bluuebunny/crossref_metadata_2025_split huggingface dataset:
769. Comparison of Vancomycin Continuous and Intermittent Infusion Dosing Strategies Among Patients in an Outpatient Antimicrobial Therapy Program
Authors: Shakeraneh Pegah , Gilotra Tarvinder S , Wang Dongliang , Fazili Tasaduq , Steele Jeffrey , Seabury Robert , Miller Christopher , Kufel Wesley D 
Published: October 2019

Abstract

Background
Vancomycin may be administered via intermittent infusion (I-I) or continuous infusion (C-I). C-I vancomycin has advantages including the potential for less nephrotoxicity; however, available data are inconsistent and varies based on inpatient and outpatient settings. Thus, the primary objective of this study was to compare rates of nephrotoxicity in patients who received C-I or I-I vancomycin in an outpatient parenteral antimicrobial therapy (OPAT) program. Secondary objectives included time to onset of nephrotoxicity and clinical failure.

Methods
This was a single-center, propensity score-matched, retrospective cohort study of patients who received C-I or I-I vancomycin for at least one week in the OPAT program between October 1, 2017 and March 31, 2019. Exclusion criteria included patients lost to follow-up, age less than 18 years old, and those requiring renal replacement therapy. Nephrotoxicity was defined as a serum creatinine (Scr) increase of >0.5 mg/dL or >50% from baseline for two consecutive measurements. Clinical failure was defined as unplanned readmission, extension of planned therapy, or change in antibiotic therapy.

Results
Three hundred patients were identified who received C-I or I-I vancomycin. After propensity score matching and exclusion criteria were applied, 74 patients were included in each cohort. Demographic information was similar between cohorts including baseline Scr, age, gender, comorbidities, concurrent nephrotoxins, indication, and vancomycin duration. C-I was associated with a 3.22-fold decrease in nephrotoxicity risk when compared with I-I [C-I: 6.8% vs. I-I 18.9%; OR (95% CI): 3.22 (1.10–9.46), P =0.027]. C-I was associated with a significantly slower onset to nephrotoxicity compared with I-I (P = 0.035; Figure 1). A significant difference in clinical failure was not observed between C-I and I-I (10/74, 13.7% vs. 17/74, 23.0%; P = 0.147).

Conclusion
C-I vancomycin was associated with a lower nephrotoxicity risk and slower onset to nephrotoxicity, but no difference in clinical failure rates when compared with I-I.

Disclosures
All authors: No reported disclosures.
772. Access Denied: Impact of Insurance Denials for High-Cost Outpatient Parenteral Antimicrobial Therapy
Authors: Bianchini Monica L , Kenney Rachel , Lentz Robyn , Zervos Marcus , Malhotra Manu , Davis Susan L 
Published: October 2019

Abstract

Background
Outpatient parenteral antimicrobial therapy (OPAT) allows patients to receive prolonged antimicrobial therapy while reducing the length of hospitalization and healthcare costs. In the United States, most public and private insurance companies require prior authorization (PA) for OPAT. The impact of OPAT PA delays is not known. This study aimed to characterize discharge barriers and authorization delays associated with high-cost OPAT antibiotics.

Methods
IRB-approved study of adult patients discharged with high-cost OPAT antibiotics from January to December 2017. Antibiotics were included based on the frequency of OPAT use and average sales price (ASP) greater than $100 per day, including: daptomycin, ceftaroline, ertapenem, and the novel β-lactam β-lactam inhibitor combinations. Patients with an OPAT authorization delay >24 hours were compared with patients without an OPAT authorization delay. Primary endpoint: total direct hospital costs, starting from the start of treatment with the OPAT antibiotic, from the institutional perspective using Healthcare Cost and Utilization Project and Center for Medicare and Medicaid Services 2019 ASP Drug Pricing data. Secondary outcomes: discharge delay and 30-day readmission or mortality.

Results
Two-hundred patients included: 151 (76%) no OPAT delay vs. 49 (25%) OPAT delay. The use of antibiotics was similar between groups, except ertapenem was more common in the no OPAT delay group: 60 (43%) vs. 15 (25%), P = 0.022. Patients with no OPAT delay were more commonly discharged with home infusion and less commonly to a facility: 75 (53%) vs. 19 (32%), P = 0.007, and 52 (37%) vs. 37 (63%), P = 0.001, respectively. Discharge delays were more common in patients with OPAT delays: 21 (15%) vs. 31 (53%), P < 0.001. The median total direct hospital costs were higher in patients with OPAT delays: $7,770 (3,031–13,974) vs. $19,576 vs. (10,056–37,038), P < 0.001. Table 1 compares the total direct hospital costs of patients with and without an authorization delay.

Conclusion
OPAT with high-cost antibiotics requires significant care coordination. Authorization delays for these antibiotics are common and may contribute to a delay in discharge. OPAT transitions of care represent an important opportunity for Infectious Diseases providers to improve care and address access barriers.

Disclosures
All authors: No reported disclosures.
786. Improving Access by Prescreening Self-Referred Patients to an Infectious Disease Clinic
Authors: Saldana Carlos S , Olender Jeff , Gordon Steven M , Holman Katherine 
Published: October 2019

Abstract

Background
Studies show that 35% of patients obtaining care in a specialty clinic are self-referred, of these, 60% do not have a PCP. Frequent changing of physicians without provider referral contributes to high costs and healthcare inefficiencies. Many subspecialty clinics do not require provider referral for access, so-called: ‘self-referral’; becoming an issue when patients discern a need for a subspecialty that does not align with their disease process. The Infectious Disease (ID) Department of the Cleveland Clinic Main Campus began prescreening all self-referred patients in July 2016. (Figure 1) We reviewed this process after sustained implementation.

Methods
Retrospective cohort study examining “self-referred” patients (lacking an internal referral order) to the ID Clinic from December 2016–October 2018. Grouped patients by chief complaint using system-based categories, subsequently reviewed records received for prior workup and identified if they had been seen by a specialist or received antibiotics in the past 6 months prior to visit. Those seen in our department were evaluated for: (1) additional workup ordered (2) if antibiotics were prescribed, and (3) referral to another specialty.

Results
1449 patients self-referred. By prescreening them, waiting time for appointment fell from >40 to 13 days, no-shows steadily drop from 11% to 8%. We audit 105 (40%) of patients seen, most common reasons for referral: Skin 19 (18%), Bone/Joint 18 (17%), Concern for Lyme Disease 16 (15%). 73% had been previously seen by a subspecialty; majority by ID. 75% received antibiotics in the past 6 months. After the visit, 53% had new work up ordered, 21% were prescribed antibiotics and 26% patients were referred to another specialty.

Conclusion
Prescreening self-referred patients contributed to improved access to subspecialty care and decreased”no-show’ appointments. The majority of self-referred patients had previous evaluation, frequently by the specialty being requested.

Disclosures
All authors: No reported disclosures.
999. Examining the Impact of a Penicillin Allergy Skin Testing Brochure on Inpatient Perceptions: a Pre-Post Intervention Study
Authors: Brown Mikaela , Uzoma Joy , VanSice Ryan P , Conn Kelly M , Ramsey Allison , Staicu Mary L 
Published: October 2019

Abstract

Background
Despite the negative implications associated with a penicillin (PCN) allergy label, less than 0.1% of ~25 million subjects with PCN allergy undergo a PCN skin testing (PST). There is a lack of data assessing patient knowledge and attitude about PCN allergy and PST. The purpose of this study was to evaluate the impact of an educational brochure on knowledge and perception of PST in adult inpatients with a PCN allergy label.

Methods
This was a pre-post intervention study conducted at a 528-bed community teaching hospital between June 2016 and March 2019. An electronic medical record was used to identify adult inpatients with an active PCN allergy. Participants completed a pre-brochure survey to assess demographic characteristics and baseline knowledge of PCN allergy and PST. Individuals then read an educational brochure, returned it to study personnel and were provided a post-brochure survey to complete. The primary and secondary outcomes of knowledge and perception were measured based on the level of agreement with statements about PCN allergies and PST using a 5-point Likert scale. McNemar’s test was used to compare responses for those who agreed vs. did not agree to knowledge statements.

Results
Among 125 patients approached, 101 completed the survey (80.8%). Patients were predominantly female (66.3%), >65 years of age (42.6%), Caucasian (78.2%) and completed high school or beyond (81.2%). The minority of patients (40.6%) previously heard about PST while 25.7% agreed they had previous discussions about PST with a healthcare provider. Only 24.8% agreed that people can outgrow a PCN allergy at baseline; however, after reading the brochure, this percent tripled (77.2%) (P < 0.01). Among 56 participants who disagreed that PST would be helpful for them at baseline, 30 subsequently agreed with this statement on the post-brochure survey (P < 0.001). Post-brochure, 86.1% indicated they felt better informed about PST. Despite this, 34.7% indicated they would be scared to use PCN again if future PST results were negative.

Conclusion
An educational brochure improved general knowledge of PCN allergy and PST, including subject report of feeling more informed. Although the brochure successfully educated patients, gaps remain regarding how individuals will personally apply this new information.

Disclosures
All authors: No reported disclosures.
1014. Decreasing Antimicrobial Use by 25% via Submission to NHSN-AUR Module
Authors: Kassamali Zahra , Kilcup Meg J , Werth Brian J 
Published: October 2019

Abstract

Background
Tracking antimicrobial data are a core element of antimicrobial stewardship programs. Since 2014, the Washington State Health Association (WSHA) has tracked antimicrobial use (AU) to address and reduce C. difficile infections statewide. In 2016, WA state began promoting the National Healthcare Safety Network (NHSN) tool to upload hospital AU. Both track days of antimicrobial therapy (DOT) but WSHA uses patient-days as the denominator while NHSN uses days-present. Each measure accounts for hospital length of stay but the latter is affected by unit transfers and the former is not.

Methods
Observational review of AU data submitted to NHSN and to WSHA in a 2-year period. Sixteen antibiotics selected by WSHA were reviewed and organized into 5 groups: broad-spectrum penicillins, cephalosporins, carbapenems, fluoroquinolones, and clindamycin. Data from a single center were used to compare results between each AU tracker. AU and days-present were obtained from the electronic medical record. Patient-days were obtained from the hospital quality department. The primary outcome was a difference in AU per WSHA vs. NHSN.

Results
Between January 2017 to December 2018, the median rate of antimicrobial use was 279 days per 1000 patient-days and 201 days per 1000 days-present. The median difference in total AU reported was 25% less using NHSN vs. WSHA and ranged from 18% - 31%.

Conclusion
Switching from patient-days to days-present decreased the reported rate of AU by 25%. In WA state, hospitals have nonuniformly adopted submitting antimicrobial use data to the NHSN. Until all hospitals submit their data via NHSN, both individual institutions and the state will have to contend with mismatched data. An interim solution may be to collect monthly patient-days and days-present from all hospitals and adjust the data before comparing AU among institutions. For institutions with a long history of tracking antimicrobial use, this change in denominator and resulting impact on AU represents a barrier to using the NHSN AU module.

Disclosures
All authors: No reported disclosures.
1026. Ertapenem Use During Antibiotic Stewardship Interventions in Community Hospitals
Authors: Peterson Nathan , Castro Sarah , Barbosa Felipe , Yoon Jungwon 
Published: October 2019

Abstract

Background
Antimicrobial stewardship programs (ASP) promote the judicious use of antimicrobials to reduce antimicrobial resistance and improve patient outcomes. In our institution, we identified the overutilization of ertapenem and implemented several interventions to decrease its usage. The objective of this study was to assess the impact of these interventions on ertapenem use, rates of surgical site infection (SSI), carbapenem-resistant Enterobacteriaceae (CRE), and hospital-onset Clostridioides difficile infection.

Methods
This was a retrospective study conducted in 3 community hospitals in Iowa and Illinois using surveillance of anonymized antibiotic and infection control data from 2015 to 2018. Target ASP interventions included a daily retrospective review of ertapenem use, alternative alerts to providers through electronic health records (EHR), carbapenem restriction to infectious disease (ID) providers, and educational meetings with high-use provider groups. The primary outcome was the usage trend of ertapenem, and secondary outcomes were rates of SSI, CRE, and hospital-onset C. difficile infection. Interrupted time series analysis was performed to assess changes in the rates over the study period.

Results
An overall significant reduction in ertapenem use was observed in all 3-community hospitals from 2015 to 2018. Ertapenem days of therapy adjusted for case-mix index per 1000 patient-days was 11.2 in 2015 and 2.05 in 2018. Two breakpoints were identified; the addition of an ID trained pharmacist to the ASP (10/2016) and educational meetings with colorectal surgeons (5/2017). No significant difference was seen for hospital-onset C. difficile infection, SSI, or CRE. Purchase costs decreased for ertapenem by 81% in 2018 compared with 2015(P < 0.001).

Conclusion
Adding an ID trained pharmacist to an ASP decreased usage of ertapenem. The majority of ertapenem use was for surgical prophylaxis, and our data suggested that educational meetings with a high-usage group were effective. Surgical site infection rates did not increase when narrower spectrum surgical prophylaxis was used. Overall hospital-acquired C. difficile rate was unchanged, possibly due to alternative antibiotic use. Our study suggests ASP interventions can be cost saving.

Disclosures
All authors: No reported disclosures.
1031. Effect of On-Site ID Specialist Led, Antimicrobial Stewardship Pharmacist Driven Program on Provider Acceptance, Antimicrobial Utilization and Clostridoides Infection Rates In a Community Hospital / Rural Regional Referral Center
Authors: Brailita Daniel , Lane Justin 
Published: October 2019

Abstract

Background
Antibiotic Stewardship (ASP) standards for hospitals became effective January 1, 2017. Core Elements implementation guidelines have been challenging for rural hospitals usually lacking on-site expertise. Our 170-bed Community Hospital / rural referral center has dedicated resources for on-site ASP. Our team includes on-site Infectious Disease (ID) Specialist and dedicated ASP pharmacist. Over first 2 years, our model shows very high provider acceptance, improvement in antimicrobial use pattern and reduction in the number of Clostridioides difficile infections (CDI).

Methods
The ASP Pharmacist conducted a daily review of ASP targets. He met with on-site ID Physician 3 days weekly to discuss interventions and review complex cases. The ASP team - ID Medical Director, ASP Pharmacist, Microbiologist, Invention Preventionist and Hospitalist met monthly to discuss outcomes and facility-wide interventions.
ASP audit included: positive cultures, patients on multiple or broad-spectrum antimicrobials, patients receiving dual nephrotoxic drugs, carbapenems, fluoroquinolones, candidates for IV to PO conversion
The audit results were communicated in-person to attending physician and documented in electronic medical record.

Results
ASP team recommendations were accepted in 94% of cases
ID consult was recommended in 4.69% and was accepted 100%.
Top 20 IV antimicrobial use decreased by 10%. Fluoroquinolones (29%) and carbapenems (28%) showed highest decrease. Cephalosporins showed small increase.
Hospital-acquired CDI rate decreased from 0.83 cases/ 1000 patient-days (PD) pre-ASP to 0.53 cases/ 1000 PD post-ASP. General CDI diagnosis decreased from 3.21 cases/1000 PD pre-ASAP to 2.23 cases/ 1000 PD post-ASP

Conclusion
An on-site, ID Specialist reviewed and dedicated ASP Pharmacist driven program at a rural referral center/ Community Hospital significantly improved antibiotic use and decreased Clostridium Difficile Infections in the first 2 years. Direct feedback of ASP review to providers resulted in an excellent acceptance rate. On-site ID and ASP Pharmacist collaboration is logistically difficult to achieve but expanding our model to rural referral centers should be considered. More research is needed to determine the cost-effectiveness of onsite, dual led programs.

Disclosures
All authors: No reported disclosures.
1043. Love Thy Steward – Who Does Not Love Antimicrobial Stewardship?
Authors: Kazi Aamir S , Sansom Sarah , Varughese Christy , Hodgson Hayley A , Won Sarah Y 
Published: October 2019

Abstract

Background
The impact of antimicrobial stewardship programs (ASPs) depends on physician perception of antimicrobial stewardship and institutional antibiotic prescribing culture. At Rush University Medical Center (RUMC), we conducted an antimicrobial stewardship study targeting inpatient levofloxacin (FQ) use and assessed rates of implementation of recommendations (IORs) by general medicine (GM), vs. surgical services (SS) (general surgery, urology, orthopedics and neurosurgery), vs. transplant surgery-immunocompromised host (T-ICH) teams when made by either infectious disease pharmacists (IDPharmD) or infectious disease fellows (IDMDF).

Methods
Between August 13, 2018 and January 15, 2019 at RUMC, IDPharmDs reviewed 251 inpatients on FQ, and made ASP recommendations on 36 (14%) that were communicated via telephone. No scripted discussion or note was utilized. From January 15, 2019 to April 19, 2019, an IDMDF reviewed 207 inpatients on FQ, and made ASP recommendations on 47 (22%). IDMDF’s recommendations were communicated via a scripted discussion describing the role of ASP, highlighting the importance of optimizing FQ use due to toxicity, low rates of RUMC’s FQ susceptibilities and to decrease rates of resistance. Telephone recommendations were made to the primary team house staff or attending followed by a templated electronic note left in the medical chart. Rates of IORs were assessed during each period and by each group.

Results
In 20 out of 83 recommendations (24%), no antibiotic was indicated (Figure 1). GM teams had the highest overall (IDPharmD + IDMDF) IOR (76%), compared with 40% IOR for both SS and T-ICH groups. For all groups, the scripted IDMDF recommendations had higher IOR compared with the nonscripted IDPharmD recommendations (GM 89% vs. 61%; SS 50% vs. 29%; T-ICH 50% vs. 0%).

Conclusion
ASP interventions using scripted discussions and notes by an IDMDF were more effective than nonscripted IDPharmD interventions across all service lines. Both interventions were less successful with SS or T-ICH compared with GM services. These findings demonstrate the need for further research to understand the importance of scripted vs. nonscripted communication methods by pharmacists and ID physicians, and to develop alternative communication models for nongeneral medicine service providers.

Disclosures
All authors: No reported disclosures.
1044. Impact of Interdisciplinary Rounds on Antimicrobial Use at a Community Hospital
Authors: Castillo Emma , Heuts Luke , Dodds Ashley Elizabeth , Moehring Rebekah W , Yarrington Michael E , Johnson Melissa D 
Published: October 2019

Abstract

Background
Antimicrobial stewardship (AS) implementation is challenging in resource-limited settings such as smaller community hospitals that may lack dedicated personnel resources or have limited access to infectious diseases experts with dedicated time for AS. Few studies have evaluated the impact of interdisciplinary rounds as a strategy to optimize antimicrobial use (AU) in the community hospital setting.

Methods
We evaluated the impact of interdisciplinary rounds in a 280-bed acute care nonteaching, community hospital with an established ASP. The primary outcome was facility-wide antibiotic utilization pre- and post-implementation. Rounds included key healthcare personnel (hospitalists, clinical pharmacists, case managers, nurses) reviewing all patients on inpatient wards Monday through Friday, with a discussion of diagnosis, antibiotic selection, dosing, duration, and anticipated discharge plans. AU was compared for a 7-month post-intervention period (June 1, 2018–December 31, 2018) vs. similar months in 2017 based on days of therapy (DOT)/1,000 patient-days and length of therapy (LOT) per antimicrobial use admission. In addition, trends in AU for the post-intervention period were compared with the previous 17 months (January 1, 2017–May 31, 2018) using segmented binomial regression.

Results
Interdisciplinary rounds incorporating AS principles was associated with a decrease in overall AU in this facility, with a significant decrease of 16.33% (P < 0.0001) in DOT/1,000 pd in the first month and was stable (decrease of 1.1% per month, P = 0.15) thereafter (Figure 1). There was no significant change in LOT/admission after the first month of the intervention, but the trend demonstrated a 2% per month decrease (P < 0.03) thereafter (Figure 2). Comparing 2018 intervention months with similar months of 2017, the use of antibacterial agents decreased on average by 191.3 (95% CI −128.2 to −254.4) DOT/1,000 patient-days (Figure 3) and 0.546 (95% CI: −0.28 to −0.81) days per admission (Figure 4).

Conclusion
In this community hospital with an existing antimicrobial stewardship program, implementation of interdisciplinary rounds was associated with a substantial decrease in antimicrobial use. This was sustained for at least a 7-month period.

Disclosures
All authors: No reported disclosures.