bluuebunny/crossref_metadata_2025_split huggingface dataset:
737. Novel Glycans Reduce Carbapenem-Resistant Enterobacteriaceae and Vancomycin-Resistant Enterococci Colonization in an Ex Vivo Assay by Supporting Growth and Diversity of Commensal Microbiota at the Expense of MultiDrug-Resistant Organisms (MDRO)
Authors: LeBlanc Gabby , Brooks Brandon , Hartman Madeline , Hecht Maxwell B , Luong Hoa , Pan Zheng , Sofen Stephen , Miller Kelsey J , Meehan Brian , Mahowald Michael A , Yatsunenko Tanya 
Published: October 2019

Abstract

Background
Infections with Carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant Enterococci (VRE) can result in a 50% mortality rate in compromised hosts. A major risk factor for clinical infection is intestinal colonization with CRE or VRE. There are currently no FDA-approved compounds to decolonize these organisms from the gastrointestinal tract (gut). Commensal microbes offer protection from pathogen infection; however, in immunocompromised hosts or with antibiotic treatment, the protective properties of the microbial community are compromised, leaving the gut susceptible to pathogen colonization. Higher concentrations of pathogens within the gut correlate with an increased risk of infection with MDROs. Our hypothesis is that reducing colonization of the gut with MDROs would reduce the likelihood of a clinical infection.

Methods
Kaleido built a platform that emulates the gut environment and allows for high throughput screening of Kaleido’s Microbiome Metabolic Therapies (MMT™) in human gut microbiomes ex vivo. Over 500 compounds were screened for their ability to reduce the levels of CRE and VRE in fecal microbial communities from both healthy subjects and critically ill patients receiving broad-spectrum antibiotics.

Results
Kaleido’s lead MMTs selectively favor the growth of the commensal microbiota at the expense of pathogens, resulting in a decrease of CRE and VRE from 80% of the initial community to 5% in a single batch culture, as measured by 16S rRNA gene and shotgun metagenomic sequencing. Lead MMTs do not support growth of CRE and VRE strains in culture, nor of other pathogens frequently encountered in critically ill and immunocompromised patients, such as Clostridium difficile and common fungal pathogens.

Conclusion
These results suggest that intervention with MMTs may reduce CRE and VRE colonization and support further evaluation in patients colonized with CRE or VRE pathogens.

Disclosures
All authors: No reported disclosures.
742. The Development, Implementation, and Feasibility of Multidisciplinary Treatment Planning Conference for Individuals with Unstable Substance Use Disorders and Active Infections Requiring Prolonged Antimicrobial Therapy: The OPTIONS-DC Model
Authors: Strnad Luke , Douglass Alyse , Young Kathleen , Mayer Heather , Brown Jessica , Mahoney Stacey , Dellabough-Gormley Elona , Gore Sara J , Englander Honora , Gregg Jessica , Sikka Monica , Sikka Monica 
Published: October 2019

Abstract

Background
Outpatient parenteral antimicrobial therapy (OPAT), widely used for serious infections, has high failure rates in people with substances use disorders (SUD)1–2. At our institution, completing therapy in the hospital was previously the best option for high-risk patients; but long hospital stays are often unacceptable to patients and costly. To improve outcomes, our Infectious Diseases division, OPAT program, and Improving Addiction Care Team (IMPACT) developed and implemented a novel multidisciplinary conference (OPTIONS-DC) for inpatients with SUD requiring prolonged antibiotics. This study describes the conference development, tool, and initial experience.

Methods
From June 2017 to June 2018, diverse stakeholders collaboratively created and implemented a structured conference to discuss treatment options that balance medical efficacy, patient preferences, and feasibility using harm-reduction principles. After 10 months of hospital-wide implementation, we elicited provider feedback and performed a content analysis of OPTIONS-DC notes and patient records to evaluate the impact.

Results
The goal of conference development was prioritizing patient preferences and engaging multidisciplinary input. One RN facilitates the conference using the tool (Figure 1) to elicit input from the relevant providers. The tool systematically addresses components that may predict treatment success (i.e., working phone) while emphasizing patient preference and harm reduction. The IMPACT social work PICC safety assessment informs risks for IV access. Antibiotic recommendations are not a binary of optimal/suboptimal choices for the infection but options that best fit patient context. The average conference length was 28 minutes (IQR 21). Preliminary data shows good clinical outcomes and savings to inpatient days and cost. Initial feedback suggests the model was positively experienced by medical providers (Figure 2) and supported patient preferences.

Conclusion
A multidisciplinary patient-centered conference that prioritizes patient preference and uses harm-reduction principles for this high-risk population is practical, effective, and positively experienced by providers. This model may serve as a roadmap for other institutions.

Disclosures
All authors: No reported disclosures.
743. Evaluation of Adverse Drug Reactions due to Common β-Lactam Therapies Among Patients Enrolled in an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program
Authors: Mays Erin , Kinlaw Alan C , Swartwood Michael J , Boerneke Renae A , Farel Claire E , Marx Ashley 
Published: October 2019

Abstract

Background
The UNC Medical Center Outpatient Parenteral Antimicrobial Therapy (OPAT) program was started in 2015 to provide multidisciplinary monitoring and management of patients discharged on parenteral antimicrobials. Laboratory abnormalities and adverse drug reactions (ADRs) are potential complications of OPAT that may result in readmission and treatment changes. The purpose of this study was to evaluate the time to first ADR for OPAT patients treated with BL therapies for diabetic foot infections (DFI) and osteomyelitis (OM).

Methods
This was a retrospective cohort study of patients enrolled in the UNC OPAT program between January 2015 and September 2018 for treatment of DFI or OM. Included patients received one of the following BL: cefepime, ceftriaxone, ertapenem, meropenem, and piperacillin/tazobactam. The primary outcome was time to first ADR during OPAT. Secondary outcomes were estimation of risk of ADR during OPAT for each medication; and ADR types and frequencies observed among patients treated with BL alone or with concomitant vancomycin or daptomycin.

Results
In this cohort, 178 OPAT patients received 193 OPAT courses, for a median duration of 42 days (IQR 38–50). The average patient age was 55 years, and 68% were male. Ertapenem was the most commonly prescribed BL (76 courses, 39%), followed by ceftriaxone (29, 15%), cefepime, (41, 21%), piperacillin/tazobactam (30, 16%) and meropenem (17, 9%). Approximately 40% (76) patients received concomitant vancomycin. ADR was documented in 48 patients (27%) and 56 courses of therapy (29%). Kaplan–Meier-estimated risk of at least one ADR in the first 8 weeks of therapy was 38.7% (95% CI 29.1% to 48.2%). ADR resulted in 32 therapy changes and 8 readmissions.

Conclusion
More than one-third of patients treated with BL for treatment of DFI and/or OM are at risk of ADR within 8 weeks. ADR commonly resulted in treatment changes, and possible hospital readmission. BL therapy is associated with significant ADR risk, and careful selection and monitoring is essential for optimal patient safety during OPAT.

Disclosures
All authors: No reported disclosures.
759. High-Dose Daptomycin Is Well Tolerated via 2-Minute Infusion
Authors: Gill Christian Mark , Kenney Rachel , Makowski Charles , Davis Susan L 
Published: October 2019

Abstract

Background
Intravenous (IV) base solution shortages pose issues in the administration of IV antimicrobials and necessitate alternative administration strategies. Safety data supports 2-minute infusions of IV daptomycin up to the labeled dose of 6 mg/kg. The purpose of this study was to evaluate the safety of administering high-dose daptomycin (HDD) (>6 mg/kg) as a 2 minute IV infusion compared with traditional 30-minute infusion.

Methods
IRB-approved, retrospective cohort in a five-hospital health system admitted 9/1/17–9/1/18. Inclusion criteria: Patients receiving HDD as either a rapid 2 minute IV push (IVP) or a traditional 30-minute infusion (IVI) while inpatient. Exclusion criteria: <2 doses of HDD, pregnant, age <18, concomitant medication associated with infusion reactions (e.g., amphotericin B or monoclonal antibody). Primary outcome: proportion of patients with infusion-related reactions (IRR) after daptomycin administration. Infusion-related reactions were assessed using the Naranjo algorithm and adjudicated by 2 reviewers blinded to administration strategy. Bivariate statistical tests were used to compare patient characteristics and outcomes between groups. Data were reported using descriptive statistics and measures of central tendency.

Results
300 patients included: IVP n = 200, IVI n = 100, representing a total of 1697 administrations. Median age IVP 61 (49, 71), IVI 63 (52, 74). Median BMI IVP 28 (23, 35), IVI 27 (23, 32). Median daptomycin dose IVP 700 (550, 900), IVI 700 (600, 900) with mg/kg doses of 8.2 (7.9, 10) and 8.3 (8, 10), respectively. Administration site was similar in both groups with the most common central venous catheters. Potential IRR occurred in 4% of the IVP arm and 1% of IVI arm, P = 0.28. After adjudication, IRR occurred in 1% of both treatment groups. Descriptions of IRR are in Table 1 and only 1 patient in the IVI arm required discontinuation. CPK elevations: 3% of entire cohort.

Conclusion
Administering HDD as an IVP was not associated with increased risk of IRR compared with IVI. This administration may be advantageous during fluid shortages and in outpatient administration.

Disclosures
All authors: No reported disclosures.
767. Can Integration of Addiction Treatment Facilitate Safe Discharge on OPAT for Patients with Infectious Complications of Injection Drug Use?
Authors: Solomon Daniel A , Price Christin , Johnson Jennifer A A , Montgomery Mary W , Martin Bianca , Suzuki Joji 
Published: October 2019

Abstract

Background
While there is a growing body of evidence that suggests outpatient parental antibiotic treatment (OPAT) for people who inject drugs (PWID) may be safe, research on integrating OPAT with addiction treatment for PWID has been limited.

Methods
Adults hospitalized for infectious complications of injection drug use (IDU) requiring prolonged IV antibiotics were included in this study. The suitability for OPAT was determined by the infectious disease and addiction consultation services. Eligibility criteria included safe housing, attendance at infectious disease (ID) clinic visits, and engagement with addiction treatment. Demographic and clinical outcomes were summarized, and compared with patients without any IDU history enrolled in OPAT during the same time at the same institution.

Results
Eighteen OPAT episodes among 17 individuals were included, with 9 (50.0%) males. Mean age was 38.4 (SD 9.5). Types of infection included endocarditis (38.9%), epidural abscess (38.9%), and bone/joint infections (33.3%). Opioid use disorders (OUD) were most common (94.4%), followed by cocaine (33.3%) and benzodiazepines (16.7%). All individuals completed the recommended course of IV antibiotics. All OUD patients received buprenorphine (52.9%) or methadone (47.1%). Two (11.1%) relapsed to drug use during OPAT, but no instances of line tampering, thrombosis, line infection or line dislodgement were identified. No deaths or overdoses were reported. Collectively, 504 inpatient days were avoided. Compared with 390 individuals without any history of IDU, those with IDU history were significantly younger (38.4 vs. 59.0, P < 0.0001), had fewer episodes of endocarditis (38.9% vs. 43.6%) and bone/joint infections (33.3% vs. 41.8%), but more epidural abscesses (38.9% vs. 3.1%). There were no statistical differences in rates of readmission (22.2% vs. 11.3%), line complications (0% vs. 3.5%), mortality (0% vs. 1.0%), ID clinic visit attendance (100.0% vs. 82.0%), or number of days on OPAT (28.0 vs. 30.1).

Conclusion
Results add further evidence of OPAT’s safety among PWID and that integration of addiction treatment may be feasible. OPAT outcomes were similar to those without any IDU history. More research is needed to study the impact of integrating addiction treatment with OPAT for PWID.

Disclosures
All authors: No reported disclosures.
1008. The Reduction of Fluoroquinolone Prescribing in Rural Vermont Hospitals
Authors: Smith Lindsay , Ahern John W 
Published: October 2019

Abstract

Background
In 2017 The Joint Commission required all hospitals irrespective of size to implement antimicrobial stewardship programs (ASPs) using the CDC core elements (CE) for antimicrobial stewardship (AS). Critical access and rural community hospitals have struggled with developing effective ASPs. Many ASPs seek to reduce fluoroquinolone (FQ) prescribing due to its high risk for drug-drug interactions, risk of Clostridioides difficile infection, and numerous side effects, including five black box warnings from the FDA.

Methods
We contracted with the Vermont Department of Health to help rural VT hospitals develop ASPs that are compliant with the CDC CE for AS. Six of Vermont’s 13 hospitals were recruited between June – December 2017 (Table 1). Each hospital obtained antibiotic usage (AU) data in grams (g)/1000 (1k) patient-days (PD) from their electronic medical record (EMR), starting from January 2017. All identified FQ as frequently prescribed antimicrobials. Each hospital had unique interventions to decrease FQ prescribing (Table 1), including orderset changes and pharmacist intervention. Monthly combined FQ (ciprofloxacin + levofloxacin) administration data were collected in g/1K PD. AU data from each hospital were summed and expressed as total FQ g/1000 patient-days. The FQ prescribing trend was analyzed by linear regression.

Results
Prior to implementing ASP, there was a combined FQ rate of 69 g/1K PD. After 20 months of ASP interventions, combined FQ prescribing decreased to 26 g/1K PD (Figure 1, R= 0.9797, P < 0.001). This trend is also significant for each individual FQ: ciprofloxacin (R=0.8364, P < 0.05) and levofloxacin (R= 0.9801, P < 0.01).

Conclusion
Rural and critical access hospitals can have successful antimicrobial stewardship programs. We have shown that rural hospitals in Vermont (1) can extract AU data from their EMR, (2) develop interventions to decrease high use antimicrobial agents, and (3) be successful in decreasing FQ prescribing in less than 2 years.

Disclosures
All authors: No reported disclosures.
1016. Standardized Antimicrobial Administration Ratio (SAAR) and Clostridioides difficile Infection Standardized Infection Ratio (SIR): Are they connected? An Evaluation of 28 Hospitals
Authors: Sebastian Danielle , Daragjati Florian , Saake Karl , Sturm Lisa K , Fakih Mohamad G 
Published: October 2019

Abstract

Background
Clostridioides difficile infections (CDIs) are the most prevalent healthcare-associated infection in the U.S. Of all CDIs, most are related to healthcare exposures and are potentially preventable by reducing unnecessary antibiotic use and interrupting patient-to-patient transmission of CDI.

Methods
The adult SAARs for 4 antimicrobial agent categories were compared with the CDI SIR at 28 facilities with greater than 100 beds across the health system for the calendar year of 2018. The 4 adult antimicrobial agent categories chosen for comparison were: antibacterial agents posing the highest risk for CDI, broad-spectrum antibacterial agents predominantly used for hospital-onset infections (BSHO), broad-spectrum antibacterial agents predominantly used for community-acquired infections (BSCA) and all antibacterial agents.

Results
The 2018 aggregate CDI SIR for the 28 facilities was 0.609. The aggregate SAAR for the adult antimicrobial agent categories were 1.05 for the antibacterial agents posing the highest risk for CDI, 1.05 for BSHO, 0.88 for BSCA, and 1.03 for all antibacterial agents. No correlation was seen between any of the 4 adult SAAR antimicrobial agent categories and the facility CDI SIR (Figure 1–4).

Conclusion
While reducing unnecessary antibiotics is an important strategy in preventing CDIs, having a higher observed vs. predicted administration ratio in the four antimicrobial agent categories studied was not correlated with a higher CDI SIR, including the CDI SAAR category. Reduction of CDI is challenging requiring a multipronged approach to include infection control strategies, appropriate testing, and antimicrobial stewardship.

Disclosures
All authors: No reported disclosures.
1021. Accuracy of Provider-Selected Antibiotic Indications at Point of Order Entry Compared with Electronic Health Record Documentation
Authors: Mary Bradley , Huang Joanna , Neville Nichole , Schwarz Kerry , Barber Gerard , Huang Misha , Miller Matthew A 
Published: October 2019

Abstract

Background
The Centers for Medicaid and Medicare Services (CMS) state that hospital antimicrobial stewardship (AMS) policies require indications be documented for all orders. This may be included in the electronic medical record (EMR) or during order entry per CMS. Reliance solely on EMR documentation may be inconsistent or absent at times. In an effort to optimize compliance to this new measure and improve antibiotic use tracking, the University of Colorado AMS committee implemented required indications for all systemic antimicrobial orders. To follow up on this intervention we sought to determine the accuracy of ordered indication based on EMR documentation.

Methods
Retrospective review of antibiotics ordered between May 2, 2017 and December 1, 2017 among hospitalized patients aged 18–89 years. The primary objective was the accuracy of provider-selected indications (PSI) compared with EMR documented-clinical indication (DCI). Secondary objectives included accuracy comparison between check-box and free-text PSI format, and adherence to institutional antibiotic use guidelines. Differences between proportions of antibiotic orders with certain variables were assessed with Pearson’s chi-square and Fisher’s exact as appropriate.

Results
A total of 304 patients were evaluated with a median age of 56 years, 49% male, and 31% identified as immunocompromised. Check-box was most utilized in 81%, with 93% having a single indication selected. Most orders were classified as empiric (63%), followed by prophylaxis (23%) and definitive (15%). Frequent indications chosen were pneumonia (17%), bacteremia (13%), skin and soft tissue (10%), urinary tract infection (9%), and intra-abdominal infections (5%). Accuracy by PSI/DCI match was 78%, which was not different by a method of indication entry. Only indication type (P = 0.023) and care team specialty (P = 0.009) were shown to significantly impact accuracy. Nonadherence to institutional guidelines was 19%.

Conclusion
Antibiotic indications on order entry are an effective strategy to improve documentation and meet compliance around new CMS standards. Ordering by surgical services and prophylactic indications had lower PSI/DCI match, mostly resulting from absent EMR indication documentation.

Disclosures
All authors: No reported disclosures.
1029. Clinical and economic outcomes of a newly implemented daptomycin dosing policy in a four-hospital health system
Authors: Todd Meredith , Jones Kelci , Hill Sharon 
Published: October 2019

Abstract

Background
In light of recently published clinical and pharmacokinetic data regarding the use of daptomycin in obese patients, the Charleston Area Medical Center (CAMC) Antimicrobial Stewardship Program implemented an adjusted body weight dosing strategy for obese patients. Along with this new dosing strategy, an effort to reduce drug waste was also implemented by restricting the timing of routinely scheduled daptomycin doses for inpatients. This study aims to determine the clinical outcomes for patients receiving daptomycin both before and after this policy change. Secondary objectives include assessing creatinine phosphokinase (CK) levels in the study participants, defining the risk of CK elevation with the coadministration of HMG Co-A reductase inhibitors and daptomycin, and assessing any reduction in drug waste for the pharmacy department.

Methods
This study is a single-center, one-group pretest-posttest, quasi-experimental study evaluating the implementation of a two-part daptomycin dosing policy. The pretest group included all patients meeting inclusion and exclusion criteria that received daptomycin at CAMC from September 1 - November 30, 2017. The new daptomycin dosing policy was implemented on September 1, 2018. The posttest group included all patients meeting the stated criteria that received daptomycin from September 1 - November 30, 2018.

Results
A total of 118 patients were included in this study. There were 5 (7.7%) treatment failures in the pretest group and 3 (5.7%) in the posttest group (P = 0.7). Of the patients with CK levels monitored, 6 (33%) were found to have significant elevations in the pretest group and 4 (40%) were found in the posttest group (P = 0.6). There was no difference observed in the risk of CK elevation with daptomycin administration in the presence of an HMG-CoA reductase inhibitor. For the two time periods reviewed, the pharmacy department purchased fewer vials of daptomycin in the posttest group.

Conclusion
Patients at CAMC receiving daptomycin after implementation of a new dosing policy did not experience an increased risk of treatment failure. The Antimicrobial Stewardship Program will continue to monitor patients receiving daptomycin therapy at CAMC.

Disclosures
All authors: No reported disclosures.