bluuebunny/crossref_metadata_2025_split huggingface dataset:
2081. Low 30-Day Hospital Readmission Rates in Medicare Patients Receiving Outpatient Parenteral Antimicrobial Therapy (OPAT) in Physician Office Infusion Centers
Authors: Luu Quyen , Baker H Barry , Nathan Ramesh V , Hengel Richard L , Emmanuel. Bacon Alfred , Prokesch Richard C , Lo Carson T , Couch Kimberly A , Schroeder Claudia P , Van Anglen Lucinda J 
Published: October 2019

Abstract

Background
The Hospital Readmissions Reduction Program was established under the Affordable Care Act in 2012 to reduce payments to hospitals (hosp) with excess readmissions. Standardized readmission measures include all-cause unplanned readmissions within 30 days of hosp discharge, regardless of initial diagnosis. To avoid penalties, post-acute care, including OPAT, must have a neutral or favorable impact on 30-day hosp readmissions (30-dHR). We assessed 30-dHR for Medicare (MCR) patients receiving OPAT in ID physician office infusion centers (POICs).

Methods
All records of MCR patients were identified that were discharged from hosp to 15 national ID POICs. From those, 200 records were randomly selected and reviewed for unplanned 30-dHR. Additional data extracted were demographics, Charlson comorbidities index (CCI), infection diagnosis, therapy and reasons for readmission. The 30-dHR was compared with national average estimates obtained from the Medical Expenditure Panel Survey (MEPS) database. Multivariate logistic regression was performed with P < 0.05 being statistically significant.

Results
Mean pt age was 73.5 years (range: 65–97) with 56% males. Infections included bone and joint (34%), genitourinary (16%), complicated skin and skin structure (15%), bacteremia (13%), respiratory (10%), intra-abdominal (7%), endocarditis (2.5%), and central nervous system (2.5%) with a mean OPAT duration of 21 ± 18 days. Overall, 30-day HR rate was 11% (n = 22). Median days from initial hosp discharge to readmission was 13 (range 2–28). Reasons for 30-day HR included disease exacerbation unrelated to infection (n = 7, 32%), worsening infection (n = 6, 27%), adverse drug reaction (n = 5, 23%), new infection (n = 3, 14%), and line complication (n = 1, 4%). A logistic regression model (Table 1) indicates that 30-day HR rates reported in MEPS are significantly higher than observed for patients treated with OPAT in POICs after adjustment for age, gender, CCI and initial diagnosis (OR = 3.16, 95% CI: 1.89–5.28, P < 0.0001).

Conclusion
Patients receiving OPAT in POICs had significantly lower 30-day HRs compared with a national average, and in a more comorbid population. Our data suggest that continuous oversight of patients by ID physicians and infusion center staff in the POIC setting may prevent hospital readmissions.

Disclosures
All authors: No reported disclosures.
2083. A Targeted Remote Audit and Feedback Intervention Utilizing a Local Non-ID Trained Pharmacist
Authors: Khadem Tina , Kraft Jennifer , Bariola J Ryan 
Published: October 2019

Abstract

Background
Tele Stewardship (tASP) is a developing model for hospitals without local ID expertise. We report results of a tASP initiative using a hospital’s local non-ID trained pharmacist to conduct ertapenem (erta) audit and feedback (A&F).

Methods
Evaluation of erta use before and after implementation of a collaborative A&F process from October 2018 to March 2019. A central ID physician and ID pharmacist with EMR access reviewed charts of patients receiving erta Mon-Fri by phone with a local Critical Care trained pharmacist. Advice was given to the local pharmacist on when and how to intervene. The local pharmacist made all interventions. Acceptance rates and time involved were recorded. Usage was tracked as DOT/1,000 PD of inpatient usage. No other new local ASP interventions were undertaken during this time.

Results
120 erta orders were reviewed. Figure 1 reveals usage before and after implementation. Median usage dropped 55%. Median purchasing cost decreased by 73%. 51 unique patients received erta in the month prior to intervention, and 35 patients per month on average received erta afterwards. 30 providers ordered erta in the month prior to intervention, and 17 providers per month on average ordered erta afterwards. The overall intervention acceptance rate was 88%, and Figure 2 shows the breakdown of accepted interventions. Figure 3 describes the indications for use of erta orders after intervention started. Figure 4 shows changes in other antibiotics during this time. During this time, no patients were identified that later needed a carbapenem restarted or suffered harm due to this intervention. The average daily time required was 15 minutes for the central team and 22 minutes for the local pharmacist.

Conclusion
Using a remote collaboration with a local pharmacist, we showed a marked decrease in the use of one targeted antimicrobial. The time commitment was minimal, and no patient harm was identified. Tele-stewardship utilizing local non-ID trained pharmacists can be a significant tool for improving antimicrobial use in community hospitals. tASP’s should monitor for compensatory increase in other broad-spectrum antibiotics. Further local education regarding proper management of UTI’s and other common conditions may provide additional improvements in use of erta.

Disclosures
All authors: No reported disclosures.
2086. Antimicrobial Stewardship: Why Do Not Nurses Question the White Coat?
Authors: Sumner Sharon , Hanson Sandra F , Merrill Katreena C 
Published: October 2019

Abstract

Background
Resistance to antimicrobials has become a global issue. To combat this, registered nurses (RNs) need to be active participants with prescribers in an interdisciplinary approach to antimicrobial stewardship (AS). The prescriber role in AS has been well developed; however, more is needed to understand how RNs can contribute to AS efforts. The purpose of this study was to describe nurses comfort level with questioning providers about antimicrobials.

Methods
A survey was sent to point of care RNs in a healthcare system (approx. 4000). A total of 600 useable responses were received (Response rate = 15%). The survey included 4-items about antimicrobial delivery. (1) What percent of the time do you know why the patient is receiving an antimicrobial? (2) Would you feel comfortable raising concerns about antimicrobials to the treatment team? (3) In the last 30 days have you questioned the antimicrobial choice, dose, route or duration? (4) Have you ever given an antimicrobial you thought was inappropriate? Data were analyzed using descriptive statistics. Differences by demographics (age, gender, ethnicity, education level and location) were assessed using χ 2 statistics.

Results
Nurses reported that 84% of the time they knew “why” an antimicrobial was given. There was no difference by demographics. Over 80% of nurses also reported they felt comfortable raising concerns about antimicrobials. Nurses working in smaller hospitals reported being more comfortable raising concerns than nurses working in larger hospitals (P = 0.023). In the past 30 days, 19% of RNs questioned choice, 13% dose, 16% route, and 27% duration of antimicrobials. Nurses with Baccalaureate degree or higher were more likely to question antimicrobial dose (P = .023). However, 27% of RNs reported they had given an antimicrobial they thought was inappropriate. More RNs working in rural hospitals reported giving antimicrobials they thought were inappropriate compared with those working in larger hospitals (P = .013).

Conclusion
Providers as well as RNs need to collaborate to improve AS. Nurses in this study were not always comfortable raising concerns and administered antimicrobials they viewed as inappropriate. Providers may want to take steps to encourage collaboration with RNs about AS.

Disclosures
All authors: No reported disclosures.
2089. Effect of the Duke Antimicrobial Stewardship Outreach Network (DASON): A Multi-Center Time Series Analysis
Authors: Yarrington Michael E , Dodds Ashley Elizabeth , Johnson Melissa D , Davis Angelina , Dyer April , Jones Travis M , Sexton Daniel J , Anderson Deverick J , Moehring Rebekah W 
Published: October 2019

Abstract

Background
DASON is a 30-member, community hospital network in the southeastern United States that supports the development and growth of local antibiotic stewardship programs (ASPs). Collaborative activities include on-site visits from liaison clinical pharmacists, data sharing for routine feedback and benchmarking, and educational programs.

Methods
We performed a retrospective cohort analysis of antibiotic use (AU) in 17 hospitals that participated in DASON for a minimum of 42 months during 2013–2018. Segmented negative binomial regression models were used to estimate the change in facility-wide AU after an initial 1-year assessment, planning, and ASP intervention initiation period. Baseline AU trend (1 to 12 months) was compared against AU following the first year (13 to 42 months). Monthly AU rates were measured in days of therapy (DOT) per 1,000 patient-days (pd). Models assessed overall AU and specific antibiotic groups, as defined by the National Healthcare Safety Network AU option. The models controlled for hospital size, presence of a pre-existing formal ASP upon network entry, and year of network entry.

Results
Hospital data included a total of 2,988,930 pd over 5 years. Facility-wide AU was increasing during the first year of network entry and then began decreasing by 0.2% per month (P = 0.01, figure). Fluoroquinolone use was stagnant in year one and then decreased by 1.5% per month (P ≤ 0.001, figure). Antifungal agents were decreasing in year one and continued to decrease 0.7% per month thereafter (P = 0.03, figure). Agents predominantly used for resistant Gram-positive infections and broad-spectrum agents used for hospital-onset infections were increasing during year one and then attenuated afterward, though the slope change did not reach statistical significance. The presence of a pre-existing formal ASP was not a significant covariate in any model, while bed size and year of network entry significantly contributed to models of some antibiotic groups.

Conclusion
Participation in DASON was associated with a decline in total AU and fluoroquinolone use, and a trend toward attenuated use of other broad-spectrum agents in community hospitals. Collaborative network experiences can help local ASPs achieve reductions in AU.

Disclosures
All authors: No reported disclosures.
2103. Emergency Department (ED) Stewardship: Stratifying ED Sepsis Order Sets by Penicillin (PCN) Allergy Severity
Authors: Staicu Mary L , Laguio-Vila Maryrose R , Ramsey Allison , Conn Kelly M , Woodring Kristin 
Published: October 2019

Abstract

Background
The Surviving Sepsis Campaign Guidelines recommends administration of broad-spectrum antibiotics within 1 hour of sepsis diagnosis; electronic order sets drive antibiotic selection with pre-populated regimens based on the suspected infectious indication. Given the low rate of cephalosporin cross-reactivity in patients with a PCN allergy, we modified our ED sepsis order set (Images 1 and 2) to include cephalosporin options in patients with reported mild-to-moderate PCN reaction histories. This was a single-center, retrospective analysis evaluating the impact of this change on antibiotic prescribing and associated outcomes.

Methods
An electronic medical record (EMR) report identified patients ≥18 years of age with a documented PCN allergy that received antibiotics via the ED sepsis order set from December 30, 2012 to September 28, 2013 (pre-intervention) and January 3, 2014 to July 18, 2015 (post-intervention). The primary objective was to compare antibiotic days of therapy (DOT) and length of therapy (LOT) between the pre- and post-groups. The secondary objectives included 30-day readmission and mortality, hospital length of stay (LOS), incidence of C. difficile within 6 months and documented hypersensitivity reactions. Bivariate analyses, with chi-square, Mann–Whitney U, and Poisson means test, were used.

Results
A total of 180 patients (90 pre- and 90 post-intervention) were included. Demographics were similar between groups, with the exception of congestive heart failure (CHF) which was more prevalent in the post-intervention group (P = 0.039). Aztreonam, vancomycin, aminoglycoside, and fluoroquinolone DOTs were significantly reduced (P &lt; 0.001) while cephalosporin DOTs significantly increased (P &lt; 0.001) in the post-intervention group. There were no statistical differences in antibiotic LOT, 30-day readmission and mortality, hospital LOS, or incidence of C. difficile infection. For those patients that received cephalosporin antibiotics, there were no hypersensitivity reactions documented in the EMR.

Conclusion
Stratifying ED sepsis order sets by PCN allergy history severity is a safe and effective intervention that reduces second-line antibiotics in PCN allergic patients presenting to the ED with suspected sepsis.

Disclosures
All authors: No reported disclosures.
2105. Liposomal Amphotericin B Use Before and After Implementation of Voriconazole Prophylaxis in Cancer Patients
Authors: Shams Madeeha , Heil Emily , Oni Ibukunolupo , Morales Megan K , Bork Jacqueline 
Published: October 2019

Abstract

Background
Invasive fungal infections (IFI) are life-threatening complications of prolonged neutropenia in hematologic cancer or after hematopoietic stem cell transplantation (HSCT). Guidelines recommend mold prophylaxis (ppx) for patients at high risk of IFI. Patients receiving ppx with new signs of infection are often escalated to Liposomal Amphotericin B (L-AmB) for concerns of breakthrough mold infections. We describe the impact of implementing voriconazole (VZL) ppx in cancer patients.

Methods
We performed a quasi-experimental study of all adult patients prescribed L-AmB for ≥1 dose in Cancer Center at the University of Maryland Medical Center. VZL ppx was implemented for patients with hematologic cancer with anticipated prolonged neutropenia (≥ 7 days) in 4/2017. HSCT patients routinely received posaconazole ppx for ≥ 1 year during study period. Comparisons were made pre (November 2015–June 2017) and post (July 2017–December 2018) implementation of VZL ppx allowing for 3-month wash-in period. Cancer center-specific L-AmB days of therapy (DOT) per 1,000 patient-days (PD) were compared using segmented regression and Student t-test. Comparison of patient characteristics, mortality, nephrotoxicity and hospital length of stay (LOS) among patients receiving L-AmB in pre vs. post periods was done using Χ 2 and Student t-test.

Results
There were 87 (24 pre, 63 post) unique patients included in the analysis, translating to a total of 17.6 L-AmB DOT per 1,000 PD for the study period. Mean L-AmB utilization in cancer center was 9.9 and 24.4 DOT per 1,000 PD (P = 0.0037) for pre and post-implementation, respectively. There was an average 16% increase of L-Amb quarterly (P = 0.93). Among patients receiving L-AmB, most had acute myelogenous leukemia (63% vs. 60%) with lung source (71% vs. 73%, P = 0.8). More patients had proven IFI pre-implementation (42% vs. 29%, P = 0.3). Nephrotoxicity (46% vs. 48%, P = 0.9), median LOS (17 vs. 28, P = 0.4) and inpatient mortality (30 % vs. 38%, p = 0.5) all increased without statistical significance.

Conclusion
After implementation of VZL ppx there was a significant increase in L-AmB use, and associated non-significant increases in LOS, mortality and nephrotoxicity for those receiving L-AmB. Larger, robust longitudinal studies are needed to better understand the implications of VZL ppx on this population.

Disclosures
All authors: No reported disclosures.
2106. Evaluation of Isavuconazole for the Prophylaxis and Treatment of Invasive Fungal Infections at a Large Academic Medical Center
Authors: Vu Christine , Rana Meenakshi , Saunders-Hao Patricia 
Published: October 2019

Abstract

Background
Isavuconazole is an azole antifungal with in vitro activity against various fungi, including Candida spp, Aspergillus, and Mucormycetes. Currently, isavuconazole is FDA approved for the treatment of invasive aspergillosis and mucormycosis; however, there remains limited data to support prophylaxis use. Compared with other first-line azoles, isavuconazole’s broad spectrum of activity, favorable safety profile, and oral bioavailability makes it an attractive antifungal option. In July 2017, isavuconazole was added to our hospital formulary as a restricted antimicrobial. Since then, we have seen increased use for both prophylaxis and treatment of invasive fungal infections.

Methods
A single-center, retrospective chart review was conducted on adult patients who received at least 1 dose of isavuconazole at The Mount Sinai Hospital between July 1, 2017 and December 31, 2018. The electronic medical record was utilized to collect information on therapeutic indication, dosing, formulation, duration, reasons for switching to isavuconazole, prior antifungals, and proven or probable breakthrough invasive fungal infections (bIFIs) based on EORTG/MTG definitions.

Results
54 patients received 61 courses of isavuconazole. Reasons for switching to isavuconazole are described in Table 1. Eleven patients received inappropriate intravenous formulations and 14% of orders were prescribed isavuconazole without a loading dose (Table 2). We identified 4 proven/probable bIFIs, representing 7.4% of patients and 6.6% of courses (Table 3). All patients died within 60 days of bIFI onset.

Conclusion
Since its addition to hospital formulary, we have observed varying isavuconazole prescribing practices, highlighting the need for improved antifungal stewardship. Rates of bIFIs on isavuconazole were lower than previously reported studies. Additional studies are needed to provide guidance on isavuconazole use and determine its role as prophylaxis therapy.

Disclosures
All authors: No reported disclosures.
2108. Comparison of Voriconazole vs. Itraconazole in the Treatment of Histoplasmosis – A Retrospective Analysis
Authors: Hendrix Michael J , Larson Lindsey , Rutjanawech Sasinuch , Franklin Alexander , Spec Andrej 
Published: October 2019

Abstract

Background
The guideline-preferred azole for histoplasmosis (HP) is itraconazole (IC). While voriconazole (VC) has shown success in in-vitro and in retrospective analyses, there has not been enough data to include newer generation azoles as first-line treatment for infections with Histoplasma capsulatum.

Methods
We conducted a single-center retrospective cohort study of adult patients diagnosed with HP from 2002 through 2017. Data included demographics, clinical features and sites of infection, immune status, treatments, and mortality. Patients were categorized into two groups based on initial choice of azole (IC or VC) and mortality was compared between these two groups. The treatment groups were defined based on the first azole received, either IC or VC, as initial or as step-down therapy from amphotericin. Patients initiated on other azoles were excluded.

Results
We identified 263 cases of HP from 2002 to 2017. After excluding patients initiated on other azoles, 194 patients remained. 175 (90%) patients were started on IC and 19 (10%) were started on VC, either as stepdown or initial choice of antifungal. There were no significant demographic differences between patients receiving IC compared with VC as their initial azole treatment. Patients with hematologic malignancies tended to be prescribed VC more frequently but this was not statistically significant (OR 3.1 [0.77–12.4]). Death occurred in 40 (23%) patients from the IC and 5 (26%) patients from the VC group. The hazard ratio for mortality with the use of VC was 1.21 (CI 0.4–3.6, P = 0.73).

Conclusion
IC is the mainstay in the treatment for HP. It appears that VC has comparable outcomes to IC and can be considered an alternative treatment option for HP, at least for patients with contraindications to IC treatment.

Disclosures
All authors: No reported disclosures.
2127. Parental Acceptance of Over-the-Counter (OTC) Testing for Streptococcal Pharyngitis
Authors: Szigeti Aviva , Tena Meseret , Jose Temitope , Hammerschlag Margaret 
Published: October 2019

Abstract

Background
Group A Streptococcus (GAS), is currently diagnosed by throat culture or rapid antigen detection test (RADT) by a healthcare provider (HP), usually in an outpatient (OP) setting. There is current interest in expanding OTC diagnostics (FDA approved for HIV and hepatitis C) to other infectious diseases such as GAS pharyngitis. There are no data on parental acceptance of such a test. Our aim was to determine parental acceptance of expanding OTC diagnostic availability for GAS pharyngitis testing.

Methods
Caregivers of 3–18 years old in OP primary care pediatric clinics were given a questionnaire: data included demographics (excluding all patient identifiers), interest in buying/using an OTC GAS test, education level, type of health insurance (HI), comfort level swabbing their child, interest in available support/free hotline with the test. Statistical analysis included Mann–Whitney U test for non-continuous and T-test for continuous variables.

Results
90 questionnaires were collected, 14 duplicates excluded. 34 (45%) parents indicated they would buy an OTC GAS test, 35 (46%) would not, 4 (5%) were unsure, 3 (4%) did not respond. There was no correlation between interest in OTC test and age (P = NS), or education level (P = NS). There was a trend of OTC test interest among those with private HI vs. Medicaid (P = 0.067). There was a statistically significant association between interest in buying an OTC GAS test and the following variables: high self-swab comfort level and availability of support (P = 0.009 and 0.001, respectively). The majority of participants [73/76 (96%)] did not respond to questions about acceptable pricing.

Conclusion
There was mixed interest in OTC GAS testing among respondents. Neither age nor educational level affected interest. Surprisingly, 96% of respondents declined to select a price they would pay for an OTC GAS test. Greater interest in OTC GAS testing among respondents with private HI suggests those parents are more likely to purchase the kits to avoid an HP visit (and co-payment). Since most respondents were comfortable self-swabbing or unsure, further education including swab tutorial and support availability may lead to greater comfort level with such testing.

Disclosures
All authors: No reported disclosures.