bluuebunny/crossref_metadata_2025_split huggingface dataset:
718. Activity of Ceftolozane–Tazobactam and Ceftazidime–Avibactam Against Clinical P. aeruginosa Isolates Collected in United States and Canada—SMART 2018
Authors: Lob Sibylle , Kazmierczak Krystyna , Raddatz Janet , DePestel Daryl , Young Katherine , Motyl Mary , Sahm Daniel F 
Published: October 2019

Abstract

Background
Ceftolozane–tazobactam (C/T) is an antipseudomonal cephalosporin combined with a β-lactamase inhibitor. The combination was cleared by FDA and EMA and is approved in the United States and over 60 countries worldwide. Using clinical isolates collected in the United States and Canada as part of the global SMART surveillance program, we compared the activity of C/T and ceftazidime–avibactam (CAZ/AVI) against P. aeruginosa isolates and subsets nonsusceptible (NS) to selected antimicrobial agents.

Methods
In 2018, 31 clinical laboratories from United States and Canada collected up to 250 consecutive, aerobic or facultatively anaerobic, Gram-negative pathogens (GNP) from blood, intra-abdominal, urinary, and lower respiratory tract infections. A total of 6,178 GNP were collected, of which 1,138 (18.4%) were P. aeruginosa. MICs were determined using CLSI broth microdilution and interpreted with CLSI 2019 breakpoints.

Results
The MIC distributions of C/T and CAZ/AVI against 1,138 P. aeruginosa are shown below. The modal MIC value for C/T was ≥2 doubling dilutions lower than that for CAZ/AVI, and it was ≥3 dilutions lower than the C/T CLSI susceptible breakpoint, whereas the modal MIC value for CAZ/AVI was 2 dilutions lower than its susceptible breakpoint. Among all P. aeruginosa isolates, percentages of susceptibility were 96.0% (C/T), 93.8% (CAZ/AVI), 76.6% (CAZ and cefepime), 67.0% (imipenem [IMI]), 74.0% (meropenem [MEM]), 71.5% (piperacillin–tazobactam [TZP]), and 64.9% (aztreonam). Among subsets of nonsusceptible isolates, susceptibilities to C/T and CAZ/AVI were 83.5% and 74.4%, respectively (CAZ-NS subset, n = 266), 91.0% and 85.1% (IMI-NS, n = 376), 87.5% and 80.1% (MEM-NS, n = 296), 87.0% and 79.6% (TZP-NS, n = 324), and 72.4% and 57.8% among isolates nonsusceptible to all tested β-lactams (n = 116).

Conclusion
The activity of C/T exceeded that of CAZ/AVI and other tested comparators against a recent collection of clinical isolates of P. aeruginosa, including subsets of isolates nonsusceptible to other β-lactams. Susceptibilities to C/T were 6–14 percentage points higher than observed for CAZ/AVI among β-lactam-NS subsets. C/T promises to be an important treatment option for patients with antimicrobial-resistant P. aeruginosa infections.

Disclosures
All authors: No reported disclosures.
745. Operationalization of Comprehensive Sexual Wellness Clinic at a Large Urban Emergency Department
Authors: Hazra Aniruddha , Schmitt Jessica , Bender Alvie , Moore Michelle , Scott Cheryl , Garcia Damaris , Pitrak David 
Published: October 2019

Abstract

Background
Due to the closure of surrounding city-run sexually transmitted infection (STI) clinics, uninsured and underinsured patients living near an urban academic medical center have been relying on the Emergency Department (ED) for their sexual health needs. A novel Sexual Wellness Clinic (SWC) was created to provide comprehensive sexual healthcare and primary care linkage to patients presenting to the ED with STI complaints.

Methods
SWC-eligible patients are identified at ED intake and undergo a Medical Screening Exam (MSE) by a triage physician before transport to clinic. Notable exceptions to the SWC are patients who are pregnant, younger than 18 years of age, victims of sexual assault, or deemed to require higher acuity care. Once at the SWC, patients undergo a complete history and physical examination, comprehensive STI testing, and, if indicated, empiric treatment as well as same-day initiation of Pre-Exposure Prophylaxis (PrEP). Social services within the clinic also assist in arranging primary care follow-up either at the medical center or an affiliated Federally Qualified Health Center (FQHC).

Results
During its initial 8 weeks, 28 patients were seen in the SWC; 35.6% were cis-female and 64.2% were cis-male. All female patients identified as women who have sex with men, 89% of male patients identified as men who exclusively have sex with women. Patient ages ranged from 18 to 55 with a mean age of 25. Overall, 17.8% of patients tested positive for gonorrhea; 7.1% tested positive for chlamydia, and 0% tested positive for syphilis. One new HIV diagnosis was identified. Same-day PrEP was initiated in 28.5% of patients of which 62.5% (n = 5) were female and 37.5% (n = 3) were male. SWC linked 79% of patients to primary care.

Conclusion
We demonstrated the feasibility of this unique workflow bringing patients from the ED to a specialized sexual health clinic. The majority of patients visiting SWC identified as heterosexual men and women, which differs from other metropolitan STI clinics. Identifying these populations with untreated STIs and other HIV risk factors for targeted intervention is integral to local and national HIV elimination efforts.

Disclosures
All authors: No reported disclosures.
746. Improving Monitoring of Outpatient Parenteral Antimicrobial Therapy (OPAT) for Solid Tumor Patients at a Comprehensive Cancer Center
Authors: Dishner Emma L , McDaneld Patrick , Rowan Meagan , Robins Alison , Bartek Jalen , Dailey Garnes Natalie J 
Published: October 2019

Abstract

Background
Increasing rates of antimicrobial resistance require more frequent parenteral antimicrobial therapy. OPAT improves patient quality of life and is cost-effective. Although IDSA OPAT guidelines are applied to cancer patients, few studies have addressed implementation in this unique population. Through our quality improvement project, we aimed to improve monitoring of solid tumor patients recommended for OPAT by infectious diseases (ID) consultation as measured by an increased percentage of patients with physician follow-up and laboratory monitoring.

Methods
We used the plan-do-study-act methodology to guide our quality improvement project. To establish baseline frequencies, we retrospectively reviewed a subset of solid tumor patients seen for ID consultation and recommended for OPAT. We used brainstorming, fishbone analysis, and process mapping to analyze our current process. We standardized a sign-off note for inclusion with OPAT recommendations within our electronic medical record. We reminded ID providers of the new process weekly and to notify the OPAT team and outpatient clinical nursing staff of OPAT-enrolled patients.

Results
We found that clarifying recommendations addressed several identified obstacles to monitoring. After instituting our intervention, the percentage of patients who completed follow-up increased from 44% to 78% during the 6-week intervention period. Although the frequency of laboratory monitoring recommendations increased from 43% to 86%, the percentage of patients completing such monitoring did not improve. Our results were sustainable during the 3-month post-intervention observation period.

Conclusion
By standardizing ID recommendations, we increased outpatient follow-up frequency. Our inability to increase the frequency of laboratory monitoring likely reflects the increased complexity of the process, which requires action from external stakeholders. We learned that a simple intervention can have a meaningful impact and that gains can be limited without involvement of all stakeholders. We plan to expand to a comprehensive OPAT clinic for all patients at our facility and further characterize challenges and opportunities for utilizing OPAT in cancer patients.

Disclosures
All authors: No reported disclosures.
747. Implementation of a Pharmacist-led Intervention for Infectious Diseases Patients Discharged on Antimicrobials: the Infectious Diseases Discharge Outreach and Retention (ID DOOR) Program
Authors: Walston Bobbi Jo , Fletcher Lisa A , Wilson William , Boerneke Renae A , Marx Ashley H , Vargas John D , Farel Claire E 
Published: October 2019

Abstract

Background
Hospitalized patients who require Infectious Diseases (ID) consultative services and are discharged on antimicrobials (AM) are medically complex and at high risk of readmission. Complications related to AM toxicity, suboptimal regimen completion, or lack of AM access are prevalent. Our ID clinic pharmacist contacted patients affiliated with ID services within 72 hours of discharge to identify and intervene on needs such as AM access and management, toxicity monitoring, AM administration teaching, and to assess discharge care progression. The goal of this intervention was to leverage the subject matter expertise of an ID-trained pharmacist to create a protocolized intervention to improve the inpatient-to-outpatient transition for ID patients.

Methods
During a 12 week time period, 173 patients were identified and enrolled in the ID DOOR intervention. Patients who received consultative care by an ID physician were tracked and automatically referred to ID DOOR; those discharged on antimicrobials were included in the intervention group. Phone-based assessment of discharge AM access, education, and administration was initiated by the ID pharmacist within 72 hours of discharge (Table 1).

Results
Of the 173 patients, 155 (90%) were successfully contacted post-discharge. The majority of needs identified were AM education, access, and coordination of care (Table 2). In addition, discrepancies between discharge orders, summary content, and patient instructions were prevalent. Based on the medication-related assessment performed by the ID-trained pharmacists, they were able to resolve AM-related issues and identify, triage, and link patients to appropriate multidisciplinary providers to coordinate care plans.

Conclusion
The data highlight the prevalence of immediate post-discharge needs related to antimicrobial for patients and the critical role of ID-trained pharmacists in addressing these needs. In a large public academic medical center with uninsured and underinsured patients, additional support for AM access, education, and navigation of care plans is needed. For medically and socially complex ID patients, an ID-trained pharmacist plays a critical role in reducing risk inherent in the transition from inpatient to outpatient care.

Disclosures
All authors: No reported disclosures.
752. Timing of Antibiotics Administration in Emergency Department and Mortality in Sepsis by Sepsis-3 Definition
Authors: Seok Hyeri , Song Ju-Hyun , Hoon Jeon Ji , Kyoung Choi Hee , Suk Choi Won , Moon Sungwoo , Won Park Dae 
Published: October 2019

Abstract

Background
Even after the introduction of the Sepsis-3 definition, there is still debate on the ideal antibiotic administration time in patients with sepsis. This study was performed to evaluate the association between the timing of antibiotic administration and mortality in sepsis patients who visited the emergency room.

Methods
A prospective cohort study was conducted on patients who were diagnosed as sepsis with Sepsis-3 definition among patients who visited the emergency department (ED) of Korea University Ansan Hospital from September 2017 to January 2019. The timing of antibiotic administration was defined as the time in hours from ED arrival until the first antibiotic administration. Cox logistic regression analysis was used to estimate the association between time to antibiotics and 7-, 14-, and 28-day mortality.

Results
During the study period, a total of 251 patients were enrolled with a 7-, 14-, and 28-day mortality of 16.7%, 36.3%, and 57.4%, respectively. The median time to antibiotic administration was 247 minutes (interquartile range 72 – 202 minutes). The mean age was 72 ± 15 years old and 122 patients (48.6%) were female. The most common site of infection was respiratory infection. The timing of antibiotic administration were not associated with 7-, 14-, and 28-day mortality. Female (adjusted hazard ratio [HR] 2.06 [95% confidence interval (CI) 1.21 – 3.53]; P value = 0.008), SOFA score (aHR 1.17 [95% CI 1.05 - 1.31]; P = 0.005), and initial lactate level (aHR 1.13 [95% CI 1.05 - 1.22]; P = 0.001) increased the risk of 7-day mortality. Female (aHR 2.07 [95% CI 1.48 – 2.89]; P ≤ 0.001), Charlson comorbidity index (aHR 1.12 [95% CI 1.02 - 1.24]; P = 0.025), and initial lactate level (aHR 1.19 [95% CI 1.02 - 1.16]; P = 0.011) increased the risk of 14-day mortality. Female (aHR 1.95 [95% CI 1.50 – 2.54]; P = 0.001) increased the risk of 28-day mortality in patients with sepsis.

Conclusion
The timing of antibiotic administration did not increase the risk of mortality in the treatment of sepsis patients who visited ED. Rather, the SOFA score, lactate, female, and comorbidity increased the mortality associated with sepsis.

Disclosures
All authors: No reported disclosures.
768. Use of a Machine-Learning-based Prediction Model to Guide Antibiotic De-escalation in the Treatment of Urinary Tract Infections
Authors: Huggins Jonathan , Hamilton Keith W , Barnett Ian 
Published: October 2019

Abstract

Background
A patient-specific antibiogram (PS-ABG) issues personalized predicted antibiotic susceptibility results by incorporating patient factors into a prediction model. Predictions, reported as percent likelihood of susceptibility, are available to providers in real-time. In this study, we evaluated the performance characteristics of a PS-ABG based on a machine-learning algorithm in predicting susceptibility of Enterobacteriaceae isolated on urine cultures.

Methods
This cross-sectional study included 2,517 urine cultures with Enterobacteriaceae collected from 2,211 unique patients over a 12-week period from January 1 through April 15, 2019 in a single health system. Receiver operating curves (ROC) were generated for commonly prescribed antibiotics to assess discrimination. Threshold values to determine when an antibiotic could be used were then determined based on ROC curves. Brier scores were generated for all antibiotics collectively and for individual antibiotics to evaluate the accuracy of the predictions compared with that of the usual practice (UP) of traditional antibiograms.

Results
The ability of the PS-ABG to discriminate susceptible and nonsusceptible isolates varied by antibiotic [area under the curve (AUC) range: 0.71 - 0.95]. When all antibiotics were considered, AUC was 0.88 (95% C.I. 0.88 – 0.89). Brier score ranged from 0.0037 - 0.2087, representing between a 9 - 56% improvement compared with UP. For all antibiotics, the software had a 32% improvement over UP (median Brier score 0.0794 v. 0.1114, P < 0.0001). Overall, a susceptibility threshold of 95% was associated with a specificity of 96%. A threshold of 95% was associated with a ≥90% specificity in all agents except for cefepime (specificity 70%) and meropenem (specificity 73%). For cefepime and meropenem, specificity reached 90% at a threshold of 97%.

Conclusion
The PS-ABG demonstrated excellent discriminatory power for all antibiotics tested and was more accurate than UP. A cutoff of 95% likelihood of susceptibility affords high specificity for most agents and may be a reasonable threshold for selecting an appropriate antibiotic. A higher susceptibility threshold yields similar specificity for cefepime and meropenem, but this finding is likely a result of the low number of resistant isolates.

Disclosures
All authors: No reported disclosures.
776. Effect of the SEP-1 Sepsis Bundle on Mortality in Hospital-Onset v. Community-Onset Sepsis
Authors: Baghdadi Jonathan , Uslan Daniel , Bell Douglas , Wong Mitchell 
Published: October 2019

Abstract

Background
The SEP-1 sepsis bundle is a performance measure from the Centers for Medicare and Medicaid Services that requires blood cultures, serum lactate, broad-spectrum antibiotics, and IV fluids (in some cases) within 3 hours of onset of sepsis. Published evidence regarding an effect of SEP-1 on mortality is mixed and largely excludes cases of hospital-onset sepsis.

Methods
Retrospective cohort study using clinical data from 4 University of California hospitals. Sepsis-related admissions from 2014–2017 were identified by diagnosis codes. We compared the effect of the SEP-1 sepsis bundle on in-hospital mortality in cohorts with community-onset and hospital-onset sepsis. To control for selection bias, patients who did and did not receive the SEP-1 bundle from each cohort were balanced on key variables related to likelihood of treatment using Mahalanobis distance matching.

Results
5,034 out of 6,005 sepsis-related patient encounters were matched, including 1,770 (35%) patients who received the SEP-1 bundle and 3,264 (65%) who did not. The SEP-1 bundle was not associated with an effect on mortality in the unmatched (Table 2) or matched analyses (Table 3). Point estimates from the matched analysis suggested a greater potential benefit associated with SEP-1 and its components in community-onset sepsis, but differences in effect size between community-onset and hospital-onset were nonsignificant. Among bundle components, timely blood cultures, lactate, and antibiotics were not associated with an effect on mortality, while IV fluids were associated with a 3-percentage-point increase in mortality risk. In subgroup analysis, IV fluids were associated with increased mortality in patients with pneumonia and immunosuppression.

Conclusion
The use of the SEP-1 sepsis bundle was not associated with an effect on mortality. Subgroup analyses suggested situations in which IV fluids may be harmful, though prospective data are needed.

Disclosures
All authors: No reported disclosures.
777. Experience with Liposomal Amphotericin B in Outpatient Parenteral Antimicrobial Therapy (OPAT)
Authors: Burnett Yvonne , Hamad Yasir 
Published: October 2019

Abstract

Background
While OPAT is known to be a safe, effective, and convenient treatment strategy for patients receiving intravenous antimicrobials in the outpatient setting, the risk of adverse events (AEs) increases when high-risk medications, such as liposomal amphotericin B (L-AMB), are utilized. There is limited data available describing the use and safety of L-AMB in the OPAT setting.

Methods
Electronic medical records of patients discharged from Barnes Jewish Hospital on L-AMB between January 2015 and July 2018 were retrospectively reviewed. The primary objective of this study was to describe the population of OPAT patients discharged on L-AMB and to evaluate factors associated with readmission and AEs. Univariate analysis was performed to evaluate for predictors of worse outcomes.

Results
Forty-two patients (67% male, median age 50 years) were identified. The most common indications were histoplasmosis (n = 13, 31%) and aspergillosis (n = 7, 17%). The majority of patients were discharged to home (n = 35, 83%) on a median dose of 4 mg/kg L-AMB. More than half of the patients completed their anticipated course of L-AMB (n = 26, 62%), 17 without any interruption or change in therapy, while 16/42 patients required early discontinuation of therapy, 11 of which required a change in therapy. Twenty-one patients (50%) were readmitted during their L-AMB course with a median time to readmission of 10 days (IQR 4–18). While hypokalemia and AKI (increase in serum creatinine by 0.5 mg/dL or 50% from baseline) were common AEs, occurring in 62% (n = 26) and 49% (n = 20), only 5 (12%) were readmitted to the hospital due L-AMB-associated AE (hypokalemia (K < 3 mEq/L), n = 2; AKI, n = 3. Factors associated with all-cause readmission included malignancy (not readmitted 6/21 vs. readmitted 13/21, P = 0.02) and duration of therapy (median of 15 vs. 32 days in not readmitted vs. readmitted, P = 0.02). OPAT lab monitoring was performed at a median of 2 times per week. No patients required hemodialysis due to AKI.

Conclusion
L-AMB is associated with significant AEs; however, these results suggest treatment is feasible in the outpatient setting with close monitoring. The majority of AEs were managed effectively as an outpatient without long-term sequelae.

Disclosures
All authors: No reported disclosures.
782. Provider to Provider Electronic Consultation (E-consult): A Tool for the Pediatric Infectious Diseases Specialist to Document Encounters and Quantify Effort.
Authors: Gonzalez Blanca E , Foster Charles B , Esper Frank , Daniels Heather , Saracusa Carla , Boutros Jasmine , Isakov Daniela , Sabella Camille 
Published: October 2019

Abstract

Background
Curbside consultation is a ubiquitous practice within the medical field informally providing advice to community providers. The electronic consult (E-Consult) allows direct provider-to-provider communication between the primary care provider (PCP) and specialists using a secure electronic platform while documenting these interactions within the patient’s medical record (EMR). They offer PCP’s a forum for asking nonurgent questions. For the specialist, it allows review of the EMR, reduces medical liability of the curbside consult and provides a mechanism for generating RVUs. This service was implemented in our healthcare network (of over 300 pediatricians and pediatric specialists who see more than 500,000 pediatric visits each year) in April 2018. Our aim was to review and analyze the E-consults provided by the Pediatric Infectious Diseases (PID) service.

Methods
Cross-sectional study of E-consults performed by the PID from April 11 -2018-April 22 2019. Clinical queries were categorized by type and tabulated. Consult Billing was as following: Level 1=5 minutes (min); Level 2 =10min; Level 3= 15 minutes; Level 4= 25 minutes. RVU values were institutionally derived and assigned.

Results
We performed 171 E- consults with an average of 13 per month (range 3–18) generated from 59 providers (52 (88%) physicians and 7 (12%) certified nurse practitioners). Common reasons for the E-consult included: vaccine questions (25.7%), diagnosis questions (21.6%), exposure questions (20.4%) and treatment recommendations (10.5%). Of vaccine questions, 43% related to vaccine schedules /boosters, 13% vaccines for travel and 11.3% vaccines for the immunocompromised host. Consultation in the PID clinic was recommended for 25.7% patients, 9% requiring urgent evaluation. Of the 171 E-consults, 12.2% were evaluated in the PID clinic and 5% by another specialty. Billing was performed for 168 of the E consults= 9 level 1, 35 level 2, 83 level 3 and 41 level 4 generating 161 RVUs (equivalent to 53 level 4 new outpatient visits at our institution).

Conclusion
E-consults are an alternative to informal curbside consults for nonurgent clinical queries. Encounters are documented in the EMR and professional effort devoted to the task is tracked providing an additional source of RVU generation for the PID physician.

Disclosures
All authors: No reported disclosures.