bluuebunny/crossref_metadata_2025_split huggingface dataset:
2074. A Successful Acute Respiratory Tract Infection Campaign to Improve Antibiotic Prescribing in Outpatient Clinics and an Emergency Department
Authors: Fatima. de Lima Corvino Daniela , Gauthier Timothy , Virginia Romero Alvarez Maria , Madaras-Kelly Karl , Lichtenberger Paola 
Published: October 2019

Abstract

Background
Acute Respiratory tract infections (ARI) are infections involving the upper respiratory tract. Most ARIs are viral in nature and self-limited in which most of the times antibiotic treatment is unnecessary. A recent VA medication utilization evaluation conducted in 28 medical centers identified high rates of unnecessary antibiotic prescribing for ARI. Based on these analyses the VA National Academic Detailing Service (VANADS) created the ARI campaign, providing materials for VA systems to employ as the seek to improve ARI management. Our project consists of implementation of the ARI Campaign in a South Florida Veteran Affairs HealthCare System (Miami VAHS).

Methods
We utilized VANADS resources for our campaign. Activities included assessing ARI prescribing patterns, garnering stakeholder support, identifying pharmacist and physician champions, providing targeted academic detailing, handing out provider ARI guidance documents (in paper and electronically), disseminating provider-specific feedback with peer comparison, order-set development with advertisement, promoting appropriate coding, and reporting to the Miami VAHS antimicrobial stewardship program (ASP) subcommittee. Campaign activities were initiated in October 2017. The ARI Campaign was selected as the priority item for FY-2019, from our annual ASP risk assessment with a goal of reducing antibiotic prescribing for ARI diagnosis to below 40%. We present the data up to March 2019.

Results
Baseline data from October 2015 through September 2017 revealed an antibiotic was prescribed to 1,651 of 2,843 (58%) encounters in which an ARI diagnosis was made in our system. In the months following ARI Campaign initiation, a decline in antibiotic prescribing for ARI diagnosis was found. In the most recent quarter (January–March 2019), the prescribing rate was 39%. Figure 1 shows system-wide vs. Florida region prescribing rates. Table 1 provides data by major site and for the top 10 priority providers we identified.

Conclusion
Implementation of a multifaceted ARI Campaign at a single-center resulted in a substantial reduction in antibiotic prescriptions. Future work is warranted investigating which activities are most impactful for reducing unnecessary antibiotic prescribing for ARI.

Disclosures
All authors: No reported disclosures.
2077. Fluoroquinolone Usage Reduction in the Outpatient Setting
Authors: Lin Kevin , Zahlanie Yorgo , Ortwine Jessica , Mang Norman , Wei Wenjing , Prokesch Bonnie C 
Published: October 2019

Abstract

Background
Fluoroquinolones (FQs) are the third most commonly prescribed outpatient antibiotic due to ease of dosing, broad spectrum of activity, and favorable pharmacokinetics. However, since 2016, the Food and Drug Administration (FDA) has released warnings about adverse effects, concluding that risks outweigh benefits especially for uncomplicated sinusitis, bronchitis, and cystitis. In fall 2016, our antimicrobial stewardship team began an initiative to decrease outpatient FQ usage involving provider education, addition of FDA warnings to oral FQ orders in Epic, and suppression of FQ susceptibilities. This evaluated the effectiveness of these initiatives in decreasing inappropriate outpatient FQ usage.

Methods
Retrospective chart review of FQ prescription was performed on all outpatient clinic, emergency department (ED), and urgent care emergency center (UCEC) visits during October 2016, 2017, and 2018. Inappropriate use was defined as an indication for cystitis, bronchitis, or sinusitis without a history of Pseudomonas aeruginosa or other multi-drug-resistant organism, or drug allergies precluding the use of non-FQs.

Results
1,033 outpatient FQ prescriptions were reviewed. Total FQ prescribing decreased 34% from 405 in October 2016 to 267 in October 2018, with the proportion of inappropriate FQ use decreasing from 53% to 34%. Over 90% of the inappropriate FQ use was for cystitis. Inappropriate prescribing for cystitis and sinusitis decreased by 58% and 33%, respectively, but increased for bronchitis by 25%. The outpatient clinics, ED, and UCEC saw declines in the percentage of inappropriate FQ use of 10%, 15% and 22%, respectively, from October 2016 to October 2018. Despite these decreases, rates of inappropriate FQ utilization for the outpatient clinics, ED, and UCEC were 64%, 25%, and 31%, respectively, at the end of the last study period.

Conclusion
A multi-modal FQ stewardship initiative effectively reduced the volume of outpatient FQ utilization and inappropriate FQ usage. Continued efforts to educate providers about the risks of FQ use and implement system-level initiatives are likely necessary to improve the rates of appropriate use and sustain the effects demonstrated in this study, especially for primary care providers in the outpatient setting.

Disclosures
All authors: No reported disclosures.
2079. Outpatient Antimicrobial Stewardship Initiative to Reduce Unnecessary Use of Antibiotics in Patients with Upper Respiratory Infections: Findings Shared by a Metropolitan Community Hospital in NYC
Authors: Shah Jilan , Izaguirre-Anariba Dora , Rao Hariprasad , Patel Yash , Zin Win Kyaw , Akande Olawale Samuel , Ward Laurie , Badem Olga 
Published: October 2019

Abstract

Background
Antibiotic-resistant infections are one of the greatest public health issues with more than 2 million infections and 23,000 deaths per year in the United States. Reducing inappropriate antibiotic use is essential to reduce both antibiotic resistance and adverse events. The most important modifiable risk factor for antibiotic resistance is inappropriate prescribing of antibiotics. At least 30% of outpatient antibiotic prescriptions in the United States are unnecessary. We aimed to pilot our outpatient antimicrobial stewardship initiative to track and reduce antibiotic prescriptions among adult patients presenting with common acute respiratory infections in our hospital’s outpatient primary care settings.

Methods
A retrospective and prospective cohort study from October, 2017 to March, 2019. Implemented a robust outpatient antimicrobial stewardship initiative with a dedicated team and data analyst based on CDC core elements for outpatient antimicrobial stewardship and a prior UHF initiative. Data of common respiratory tract infections and the respective rates of antibiotic prescriptions from 3 adult primary care sites were collected from the EHR. Serials of educational interventions were performed between June, 2018 to September, 2018. We disseminated resources from the CDC and DOH like brochures, posters, viral prescription pads, pocket guidelines, grand rounds and electronic lectures for providers and periodic provider feedback reports.

Results
Our findings revealed that the physician compliance rate of antibiotics not prescribed for common respiratory tract infections remarkably improved from 72% to 85% after implementing our interventions (Figure 1). The chi-square test showed 40, and P value is 0.000034 which is less than 0.05. Thus, we are 95% confident that there is a significant association between our interventions and reduction of inappropriate antibiotic use (Figure 2).

Conclusion
Introduction of a robust and multifaceted Outpatient Antimicrobial Stewardship initiative with a dedicated team can substantially decrease outpatient antibiotic prescription rates for respiratory tract infections in metropolitan community hospital-based primary care settings.

Disclosures
All authors: No reported disclosures.
2094. Acceptability of Antibiotic Substitutions for Fluoroquinolones and Third and Fourth-generation Cephalosporins: A Report from the VA-CDC Practice-Based Research Network (PBRN)
Authors: Goetz Matthew B , Hockett Sherlock Stacey , Goedken Cassie , Balkenende Erin C , Evans Charlesnika T , Perencevich Eli , Echevarria Kelly , Reddy Sujan , Neuhauser Melinda M , Reisinger Heather , Suda Katie J 
Published: October 2019

Abstract

Background
Studies suggest fluoroquinolones (FQ), and third (3C) and fourth (4C) generation cephalosporins, agents often used for empiric therapy, place patients at higher risk for C. difficile infection. Substituting alternative antibiotics for empiric therapy might reduce risk. We surveyed inpatient physician (MD) and pharmacist (PharmD) antimicrobial stewardship champions to evaluate their preferred FQ, 3C and 4C substitutions for empiric therapy.

Methods
Semi-structured interviews were conducted with the antimicrobial stewardship MD and the PharmD champion from each of the 15 VA-CDC Practice Based Research Network (PBRN) sites. Interviewees were asked what empiric antibiotics for pneumonia and urinary tract infections would be recommended in local guidelines if all 3C, 4C and FQ were restricted. Respondents could list multiple antibiotics. Templated data collection and analysis were used to assist in rapid analysis of interviews.

Results
Narrow β-lactams were identified as appropriate options for CAP by 8 MD and 9 PharmD (table). Piperacillin/tazobactam was the preferred choice by MDs and PharmDs for HCAP (7 and 12, respectively) and HAP (10 and 12, respectively). For community-onset urinary tract infections (cUTI), numerous alternatives to FQ, 3C and 4C were identified. For hospital-onset (hUTI), piperacillin/tazobactam was most frequently mentioned by MD and PharmDs (7 and 9, respectively). 4 of 5 MDs and 5 of 7 PharmDs who chose 3C for CAP indicated that 3C were preferred over all other choices for CAP, few stewards indicated that 3C were the sole preferred agents for other conditions.

Conclusion
Antimicrobial stewardship MD and PharmD champions were readily able to find FQ substitutions for all indications; 3C and 4C substitutions were found for all indications with a notable exception of treatment of CAP. These results suggest considerable opportunity to reduce use of these antibiotic classes. Future studies should examine the appropriateness and acceptability of the substitutions identified by stewardship champions to providers and the impact of restriction of FQ, 3C and 4C on clinical outcomes.

Disclosures
All authors: No reported disclosures.
2116. Comparative Effectiveness of Amphotericin B, Azoles, and Echinocandins in the Treatment of Candidemia and Invasive Candidiasis: A Systematic Review and Network Meta-Analysis
Authors: Demir Koray K , Butler-Laporte Guillaume , Lee Todd C , Cheng Matthew P 
Published: October 2019

Abstract

Background
Current guidelines recommend the use of echinocandins, amphotericin B or fluconazole for the treatment of invasive candidiasis and candidemia. The objective of our study was to compare these agents through a systematic review of the literature and network meta-analysis of randomized controlled trials.

Methods
Three electronic databases (Medline, PubMed, and the Cochrane Database of Systematic Reviews) were searched from database inception to January 1 2019. Randomized controlled trials that compared triazoles, echinocandins and/or amphotericin B (either in lipid formulation or deoxycholate form) for the treatment of invasive candidiasis or candidemia were included. Among included studies, treatment success was collected as the primary outcome and was assessed by a random effect network meta-analysis using Bayesian estimation methods. A sensitivity analysis was performed for all patients with candidemia.

Results
Eleven randomized controlled trials met the study inclusion criteria. Of the 2,475 patients included from these trials, 684 received an echinocandin, 855 received amphotericin B and 936 received a triazole. Echinocandins were associated with the highest rate of treatment success when compared with amphotericin B (OR 1.40, 95% CI 1.02–1.93) and the triazoles (OR 1.80, 95% CI 1.32–2.51). Similarly, in the pre-specified analysis of candidemic patients, echinocandins were also more effective overall than amphotericin B (OR 1.25, 95% CI 0.84–1.87) and triazoles (OR 1.66, 95% CI 1.16–2.44). Patients treated with triazoles had a lower rate of treatment success than amphotericin B in the overall (OR 0.78, 95% CI 0.60–1.01) and candidemia sensitivity analyses (OR 0.76, 95% CI 0.56–1.01) Rank probability analysis favored echinocandins as the most effective treatment choice 98% of the time.

Conclusion
In our meta-analysis comparing treatment strategies for severe Candida infections, the echinocandins had the highest rate of treatment success compared with both amphotericin B and triazoles. Echinocandins should be considered as first-line agents in the treatment of invasive candidiasis and candidemia. Further research is needed to determine the minimum duration of echinocandin treatment prior to using step-down therapy.

Disclosures
All authors: No reported disclosures.
2121. Isavuconazole (ISAV) as Primary Anti-Fungal Prophylaxis (PAP) in Patients with Acute Myeloid Leukemia (AML) or Myelodysplastic Syndrome (MDS): An Open-Label, Prospective Study
Authors: Bose Prithviraj , McCue David , Wurster Sebastian , Wiederhold Nathan P , Kadia Tapan M , Borthakur Gautam , Ravandi-Kashani Farhad , Masarova Lucia , Konopleva Marina , Estrov Zeev , Takahashi Koichi , Yilmaz Musa , Rausch Caitlin R , Marx Kayleigh , Qiao Wei , Huang Xuelin , Bivins Carol A , Pierce Sherry A , Kantarjian Hagop M , Kontoyiannis Dimitrios P 
Published: October 2019

Abstract

Background
Mold-active antifungal prophylaxis (ppx) is recommended in neutropenic patients with newly diagnosed AML or MDS. ISAV is an extended spectrum triazole with superior tolerability, reliability of absorption, fewer drug–drug interactions, lack of QTc prolongation or need for therapeutic drug monitoring, approved for the treatment of invasive aspergillosis (IA) and mucormycosis. NCT03019939 is an investigator-initiated, phase 2 trial of PAP with ISAV in patients with AML/MDS.

Methods
Treatment-naïve adult patients with AML or MDS initiating remission-induction chemotherapy (RIC) received ISAV per the dosing recommendations in the United States label until recovery from neutropenia (neutrophils (ANC) ≥ 0.5 × 109/L) and attainment of complete remission (CR), occurrence of proven or probable invasive fungal infection (IFI, EORTC/MSG criteria), or for a maximum of 12 weeks. The primary endpoint was incidence of proven/probable IFI during the study period (up to 30 days from the last dose of ISAV).

Results
67 patients were enrolled (April 28, 2017 to February 14, 2019) and 60 patients were eligible for assessment (median age 67 years, 57 patients with AML, median ANC on enrollment was 660). Reasons for study completion were achievement of CR with ANC recovery (n = 35), completion of 12 weeks of PAP (n = 9), possible IFI (n = 7), investigator decision (n = 3), death (n = 2, 1 disease progression, 1 cardiac arrest), proven/probable IFI (n = 3), and mild transaminitis, possibly ISAV-related (n = 2). The median durations of neutropenia and ISAV ppx were 33 (7–86) and 31 (7–86) days, respectively. One microbiologically-proven (gluteal abscess due to Candida glabrata) and 2 cases of probable breakthrough IFIs (probable IA with positive galactomannan) occurred (IFI incidence 5%). ISAV trough serum concentrations were available in 31 patients on both day 8 (median 3.74 µg/mL, 2.03–7.65) and day 15 (median 4.10 µg/mL, 2.17–9.25), and were not significantly different.

Conclusion
ISAV is a safe and effective alternative for PAP in patients with newly diagnosed AML/MDS undergoing RIC, with a breakthrough (proven/probable) IFI rate of 5%. ISAV serum levels were adequate in patients with AML/MDS undergoing RIC. Pharmacological features make ISAV attractive for PAP in the era of recently approved or emerging small-molecule AML therapies.

Disclosures
All authors: No reported disclosures.
2122. Isavuconazonium for Invasive Fungal Therapy: Single-Center Pediatric Experience
Authors: Mongkolrattanothai Kanokporn , Mohandas Sindhu , Stach Leslie , Orbach Regina , Neely Michael 
Published: October 2019

Abstract

Background
Isavuconazole (ISZ), dosed as the pre-drug isavuconazonium (ISM), is active against a wide variety of clinically important fungal pathogens. ISM is approved for the treatment of invasive aspergillosis and mucormycosis in adults ≥18 years of age. We present our experience with ISM to treat proven or to prevent fungal infection in pediatric patients.

Methods
In a retrospective review of patients who received ISM at our institution between April 2016 and April 2019, we abstracted demographic information, primary diagnosis, indication for ISM therapy, ISZ serum concentrations if available, and outcomes.

Results
Of 16 patients who received ISM, 12 were < 18 years of age (range 6–17 years). Underlying conditions included leukemia (n = 8), lymphoma (n = 1), post BMT (n = 1), diabetes (n = 1), and cardiac transplant (n = 1). Nine (75%) had proven invasive fungal infection with aspergillosis (n = 2), zygomycosis (n = 3), mixed aspergillosis and zygomycosis (n = 2), mixed Rhizopus and Scedosporium (n = 1), and pathology only (n = 1). Five of these 9 patients received combination ISM and liposomal amphotericin initially, followed by monotherapy with ISM in 4 patients after a mean of 26 days (range 6–63), and continued dual therapy in the fifth. The other 4 received liposomal amphotericin with or without other azoles prior to changing to ISM monotherapy. ISM dosing was 10 mg/kg q8h on days 1 and 2, followed by q24 thereafter, up to a maximum of 372 mg/dose. There were 19 measured ISZ serum concentrations obtained from 8 patients after >1 week of verified inpatient dosing, ranging from 1.0 to 7.5 mg/L, above the MIC in all cases when known. Five (42%) patients died of underlying non-mycological causes, 1 (8%) died of progressive scedosporiosis, and 6 (50%) improved. The two patients receiving ISM prophylaxis did not suffer a breakthrough fungal infection. ISM was well tolerated with no dose-limiting, drug-related toxicities noted.

Conclusion
ISM is a well-tolerated therapeutic option in pediatric patients at risk for or with invasive mycosis. Only 1 of our 12 patients died from progressive fungal disease.

Disclosures
All authors: No reported disclosures.
2137. Impact of Accelerate Pheno™ Rapid Blood Culture Detection System with Real-time Notification vs. Standard Antibiotic Stewardship on Clinical Outcomes in Bacteremic Patients
Authors: Pearson Courtney , Lusardi Katherine , McCain Kelsey , Painter Jacob , Lakkad Mrinmayee , Rosenbaum Eric R , Daniels Kay , Van Serena , Bariola J Ryan , Dare Ryan K 
Published: October 2019

Abstract

Background
Accelerate Pheno™ blood culture detection system (AXDX) provides identification (ID) and antimicrobial susceptibility testing (AST) within 8 hours of growth in blood culture. We previously reported length of stay (LOS), time to optimal therapy (TTOT), and antibiotic days of therapy (DOT) decrease following AXDX implementation alongside an active antimicrobial stewardship program (ASP). It is unclear whether real-time notification (RTN) of results further improves these variables.

Methods
A single-center, quasi-experimental before/after study of adult bacteremic inpatients was performed after implementation of AXDX. A 2017 historical cohort was compared with two 2018 intervention cohorts. Intervention-1: AXDX performed 24/7 with results reviewed by providers or ASP as part of their normal workflow. Intervention 2: AXDX performed 24/7 with RTN to ASP 7 days per week 9a-5p and overnight results called to ASP at 9a. Interventions 1 and 2 were utilized on an alternating weekly basis during the study (February 2018–September 2018). Historical ID/AST were performed using VITEK® MS and VITEK®2. Exclusion criteria included polymicrobial or off-panel isolates, prior positive culture, and patients not admitted at the time of AST. Clinical outcomes were compared with Wilcoxon rank-sum and χ 2 analysis.

Results
540 (83%) of 650 positive cultures performed on AXDX had on-panel organisms. 308 (57%) of these cultures and 188 (77%) of 244 reviewed historical cultures met inclusion criteria. Baseline illness severity and identified pathogens were similar between cohorts. Clinical outcomes and antimicrobial DOT are reported in Tables 1 and 2.

Conclusion
Following our implementation of AXDX, clinical outcomes including LOS, TTOT, total DOT, BGN DOT, and frequency of achieving optimal therapy were significantly improved compared with a historical cohort. Addition of RTN for AXDX results in the setting of an already active ASP did not further improve these metrics. However, compared with historical arm, AXDX with RTN did significantly impact specific subsets of antibiotic use while AXDX alone did not. This may be due to earlier vancomycin de-escalation. These results support the benefit of integration of AXDX into healthcare systems with an active ASP even without the resources to include real-time notification.

Disclosures
All authors: No reported disclosures.
2138. Follow-up Investigation of Antibody Titers and Diagnostic Antibody Cut-Off Values in Scrub Typhus Patients in Korea
Authors: Kim Dong-Min , Kim Choon-Mee , Ra Yun Na 
Published: October 2019

Abstract

Background
Scrub typhus is a mite-borne infectious disease caused by Orientia tsutsugamushi. There have been few follow-up studies assessing antibody titers using serologic tests from various commercial labs.

Methods
A prospective investigation to assess antibody titers of scrub typhus patients and seroprevalence for health checkup individuals were evaluated. The antibody titers of former patients diagnosed with scrub typhus at least 1 year and a maximum of 13 years were also investigated. The following tests were performed simultaneously: (i) immunofluorescence antibody assays (IFAs) that detect immunoglobulin(Ig) M and IgG, (ii) IFA that detects total Ig by a commercial lab, (iii) antibody tests using two commercially available kits.

Results
In prospective analyses with cutoff values set to ≥1:16 for IgM, ≥1:256 for IgG based on the KCDC’s criteria, and ≥1:40 for total Ig. The antibody positive rates of 102 confirmed scrub typhus patients were 44%, 35.3%, and 57.6%, respectively, in the first week after symptom onset. Among 91 former patients recovered, the follow-up IgM, IgG, and total Ig positivity rates were 38.5% (35/91), 22% (20/91), and 76.9% (70/91), respectively. In overall cohort of 216 health checkup subjects, 4.2% (9/216) IgM and 0% (0/216) IgG seroprevalence was observed.

Conclusion
The IFA from KCDC and commercial lab, and rapid commercial kits cannot differentiate between former patients recovered from scrub typhus and current scrub typhus. In Korea and other countries where low antibody cut-off titer values have been used as criteria for diagnosing and reporting scrub typhus, upward adjustments of cut-off values may be necessary.

Disclosures
All authors: No reported disclosures.