bluuebunny/crossref_metadata_2025_split huggingface dataset:
741. TravMil Surveillance of Travel-Related Illness in a Prospective Cohort of US Military Beneficiaries, 2010–2018
Authors: Manley Morgan , Lalani Tahaniyat , Telu Kalyani , Tribble David , Tilley Drake H , Ganesan Anuradha , Kunz Anjali , Geist Charla , Fraser Jamie , Mitra Indrani , Yun Heather , Lindholm David 
Published: October 2019

Abstract

Background
Increasing international travel places larger populations at risk for infections outside of their usual exposure. Deployed military personnel have unique risks for such infections. Our cohort’s rates of travelers’ diarrhea and influenza-like illness have been defined, but the rate of travelers with symptoms apart from a clinical syndrome has not. We present a survey of intra-travel symptoms of all travelers and confirmed diagnoses of ill-returned travelers in a cohort of military and civilian travelers.

Methods
TravMil is a prospective, multicenter observational study enrolling US military beneficiaries traveling outside the continental United States from 2010–2018; beneficiaries could also enroll after travel if they presented for a possible travel-related illness. Demographic information, intra-travel symptoms, and confirmed diagnoses were recorded.

Results
2671 travelers embarked on 3050 trips: 63.1% male; median age 38 years (IQR 27, 57); median trip duration 20 days (IQR 13, 46). Common purposes of travel: military deployment (45.9%), vacation (23.7%), and visiting friends/relatives (10.9%). Ninety-seven travelers (3.2%) enrolled post-travel. Top regions of travel: Africa (31.5%), South and Central America/Caribbean (25.5%), and Southeast and North Asia/Oceania (19.4%). During travel, 56.6% experienced gastrointestinal (GI) symptoms, 11.9% respiratory symptoms, and 3.0% fever; of those, 10.3% sought medical care. Eighty returned travelers sought medical care (21 prospective enrollees vs. 59 post-travel enrollees): 5 vs. 17 malaria cases, 3 vs. 16 arbovirus infections, and 6 vs. 14 GI syndromes. All malaria cases in prospective enrollees were in military subjects. Post-travel enrollees accounted for 1 acute human immunodeficiency virus and 3 rickettsial infections.

Conclusion
A majority of our travelers experienced symptoms during travel. Post-travel diagnoses, although uncommon, emphasize needed improvements in the application of known risk mitigation strategies. Our findings can help clinicians optimize their pretravel counseling by focusing education on self-treatment of common travel-related symptoms, prevention of GI, arthropod-borne, and respiratory illness, and emphasizing symptoms that should prompt medical care.

Disclosures
All authors: No reported disclosures.
755. Outpatient Parenteral Antimicrobial Therapy Program Evaluation within a Large Veterans Affairs Healthcare System
Authors: Kent Michael , Kouma Marcus , Tomasz Jodlowski , Cutrell James B , Cutrell James B 
Published: October 2019

Abstract

Background
Outpatient parenteral antimicrobial therapy (OPAT) allows safe delivery of IV antibiotics in ambulatory settings to facilitate hospital discharge. Within the Veterans Affairs (VA) system, OPAT programs face the unique challenges of large geographic coverage areas and referrals for veterans from non-VA hospitals.

Methods
Patients enrolled in the VA North Texas Health Care System OPAT program during fiscal years 2016 to 2018 had data collected on demographics, comorbidities, OPAT indications, antimicrobials used, pharmacist interventions, and complications during therapy. Data were collected from retrospective chart review as a quality improvement project. All enrolled OPAT patients required either an inpatient infectious disease (ID) consult or, for patients from non-VA facilities, required medical records review and telephone consultation with approval by a VA ID clinician. A third-party infusion company provided all medications and line care. Weekly laboratory monitoring and follow-up telephone visits were conducted by ID-trained pharmacists.

Results
During the evaluation period, 485 unique OPAT encounters (425 patients) were completed, with 164 patients (33%) directly admitted to OPAT upon referral from non-VA hospitals. Most common OPAT indications were osteomyelitis/diabetic foot infections (40.4%), bacteremia (17.3%), prosthetic joint infections/septic arthritis (12.4%), and urinary/intrabdominal infections (11.7%). Following standardization of pharmacist documentation, the volume and consistency of documented notes and interventions increased. Readmission rates while on therapy were similar, ranging from 13.4% to 13.7% each year. Patient demographics and OPAT outcomes demonstrated steady growth in the program (Table 1) with low rates of complications on therapy (Table 2). The program served patients in 35 counties and 158 zip codes across a broad geographic region in North Texas and southern Oklahoma (Figure 1). The most commonly used antibiotics are shown in Figure 2.

Conclusion
Our program has demonstrated the ability to safely and effectively provide OPAT across a large geographic region from a central location. ID-trained clinical pharmacists are critical to the care coordination and safety monitoring of OPAT in this unique setting.

Disclosures
All authors: No reported disclosures.
781. Nurse-Driven Time-of-Triage Sepsis Screening Tool Improves Timely Intervention in Ambulatory Emergency Department (ED) Patients with Suspected Sepsis
Authors: Howland Catalina , Chang Arthur , Selvanayagam Stephen , Kim Stacy , Bounthavong Mark , Catipon Nora , Rambaran Kerry , Yoon Christine , Sinha Rakesh , Ha David 
Published: October 2019

Abstract

Background
Sepsis is a potentially life-threatening, systemic complication of infection. Rapid intervention is critical to reduce morbidity and mortality; however, early recognition of sepsis is challenging due to a highly variable and nonspecific presentation. Recognition is particularly problematic in ambulatory (walk-in) patients who receive minimal to no medical attention prior to ED presentation. There is limited literature addressing sepsis intervention among the ambulatory population in the ED. Our organization has employed an electronic, nurse-driven sepsis screening tool into the triage process for all ambulatory patients who present to the ED.

Methods
This was a retrospective, quasi-experimental study conducted from November 2015 to May 2018 in three consecutive timeframes: pre-implementation (12 months), implementation (7 months), and post-implementation (12 months). Adult ambulatory ED patients were included if they had a coded diagnosis of sepsis, septic shock, or an infectious syndrome, had fever or hypothermia and systemic inflammatory response syndrome signs on presentation. The primary outcome measure was hourly time interval to antibiotic administration from time of ED registration.

Results
A total of 902 patients were included with 286, 208, and 408 patients in the pre-implementation, implementation and post-implementation cohorts, respectively. Baseline characteristics including comorbid conditions and infection source were similar between cohorts. The primary outcome of hourly time interval to antibiotic administration was significantly different (P = 0.044) between the three cohorts with the most substantial increase in administration specifically in the less than 1-hour interval. Between the pre-implementation, implementation, and post-implementation cohorts, significant decreases were observed in mean time to fluids (3.6, 3.0, and 2.5 hours, respectively, P = 0.003) and average length of stay (5.5, 5.8, and 4.2 days, respectively, P < 0.001) and a significant increase was observed in ED sepsis alert activations (26%, 48%, 51%, respectively, P < 0.001).

Conclusion
A nurse-driven electronic time-of-triage sepsis screening tool improved timely recognition and intervention in ambulatory ED patients with suspected sepsis.

Disclosures
All authors: No reported disclosures.
787. Improving ED Sepsis Care
Authors: Sloan William A , Kemmerly Sandra , Jain Surma , Shreves Ashley , Dauterive Kirsten 
Published: October 2019

Abstract

Background
Sepsis is a severe, life-threatening illness in response to an infection from the body’s immune system. Sepsis can progress rapidly, causing hypotension, organ failure, and death. Mortality from severe forms of sepsis and septic shock range between 20% to 50%, but with appropriate and timely treatment, mortality decreases to 5%-10%.
Before completing the Improving ED Sepsis Care project, there was only 18% and 12% compliance with the CMS 3 and 6-hour core measure bundles, respectively, within the Ochsner Main Campus Emergency Department.

Methods
A multi-disciplinary team followed Lean methodology for process improvement. The failure to identify sepsis patients as high acuity in triage was a key root causes identified. There was also a need to simplify the process and workflow to facilitate antibiotic administration and resuscitation.
A triage tool called “Code Sepsis” was created to allow for early identification of severe forms of sepsis, to ensure an appropriate ESI score, and to dedicate immediate attention from staff. A provider order set was created that included the necessary lab work standardized antibiotics.

Results
3-hour bundle compliance increased from 18% to 90% following the intervention. Improvements were noted in time to antibiotic administration, volume resuscitation, and appropriate initiation of vasopressors. The addition of the “Code Sepsis” triage tool decreased the median time to antibiotic administration from 1 hour 53 minutes to 33 minutes. Improvements were also noted in the elements of the 6-hour “perfect care” bundle; however, compliance rates were lower than goal.

Conclusion
Early identification and appropriate treatment of sepsis is key to improving survival. Despite widespread knowledge early treatment, many EDs struggle to meet the CMS sepsis care bundles. Utilizing the Lean framework allowed the improvement team to breakdown a multi-siloed, interdependent care process.

Disclosures
All authors: No reported disclosures.
993. Pharmacist-driven Penicillin Allergy Assessment in the Emergency Department – Antimicrobial Stewardship at the Point of Prescription
Authors: Campbell Samantha , Srinivas Pavithra , Hauler Gregory , Immler Ellen , Seiti Susan , Dandache Patricia 
Published: October 2019

Abstract

Background
Β-lactam allergy assessment is endorsed by the IDSA as an antimicrobial stewardship tool to enhance the use of first-line agents. We evaluated the impact of pharmacist-driven penicillin (PCN) allergy assessment at the point of prescription on antibiotic use in our emergency department (ED).

Methods
Retrospective, quasi-experimental study of adult patients with a PCN allergy receiving antibiotics at a community hospital ED. The intervention comprised an ED pharmacist performing allergy assessment and discussing therapy options with providers at the point of prescription. The primary outcome was to evaluate impact on guideline-preferred antibiotic prescription in the ED pre-intervention (March 1, 2017–August 31, 2017) vs. post-intervention (March 1, 2018–August 31, 2018). Secondary outcomes included types of reported allergic reactions, safety of allergy assessment process, and impact on downstream antibiotic use.

Results
Overall, 381 patients were evaluated (256 pre-intervention, 125 post-intervention). The median age was similar between groups and 85% of patients presented to the ED from the community. Most common infectious syndromes encountered in the ED were UTIs (35%), respiratory tract infections (25%), and skin/soft-tissue infections (18%). The proportion of guideline-preferred antibiotic prescriptions in the ED increased from 37% pre to 44% post (P = 0.171). Proportion of fluoroquinolone (FQ) prescriptions in the ED was reduced from 37.5% pre to 26% post (P = 0.021). Proportion of cephalosporin prescriptions increased from 26% pre to 42% post (P = 0.002). Types of reported allergic reactions were similar between groups and 55% of patients had tolerated a β-lactam agent since the listed allergy. Overall, 70% of patients were hospitalized from the ED. Similar trends in antibiotic use were observed at admission – decreased FQs (38% pre vs. 27% post, P = 0.059), increased cephalosporins (24% pre vs. 38.4% post, P = 0.021). Two patients (1.6%) experienced a nonsevere reaction within 24 hours of β-lactam administration post-allergy assessment.

Conclusion
Pharmacist-driven PCN allergy assessment at the point of prescription in the ED was safe and effective at improving the use of guideline-preferred antibiotics and reducing FQ use.

Disclosures
All authors: No reported disclosures.
998. Challenging Penicillin Allergies: Pharmacist led program in a community hospital
Authors: Patel Radha , Saccone Nicole , Stock Kent , Utley Sara , Bouknight Dawn 
Published: October 2019

Abstract

Background
Penicillin (PCN) allergy has been approximated to be reported in 10% of the United States population. Studies utilizing PCN skin testing have demonstrated that less than 1% of the population have a true PCN allergy. With increasing data on the negative consequences associated with a PCN allergy diagnosis, correctly identifying these patients is imperative. PCN skin testing has resulted in high rates of penicillin de-labeling; however, there are limited data evaluating the impact of a pharmacist-led PCN allergy evaluation with removal through utilization of oral challenges. The aim of this study was to utilize pharmacists to correctly identify those who are not penicillin-allergic to help decrease unnecessary use of broad-spectrum antibiotics and to optimize therapy.

Methods
This is a single-center, prospective review looking at a 10-month period of a pharmacist-led de-labeling project of patients with a PCN allergy. The electronic medical record system and decision support software were used to identify eligible patients. Adults ≥18 years of age with a PCN allergy were included. During the evaluation, pharmacists utilized a series of standardized questions which was reviewed with the infectious disease physician to classify the patient’s allergy. Based on classification a protocol was followed that either led to the patient retaining their allergy, or removal. The primary objective is to evaluate the rate of removal of penicillin allergies. Secondary objectives reviewed removal rate of patients on active antibiotics, and evaluate how many were switched to β-lactam.

Results
A total of 492 patients with PCN allergies were interviewed by a pharmacist. Pharmacist de-labeled 99/492 (20%) PCN allergies. Of those patients, 23% were removed through oral challenge and 76% through patient history. There were 175 patients on active antibiotics and 52/175 (30%) had their allergies removed. Finally, 36/52 (69%) were switched to a β-lactam.

Conclusion
A pharmacist-led penicillin allergy de-labeling project is beneficial in reducing PCN allergies when skin testing is unavailable in community hospitals. As seen about 1 in 5 patients were able to remove their allergy through allergy evaluation or oral challenge. Furthermore, pharmacist evaluation of the allergy not only helped remove the allergy but also resulted in the most appropriate antibiotic.

Disclosures
All authors: No reported disclosures.
1000. The Impact of Pharmacy Students Performing Penicillin Allergy Reconciliation in a Community Health System
Authors: Jones Bruce M , Gamble Kelly , Sizemore Summer , Bland Christopher M 
Published: October 2019

Abstract

Background
Antimicrobial stewardship programs (ASP) play an important role in the assessment of patients with a reported history of penicillin allergy. Full-time pharmacists performing antimicrobial stewardship face many time barriers and limited resources to interviewing and investigating self-reported allergies. Pharmacy students on Advanced Pharmacy Practice Experience (APPE) rotations during their fourth year can potentially play an important role in this evaluation if properly trained, but data are limited. This study evaluated APPE student interventions on hospital inpatients self-reporting a penicillin allergy.

Methods
This quasi-experimental study assessed patients with a self-reported penicillin allergy who were interviewed by APPE students from October 2018 through March 2019. Students on a 5-week infectious diseases rotation were trained in allergy assessment and interview skills by their preceptor and given a daily list of all inpatients with a self-reported penicillin allergy. After reviewing patients with the preceptor, the electronic health record was updated with specifics of the allergy, including the range, reaction, and any β-lactams tolerated since. Interventions included penicillin re-challenge, graded challenge, penicillin skin testing, desensitization, or removal or the allergy. The primary outcome was interventions attributed to APPE student patient interviews.

Results
A total of 12 APPE students participated in the study. Reported reactions ranged from mild allergies (itching, rash) or adverse reactions (nausea, vomiting) to intermediate or severe allergies (hives, anaphylaxis). For the primary outcome there were 162 interventions performed, with 154 verbal, 2 re-challenges, and 6 skin tests. For the verbal interventions, 95 had their allergy updated, 34 removed, and 33 confirmed. None of the 8 patients who were skin tested or re-challenged had a subsequent reaction.

Conclusion
Pharmacy students can expand ASP allergy reconciliation services for patients with penicillin allergies in settings with limited resources. After proper training, students were effective in multiple aspects of allergy reconciliation with a significant number able to have their penicillin allergy removed.

Disclosures
All authors: No reported disclosures.
1001. Feasibility and Outcomes of a Pre-Transplant Antibiotic Allergy Evaluation Program for Allogeneic Hematopoietic Cell Transplant (HCT) Candidates
Authors: Liu Catherine , Krantz Elizabeth M , Stohs Erica J , Imlay Hannah , Rampur Lahari , Sweet Ania , Zier Jacqlynn C , Pergam Steven A , Mielcarek Marco , Henderson William , Altman Matthew 
Published: October 2019

Abstract

Background
Antibiotic allergies impact the management of hematopoietic cell transplant (HCT) patients who are often prescribed antibiotics for infection prophylaxis and treatment. We evaluated the feasibility and outcomes of an antibiotic allergy evaluation program prior to allogeneic HCT.

Methods
In August 2017, we implemented a program to expedite allergy clinic referrals for adult allogeneic HCT candidates who reported an antibiotic allergy at their initial pre-transplant evaluation visit (PTEV). Allergy labels and clinical data including outcomes of allergy evaluation were prospectively collected for patients with PTEVs between 8/10/17 and November 15/18. The use of selected antibiotics was collected in the 100 days following HCT among patients with a reported β-lactam allergy (BLA). Choice of prophylactic agent for Pneumocystis jiroveci among patients with reported sulfa allergies was assessed among HCT recipients after engraftment.

Results
Of 276 allogeneic HCT candidates, 109 (39.5%) reported >= 1 antibiotic allergy (Table 1). Of the 109, 69 (63%) were referred for allergy evaluation; 83% (57/69) of those referred were evaluated at a median of 14 days after PTEV, and a median of 18 days before transplant. Among evaluated patients, 45 (79%) had >= 1 antibiotic allergy de-labeled including 74% (28/38) of those with BLA (Figure 1). Of the 10 patients whose BLAs could not be delabeled, 1 had a possible immediate IgE-mediated reaction, 5 had a delayed type IV hypersensitivity, and 4 had other reactions or required additional testing. Post-transplant antibiotic use among evaluated vs. nonevaluated patients reporting BLA is shown in Figure 2. Among 31 patients with reported sulfa allergies who underwent HCT, those who were evaluated received TMP-SMX rather than alternative prophylaxis more often (48%; 11/23) than those who were not evaluated (25%; 2/8). 10 (43%) of 23 evaluated patients were delabeled; 7 of 10 delabeled patients received TMP-SMX.

Conclusion
Antibiotic allergies are frequently reported among HCT candidates. Pre-transplant antibiotic allergy evaluation was feasible, led to de-labeling of the majority of reported allergies, and may alter antibiotic prescribing and increase the use of preferred agents following transplant.

Disclosures
All authors: No reported disclosures.
1015. Antibiotic use and indications in a community sample of adults in Wisconsin
Authors: Schletzbaum Maria , Safdar Nasia , Shirley Daniel , LeCaire Tamara , Malecki Kristen , Peppard Paul , Sethi Ajay 
Published: October 2019

Abstract

Background
There is significant inappropriate and overuse of antibiotics in the United States. We describe patterns of self-reported actual use of antibiotics and indications in Wisconsin adults.

Methods
The Survey of the Health of Wisconsin (SHOW) is an annual health study of a wide range of health determinants and outcomes among a population-based sample of residents with targeted recruitment of underrepresented minorities. In 2016, SHOW initiated WARRIOR (Winning the War on Antibiotic Resistance), an ancillary study that assessed actual antibiotic use and indications among adults. Antibiotics were grouped by pharmacologic class, and indications were grouped into clinical categories. Descriptive statistics and logistic regression were used to examine factors associated with antibiotic use.

Results
Overall, 756 adults [435 female and 321 male; mean (SD) age=54.2 (16.5)] were recruited, and 256 (33.5%) reported antibiotic use in the past year. Females (OR=1.87, 95% CI: 1.29, 2.70), people with current comorbidities or history of certain health conditions (OR=2.04, 95% CI: 1.23, 3.39), and people with a mental health or developmental condition (OR=1.93, 95% CI: 1.33, 281) were statistically significantly more likely to report antibiotic use. BMI (kg/m2) was slightly higher among antibiotic users (31.2) than nonusers (29.8; P = 0.064). Diabetes, heavy drinking, and smoking history were not correlated with antibiotic use.
Top antibiotic classes used were penicillins (31%), macrolides (12%), first-generation cephalosporins (9%), tetracyclines (8%), quinolones (7%), and nitroimidazoles (3%). Top indications reported were upper respiratory infection (URI; 32.3%), dental condition or procedure (21.0%), surgery (12.6%), lower respiratory infection (11%), urinary tract, bladder, or kidney infection (7%), skin or soft-tissue infection (6%), and insect bite or insect-borne infection (6%).

Conclusion
Antibiotic use varies among Wisconsin adults, and certain groups are more likely to have used antibiotics in the last year. The top two reported indications for antibiotics were categories with known high rates of inappropriate (e.g., URI) and prophylactic (i.e., dental) prescribing. Further studies are needed to determine specific opportunities to reduce antibiotic use in Wisconsin.

Disclosures
All authors: No reported disclosures.