmission. In 39.7% of cases, there was no primary care provider(PCP) communication at discharge. In 137 (65.5%) cases, Infectious disease(ID) consults service was not involved in care on initial admission. 242 (60.8%) readmitted patients had a follow-up clinic appointment more than a week after discharge. 12.5% of patients were discharged with IV antibiotics on initial admission, whereas 32.9% of the readmitted patients were not provided visiting nursing services after initial discharge.

Conclusion
Reducing sepsis-related readmission requires a multidisciplinary collaboration of primary care providers, visiting nursing services and infectious disease consult team. This pilot QI project results indicate that early follow-ups are important for reducing readmission.

Disclosures
All authors: No reported disclosures.
783. Infectious complications in IV abusers: a detailed review of hospitalized IV abusers
Authors: Gonzalez Jaime , Diago-Navarro Elizabeth , Ameen Eve , Azab Nancy , Milla Lucia , Fries Bettina C 
Published: October 2019

Abstract

Background
With 337 heroin-related deaths between 2009 and 2013, Suffolk County reported more such deaths than any other county in New York State. Suffolk County’s population of 1.5 million is larger than that of some states. Compared with the rest of New York State, median annual household income is the third highest of New York’s 62 counties and the income gap between socioeconomic classes is smaller.

Methods
Detailed retrospective chart review was performed on admitted patients to Stony Brook University Hospital (SBUH) from November 2015 to October 2018 with active IV drug abuse and infection. Demographics, drug use characteristics, microbiology, co-morbidities, and outcome were assessed.

Results
198 active IV heroin users were admitted with a complicated infection during this time frame. Most patients were Caucasian (94%) and more were male (64%). The median age was 33 (range 17 to 58). Most patients (90%) had health insurance, many lived with others at home and were unemployed. Thirty-three were on methadone and 28 on suboxone. The median length of stay was 4.7 days (ranging from 1 to 140 days) and 29% of admitted patients left against medical advice. 60% of the patients had been admitted to a hospital in the prior 12 months. The majority (58%) presented with cellulitis, 12% were diagnosed with endocarditis, 10% with osteomyelitis, 6.5% with bacteremia/sepsis. Ten were also pregnant. Infectious disease was consulted in 55%, and Psychiatry and social worker in 46% of cases. HIV, HepC and HBV testing were not performed in less than 50% of patients. There was a total of 5 deaths during the hospitalization, 2 patients with endocarditis, 2 with sepsis and one overdose. 45% of patients with endocarditis and 43% of patients with osteomyelitis required surgical intervention. S. aureus was a common pathogen and identified in 61% of the cases, where a pathogen was isolated.

Conclusion
Our data show that even in an affluent community opioid addiction is not properly addressed during hospital admissions. As a consequence, users sign out against medical advice, have frequent hospital admissions, remain out of addiction treatment, and outcome is poor. A systematic multidisciplinary approach will be required to improve the care for this vulnerable patient population

Disclosures
All authors: No reported disclosures.
996. Impact of Penicillin Allergy Labels on Carbapenem Use in a Multi-Center Study
Authors: Ling Dorothy , Seidelman Jessica , Dodds Ashley Elizabeth , Davis Angelina , Dyer April , Jones Travis M , Johnson Melissa D , Yarrington Michael E , Anderson Deverick J , Sexton Daniel J , Moehring Rebekah W 
Published: October 2019

Abstract

Background
Antibiotic allergy labels lead to excess exposure to broad-spectrum antibiotics and can result in patient harm. We aimed to describe the prevalence of penicillin allergy labels (PAL) across a variety of hospital settings and its association with carbapenem exposure.

Methods
We performed a retrospective cohort analysis of inpatient admissions from 14 hospitals in the Duke Antimicrobial Stewardship Outreach Network (DASON) and Duke Health System from 2016 to 2018. Data were collected from the DASON central database which is derived from electronic health record extracts. PAL was defined from drug allergy documentation indicating any reaction to penicillin or its related agents, but did not include labels for other β-lactam agents (e.g., cephalosporin). Carbapenem exposure was defined as a binary variable indicating receipt of at least one dose of meropenem, ertapenem, doripenem or imipenem on an inpatient unit. The association between PAL and carbapenem exposure was assessed using multivariable logistical regression with candidate covariates including age, gender, comorbidity score, and exposure to intensive care or hematology/oncology unit. Hospital-level PAL prevalence was defined as the percentage of inpatient admissions. Hospital-level carbapenem use rates were assessed as days of therapy (DOT) per 1000 patient-days and stratified by PAL to understand the portion of use associated with PAL.

Results
Of the 727,168 admissions included in this study, 84,033 (11.6%) patients had a PAL. The majority of admissions with documented PAL were in patients >65 years old (47.9%, n = 40,240) and female (57.8%, n = 418,472). PAL was associated with a 2-fold higher risk of receipt of carbapenem (adjusted odds ratio 2.13, 95% CI 0.89–2.40, P < 0.0001). PAL prevalence varied among hospitals (median 14%, range 5–20%). Hospitals with antibiotic allergy-focused stewardship programs (ASP) had a similar PAL prevalence (median 13.8 vs. 15.9%, P = 0.08), but the percent of carbapenem DOT used in patients with PAL was similar (median 23% vs. 24%, P = 0.6).

Conclusion
PAL was associated with increased carbapenem exposure on the patient level. Allergy-focused ASP activities may affect PAL but it is unclear whether it reduces carbapenem use based on these observational data.

Disclosures
All authors: No reported disclosures.
1006. Do Antibiotic Choices Made in the ED Influence Inpatient Therapy?
Authors: Jones Travis M , Dodds Ashley Elizabeth , Johnson Melissa D , Moehring Rebekah W , Sarubbi Christina , Wrenn Rebekah 
Published: October 2019

Abstract

Background
Inappropriate antibiotic use (AU) is common among inpatients and may begin in the emergency department (ED). ED clinicians often make the first antibiotic decisions in patient care, but it is unknown whether or not these decisions influence inpatient AU. Understanding prescribing practices at transitions of care is critical for implementing effective stewardship initiatives.

Methods
We performed a retrospective cohort study of AU in patients admitted to Duke University Hospital through the ED between July and December 2018. Included encounters had a minimum 2-day length of stay and received an antibiotic in both the ED and inpatient setting. Individual encounter IDs were used to link ED and inpatient AU reports generated from the DASON Antimicrobial Stewardship Assessment Portal. We compared the last ED administration date/time to the first inpatient unit administration for each agent. An antibiotic started in the ED was considered continued upon admission if the first inpatient administration occurred within 30 hours following the last ED administration. Demographic, clinical indication on order entry, length of therapy, and prescriber data were also collected.

Results
We included 3,336 encounters and 2,940 unique patients in the analysis. The median (IQR) patient age was 60 (42–72) years, and the most common indications for AU in the ED were sepsis (23.1%), pneumonia (17.8%), ABSSSI (15.5%), and intra-abdominal infection (12.8%). At least one antibiotic initiated in the ED was continued upon admission within 30 hours in 2,495 (74.8%) encounters. The most common antibiotics continued upon admission were piperacillin/tazobactam (32.8%), vancomycin (24.9%), and ceftriaxone (13.7%). The most common indications for agents continued upon admission were pneumonia (18%), intra-abdominal infection (15%), and ABSSSI (15%). Two or more antibiotics were continued upon admission in 916 (27.4%) encounters.

Conclusion
In our retrospective review of ED antibiotic encounters resulting in admission for at least 2 days, three out of four encounters had at least one antibiotic continued upon admission. This finding highlights the importance of initial appropriate antibiotic selection and suggests stewardship interventions should target EDs as well as inpatient prescribing.

Disclosures
All authors: No reported disclosures.
1012. Characterization of Antibiotic Superutilizers in the Inpatient Setting
Authors: Burns Jonathan , Mersinger Katherine , Saw Stephen , Morgan Steven C , Athans Vasilios , Pegues David , Degnan Kathleen , Dutcher Lauren S , Binkley Shawn , Hamilton Keith W 
Published: October 2019

Abstract

Background
Inappropriate use of antibiotics is a major public health concern that contributes to increased antibiotic resistance, adverse effects, and healthcare costs. Little is known about the highest utilizers, or superutilizers, who may be appropriate targets for antibiotic stewardship efforts. The purpose of this study was to characterize superutilizers at an academic hospital.

Methods
All adult patients who were admitted to the Hospital of the University of Pennsylvania and received at least one day of antibiotics between July 1, 2017 and June 30, 2018 were identified. All inpatient administrations for systemic antibacterial agents were identified. Antibiotics given in procedural areas and the emergency department were excluded, as were any antifungals and antivirals. Usage was reported as days of therapy (DOT). We compared the demographics and DOT among the superutilizers (defined as the top 1% of patients) to different groupings of the rest of the population.

Results
Overall, 13,559 patients (and 183,082 DOT) were included in the analysis, including 136 superutilizers. The superutilizers received 15% of the total antibacterial DOT and a median of 56 DOT during the 12-month period. (table)

Conclusion
Inpatient antibiotic use is unevenly distributed across the population. Higher meropenem and sulfamethoxazole/trimethoprim DOT suggest that treatment of multidrug-resistant organisms and opportunistic infection prophylaxis are more common in the superutilizer group. Additional study is needed to determine whether antimicrobial stewardship efforts could impact antibiotic use in the superutilizer population.

Disclosures
All authors: No reported disclosures.
1022. Is it Time to Re-Evaluate Oral Β-Lactam Antibiotics for Step-Down Therapy of Uncomplicated Gram-Negative Bacteremia?
Authors: McAlister Michael , Rose Dusten T , Jaso Theresa , Olivares Brian , Parker Hudson F 
Published: October 2019

Abstract

Background
Bloodstream infections (BSI) due to Enterobacteriaceae often require empiric intravenous (IV) antibiotics. Oral antibiotics for the definitive treatment of these infections have been reserved to antibiotics with “high” oral bioavailability, mainly fluoroquinolones (FQ). Safety concerns and increasing resistance associated with FQ has modified clinical practice to identify alternative oral therapies. Select β-lactam (BL) antibiotics are well-tolerated, have moderately high bioavailability, and possess in-vitro activity against Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumoniae), and Proteus mirabilis (P. mirabilis). Limited evidence exists for oral BL step-down therapy for definitive treatment of BSI due to these organisms.

Methods
This retrospective cohort study compares clinical outcomes of patients treated with oral BL antibiotics to those who received oral FQ or trimethoprim/sulfamethoxazole (TS) for the treatment of BSI due to E. coli, K. pneumoniae, and P. mirabilis. The primary outcome is a composite of 30-day all-cause mortality, 30-day readmission due to recurrence, and/or change in oral antibiotic therapy. Secondary endpoints include 90-day development of Clostridium difficile infection, 90-day all-cause readmission, hospital length of stay (LOS), and 90-day recovery of a multi-drug-resistant organism.

Results
Nine hundred eighty-one patients were screened and 397 adult patients were included. Excluded patients: IV only (n = 291), polymicrobial blood culture (n = 112), immunocompromised (n = 61), other (n = 120). Two-hundred patients received oral step-down therapy with a BL, and 197 with either an FQ or TS. E. coli was the causative organism for most patients in both groups, and urinary tract was the most common source of BSI. The median total duration of therapy was 14 days in both groups. There was no significant difference in the primary composite endpoint (7% vs. 5.6%, P = 0.561). There was no mortality or differences in secondary outcomes, except LOS (6 vs. 5 days, P = 0.043).

Conclusion
Utilization of oral BL for the step-down therapy of uncomplicated BSI due to E. coli, K. pneumoniae, and P. mirabilis did not result in worse outcomes compared with those receiving oral FQ or TS.

Disclosures
All authors: No reported disclosures.
1034. Automating Assessments of Vancomycin Appropriateness
Authors: Holmer Haley K , McCracken Caitlin M , Tallman Gregory B , Gore Sara J , Shan Timothy , Yu Diana , Bearden David T , McGregor Jessina C 
Published: October 2019

Abstract

Background
Assessing appropriateness of hospital antibiotic use is typically a labor-intensive task for antimicrobial stewardship teams and relies heavily on clinician judgement rather than a systematic process. Vancomycin is a frequently used agent that is a common stewardship target. We developed an algorithm to automatically classify the appropriateness of vancomycin days of therapy (DOTs) based upon electronic health record data.

Methods
We constructed a retrospective cohort of Oregon Health and Science University (OHSU) Hospital and Doernbecher Children’s Hospital patients admitted August 1, 2017 to July 31, 2018 receiving vancomycin. Data were collected on demographic, encounter, pharmacy, microbiology, and surgery data. An electronic algorithm was applied to classify vancomycin DOTs as appropriate, inappropriate, or indeterminate. Inappropriate use was defined as any case in which there was an opportunity for de-escalation as identified using microbiology data, ICD-10 codes, and procedure codes.

Results
We included 4,231 encounters; 493 (12%) were pediatric patients. Our algorithm automatically classified 59%, 3%, and 38% of encounters as having either appropriate, inappropriate, or indeterminate DOTs, respectively. Forty-four percent of all encounters received no more than a 24-hour course of vancomycin and were considered appropriate empiric therapy; half of these were attributed to surgical prophylaxis. Nine percent of all encounters had vancomycin administered within 3 days of a blood, sputum or tissue culture in which either a methicillin-resistant Staphylococcus species or an ampicillin-resistant, vancomycin-susceptible Enterococcus species was isolated and were classified as appropriate. Six percent of all encounters had cultures in which only Gram-negatives, fungi, or yeast were isolated and were therefore considered appropriate in the empiric period (≤48 hours) but inappropriate thereafter.

Conclusion
Automated assessments of antibiotic appropriateness could facilitate more informed antimicrobial stewardship initiatives and serve as a valuable stewardship metric. Characterization of indeterminate vancomycin use may inform increased automated classification. Further effort is needed to validate these assessments.

Disclosures
All authors: No reported disclosures.