bluuebunny/crossref_metadata_2025_split huggingface dataset:
1074. Evaluation of a Pharmacist-led Antimicrobial and Anticoagulant Monitoring Initiative
Authors: Hsiang Lin Wei , Binkley Amanda , Cimino Christo L , Talati Naasha J , Mehta Jimish M , Lamore III Raymond 
Published: October 2019

Abstract

Background
Adverse drug events are associated with an increase in hospital stay and cost. Risks from these events are minimized by adjusting a medication’s dose or frequency, and changes in renal function may necessitate adjustments. Currently, there is no formal procedure for a prospective audit of renal function over the weekend at our institution. This pharmacist-driven initiative will evaluate if a prospective review identified by real-time clinical decision support alerts over the weekend will reduce the time from change in renal function to dose adjustment of select antimicrobials and/or anticoagulants.

Methods
This monitoring initiative is comprised of a pre- and post-cohort population. The pre-cohort population included patients admitted to Penn Presbyterian Medical Center (PPMC) from January to March of 2018 on select antimicrobials and/or anticoagulants, who were identified to have a change in renal function (serum creatinine change of 0.3 mg/dL or greater) over the weekend. The post-cohort population was identified with a clinical decision support system (ILÚM Health Solutions, Kenilworth, NJ) and included patients admitted to PPMC from January to March of 2019. A pharmacy resident reviewed alerts in the clinical decision support system over the weekend and contacted providers with dose adjustment recommendations. The Mann–Whitney U test was used to analyze the primary endpoint while descriptive statistics were used for the secondary endpoints

Results
Eighteen interventions were completed within the 3-month post-cohort intervention period, with a time to dose adjustment between the pre/post-cohort being reduced by 50 hours (P = 0.0001) resulting in a median time to change of 11 hours in the post-cohort. All pharmacy recommendations were accepted by the provider, and 94% of medication adjustments were antimicrobials.

Conclusion
The application of this prospective weekend initiative utilizing a clinical decision support system demonstrated a clinically and statistically significant reduction in the time to dose adjustments for antimicrobials and/or anticoagulants. Implementation of this initiative will further establish a role for pharmacist-led evaluations and could potentially be expanded to other clinical areas.

Disclosures
All authors: No reported disclosures.
1076. Antimicrobial Stewardship Program Achieves Marked Decrease in the use of Vancomycin in a Veterans Hospital
Authors: Ford Florence M , Belal Maymonah , Froehlich Morgan , Lobo Zeena , Creed Mary , Psevdos George 
Published: October 2019

Abstract

Background
Methicillin-resistant Staphylococcus aureus (MRSA)is the most common nosocomial infection worldwide. Infection control measures using molecular tests [polymerase chain reaction (PCR) on nares swabs] aid to prevent hospital transmission of MRSA. Nares screening for MRSA has proven to be a valuable tool for antimicrobial stewardship programs (ASP) to de-escalate empiric anti-MRSA therapy in patients with pneumonia (community/nosocomial acquired) not nasally colonized with MRSA. In January 2016, an ASP was initiated at our institution with emphasis on rational use of antibiotics, decrease antibiotic duration and timely de-escalation of all empiric antibiotics, including IV vancomycin using nares PCR for MRSA.

Methods
We compared the vancomycin use at the Northport Veterans Affairs Medical center by days of therapy/1,000 patient-days from 2011–2015 to 2016–2019. Screening for MRSA is by DNA PCR (Cepheid GeneXpert Infinity). ASP reviewed all restricted antibiotic requests via electronic consults and rendered approval or disapproval. In addition, ASP requested empiric vancomycin to be discontinued for patients hospitalized for pneumonia, if PCR was negative for MRSA; PCR results were available within 24hours of admission.

Results
There were 21,330 admissions (including ICU) from March 1, 2011 to February 28, 2019. Since initiation of ASP in 2016, 4,021 total antibiotic approvals were requested and 483 were denied. 484 IV Vancomycin were requested and 43 were denied. There has been a statistically significant decrease in vancomycin use from 2011–2015 vs. 2016–2019, median by quarter (year divided in 4 quarters) 250 vs. 233, P = 0.012; Comparing the same time periods there has been a decrease in positive MRSA nares screening upon admission median annual rate 354 vs. 220, P = 0.011. There was no difference in vancomycin-resistant enterococci in clinical isolates, median 16 vs. 14.5, P = 0.465. Inpatient infectious diseases consultations increased by 30% since ASP was initiated.

Conclusion
Our ASP was successful in decreasing use of vancomycin through both disapproval of medication when a request was deemed inappropriate, and by promoting de-escalation of therapy by the use of MRSA nares screening in patients who were started empirically on MRSA antibiotic therapy for pneumonia.

Disclosures
All authors: No reported disclosures.
1077. Reduce Anti-Microbial Use in Extracorporeal Membrane Oxygenation: Reduce AMMO Study
Authors: Shah Aditya , Dhungana Prabij , Vashistha Kirtivardhan , Sampathkumar Priya , Bohman John , O’Horo John C 
Published: October 2019

Abstract

Background
The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. Patients on ECMO are at high risk for infections, with 20.5% of adults acquiring infections while on ECMO. An Extracorporeal Life Support Organization (ELSO) Infectious Disease Task Force statement concluded that no antibiotic prophylaxis is needed for patients on ECMO though it also noted that this was based on limited data. We implemented an antimicrobial prophylaxis protocol for patients on ECMO at our institution and analyzed antimicrobial use and outcomes in these patients with a pre- and post-analysis.

Methods
We conducted a retrospective review of 294 patients on ECMO between July 1, 2011 and July 1, 2017. An ECMO antimicrobial prophylaxis guideline was initially implemented on July 1, 2014; there was poor adherence to the guideline and antimicrobial use actually increased. A more restrictive protocol was implemented in November 2018 with input from stakeholders including cardiac surgeons, critical care and infectious disease (ID) providers. We had a cohort of 161 patients before (July 2014–November 2018) and 37 patients after (November 2018–April 2018) the implementation of the updated protocol. We evaluated primary outcomes of gross days of antimicrobial use, percent of antibiotic-free days and days of individual antimicrobial use, adjusted for APACHE scores and ECMO duration.

Results
When adjusted for days on ECMO, mean antibiotic days decreased after implementation of the protocol; for vancomycin (0.27 vs. 0.02, P < 0.0003), cefepime (0.15 vs. 0.02, P < 0.02), meropenem (0.09 vs. 0, P < 0.02), zosyn (0.16 vs. 0, P < 0.002), caspofungin (0.346, 0.138 P < 0.003). This was accompanied by a nonsignificant increase in mean fluconazole use (0.29 vs. 0.37, P < 0.3). There was no impact on patient mortality or nosocomial infection rate. Additional results can be found in table.

Conclusion
The use of an antimicrobial prophylaxis protocol in ECMO patients led to improvement in antimicrobial usage without increasing nosocomial infections in a population at a high risk of infection.

Disclosures
All authors: No reported disclosures.
1081. Use of Antimicrobials at the End of Life (EOL): A Retrospective Cohort Study Analyzing Providers’ Reasons for Prescribing Antimicrobials at the EOL, Their Benefits and Adverse Effects
Authors: Vyas Pooja , Malhotra Prashant , Lopez Santiago , Hirsch Bruce , Finuf Kayla D 
Published: October 2019

Abstract

Background
Infections are common in terminally ill patients, and although antibiotics are frequently prescribed, their benefit for symptom relief is not clear. Antimicrobials at the end of life (EOL) increase the risk of antimicrobial resistance and Clostridium difficile infection. Very few studies have described the risks and benefits of antimicrobials in patients at EOL. Here, we describe a retrospective chart review of antimicrobial use at EOL.

Methods
We reviewed electronic medical records of patients admitted in a palliative care unit of a tertiary care hospital between 2017 and 2018 and assessed antimicrobial use in the last 14 days of life. The analysis excluded neutropenic patients. Differences in demographics and symptom control between patients who did or did not receive antibiotics (AB+ or AB−) were analyzed using chi-square analyses; P-values were computed using Mann–Whitney tests.

Results
Of a total of 133 patients included, 89 (67%) received antimicrobials (AB+); however, the role of antibiotics was documented in only 12% of patients. The AB− and AB+ groups were similar with respect to demographics, including sex, and Charleston Comorbidity Index except for age (table). Documented infections were similar between AB− and AB+ groups, except urinary tract infections. No statistically significant differences were noted in documented symptoms including pain, dyspnea, fever, lethargy, and alteration of mental state or length of stay (LOS).

Conclusion
Our study did not show differences in frequencies of documented symptoms with use of antimicrobials at EOL. These results indicate that the risks of antimicrobial use may outweigh potential benefits and their use should be a part of goals of care discussions at EOL.

Disclosures
All authors: No reported disclosures.
1092. Impact of Relieving Infectious Diseases Fellows from Off-Hour/Weekend Antimicrobial Stewardship Coverage
Authors: Lee Matthew S L , Chapin Ryan , Gold Howard , McCoy Christopher 
Published: October 2019

Abstract

Background
Antimicrobial stewardship programs (ASPs) often utilize Infectious Diseases fellows (IDFs) to cover pre-authorization processes during evening and weekend hours. IDFs often provide ASP coverage in addition to their inpatient consult roles. In response to increasing consult volume, we worked with our fellowship program to relieve IDFs of evening and weekend coverage (a decrease in fellow coverage by 26 hours per week) starting in October 2017. Members of the ASP assumed the majority of these evening and weekend hours. Additional post-prescriptive activities and a rotation in Infection Control and Antimicrobial Stewardship were implemented in response. We sought to analyze the impact of this intervention.

Methods
Intervention and medication data were extracted from the electronic medical record during 1 July 2017 through 30 September of 2017 (IDF Coverage) and the same 3 months of 2018 (ASP Coverage). Comparisons between the two periods were performed using descriptive statistics of the number of interventions, number of weekend interventions, types of interventions, and days of therapy (DOT; per 1000 patient-days).

Results
Comparing July-September of 2017 and 2018, total ASP interventions increased 16% (1192 to 1391); weekend ASP interventions increased 75% (139 to 243). The most common interventions were “Choice of Therapy” (41% in both years), “De-Escalation” (17% in 2017, 16% in 2018), and “Dose/Interval Optimization” (10% in both years). The most intervened agents were piperacillin–tazobactam, cefepime, vancomycin, meropenem, and ceftazidime.
Comparing the same time periods, total antibiotic DOT decreased 4% (714.1 to 684.9). There was a 28% decrease in piperacillin–tazobactam (41.47 to 29.85), 19% decrease in meropenem (28.08 to 22.61), and 7% decrease in vancomycin (125.09 to 116.17) use. Ceftazidime was unchanged (18.13 to 18.08). Cefepime increased by 9% (56.78 to 61.97).

Conclusion
Relieving IDFs of evening and weekend ASP coverage during busy inpatient consult rotations may help decrease burnout. The assumption of these hours by dedicated members of ASP led to an increase in documented total and weekend ASP interventions. In addition, the change was associated with a relative decrease in piperacillin–tazobactam, meropenem, and vancomycin use.

Disclosures
All authors: No reported disclosures.
1093. Evaluation of an Antimicrobial Stewardship Elective Rotation for Medicine Residents
Authors: Watanabe Mika , Jeng Arthur , Kim Brian 
Published: October 2019

Abstract

Background
In 2017, an Antibiotic Stewardship (ASP) elective was established for the medicine residents to engage directly in stewardship practice, learn how to communicate recommendations effectively to their peers, and gain further understanding of the rationale for antimicrobial stewardship. Recommendations are co-formulated with the ID Pharmacist and ID Attending Physician, and documented as an ASP Note in the electronic health record. Additionally, the residents disseminate recommendations via page and verbal communication to their peers. The purpose of this study was to evaluate the response of the primary care teams to guidance formulated and communicated by the residents while on this clinical elective.

Methods
Recommendations by the medicine residents participating on the ASP elective from January 2018 to July 2018 were reviewed. Response to the recommendations was categorized as accepted, not accepted, or partially accepted with alternative change. Recommendations were considered as accepted if changes were made by the primary team within 24 hours from time of the ASP note. Responses were further reviewed based on the following medical services: medicine (including hematology/oncology), surgery, and intensive care (ICU).

Results
A total of 124 recommendations were reviewed for response.11 of the patients were excluded as changes either occurred prior to the documentation of the ASP note, or proposed changes did not pertain to antibiotic management. Ninety-four of the included interventions were accepted. Medicine, surgery, and ICU services accepted 84%, 82.4%, and 83.3% of recommendations, respectively. The services did not accept 5%, 11.8%, and 11.1% of recommendations, and partial acceptance with alternative changes was 11%, 5.8%, and 5.6%, respectively.

Conclusion
Recommendations formulated and communicated by residents participating in the ASP Elective rotation resulted in a high degree of acceptance. The acceptance rates did not differ significantly between the medical services. The addition of the ASP Elective has demonstrated a benefit to the ASP program at Olive View-UCLA Medical Center, and other medical residency training programs should consider implementation of such an elective rotation to enhance stewardship efforts and medical resident education.

Disclosures
All authors: No reported disclosures.
1101. What Do Electrophysiologists Think about Peri-Procedural Antibiotics? A Qualitative Assessment of Factors Driving Use and Facilitators for Implementing Change
Authors: Branch-Elliman Westyn , Elwy Rani , Gupta Kalpana 
Published: October 2019

Abstract

Background
Prolonged courses of antimicrobials are common following cardiac device procedures, but there are little data to explain drivers of this practice and factors that may facilitate change.

Methods
We conducted formative evaluations consisting of semi-structured, qualitative interviews with electrophysiologists (EP) to identify perceived barriers to discontinuing post-procedure antimicrobial prophylaxis and factors that may facilitate improvements. A directed content analysis approach was used to map qualitative responses to key factors in the Proctor Implementation Outcomes Framework, with flexibility to allow for new themes to emerge. Interviews ceased after data saturation was reached.

Results
13 interviews were conducted with EPs representing diverse US regions (Northeast, Midwest, South, West) and diverse settings of care (academic, community, VA). Responses to questions about antimicrobial use and willingness (or lack thereof) to stop post-procedural antimicrobials most commonly mapped to the acceptability domain; feasibility, fidelity, cost and appropriateness were also frequently identified factors (see figure for exemplary quotes). Themes that emerged during the interview process associated with prolonged antimicrobial prescribing included beliefs and knowledge, local culture and normative behaviors, and organizational structure. There was a strong “cultural inertia” to conform to normative practices within an institution. Reasons for this ranged from reports of streamlining processes for clinical staff to ensure standardized care across all patients and concerns about being perceived as an “outlier.” Infectious diseases staff were important influencers of practice and potential facilitators of improvement.

Conclusion
Formative evaluations of stakeholders are essential for designing successful implementation interventions to facilitate behavioral change. Local culture appeared to be a major driver of antimicrobial use. The desire to conform to normative behaviors and to promote institutional standardization suggests that strategies to facilitate implementation of antimicrobial stewardship guidelines must include facility-level changes, rather than individual-provider-level interventions.

Disclosures
All authors: No reported disclosures.
LB11. A Single Dose of the MVA-BN Smallpox Vaccine Induces an Early Protective Antibody Response Similar to a Traditional Replicating Vaccine and Is Suitable for Emergency Scenarios
Authors: Maclennan Jane , Weidenthaler Heinz , Pittman Phillip , Schmidt Darja , Chaplin Paul 
Published: October 2019

Abstract

Background
Smallpox remains a high-priority threat due to its potential for re-emergence through events including bioterrorism and spontaneous mutation. While traditional replicating smallpox vaccines such as ACAM2000 are associated with serious side effects, the non-replicating MVA BN smallpox vaccine was developed as a safer alternative.

Methods
This phase 3 non-inferiority study compared indicators of efficacy between the MVA-BN smallpox vaccine and ACAM2000. The co-primary endpoints were (1) to compare vaccine-induced serum neutralizing antibodies (geometric mean titer [GMT]) at predefined Peak Visits, as measured by plaque reduction neutralization tests (PRNT) and (2) to assess the attenuation of ACAM2000-induced takes after MVA-BN administration by measuring maximum lesion area (MLA). Early neutralizing antibody GMTs at Day 14, a timepoint considered protective for traditional replicating smallpox vaccines, were also compared following single doses of either vaccine.

Results
A total of 440 subjects were evenly randomized to receive either 2 doses of MVA-BN followed by 1 dose of ACAM2000 at 4 week intervals (Group 1) or a single dose of ACAM2000 (Group 2). Peak neutralizing antibody GMTs were significantly higher following 2 MVA-BN doses (153.5) compared with ACAM2000 (79.3), with a ratio of 1.935 (95% CI: 1.562, 2.397). At Day 14, neutralizing antibody GMTs were equal following a single dose of either MVA BN or ACAM2000 (16.2, ratio of 0.997, 95% CI: 0.738, 1.348), with similar seroconversion rates (90.8% vs. 91.8%, respectively). The median MLA induced by ACAM2000 was significantly reduced when subjects received prior MVA-BN in Group 1 (0 mm2) compared with Group 2 (76.0 mm2), suggesting protection against orthopoxvirus. MVA BN was well tolerated, demonstrating a better safety profile than ACAM2000.

Conclusion
Two doses of MVA-BN induce significantly higher peak neutralizing antibody responses compared with ACAM2000. A single dose induces an early neutralizing antibody response equal to ACAM2000 at Day 14, demonstrating the suitability of MVA BN in both pre- and post-outbreak scenarios. This study was partly funded by BARDA under contract HHSO100200700034C.

Disclosures
Jane Maclennan, BSc MRPharmS, Bavarian Nordic (Employee), Bavarian Nordic (Employee, Shareholder), Heinz Weidenthaler, MD, Bavarian Nordic (Employee, Shareholder), Phillip Pittman, MD, Bavarian Nordic (Scientific Research Study Investigator), Darja Schmidt, PhD, Bavarian Nordic (Employee, Shareholder), Paul Chaplin, PhD, Bavarian Nordic (Board Member, Employee, Shareholder), Bavarian Nordic (Employee, Shareholder).
LB17. Randomized Trial to Prevent Congenital Cytomegalovirus (CMV)
Authors: Hughes Brenna 
Published: October 2019

Abstract

Background
Primary CMV infection during pregnancy carries a high risk of fetal transmission with the potential for severe sequelae. There is no universally accepted method of preventing congenital CMV. Our objective was to evaluate whether CMV hyperimmune globulin (HIG) administered to women with primary CMV during pregnancy reduces congenital infection.

Methods
Multicenter randomized double-masked trial of women with a singleton gestation <24 weeks with primary CMV infection defined by the presence of either CMV IgM and IgG with low avidity or IgG seroconversion, as assessed at a central reference laboratory. Those with presumptive or confirmed evidence of fetal CMV were not eligible. Monthly infusions of HIG (100 units/kilogram) or placebo were given until delivery. The primary outcome was fetal loss or neonatal CMV infection defined as CMV by PCR or culture in urine or saliva within 3 weeks of birth, in amniotic fluid prior to delivery or in postmortem tissue. A sample size of 800 was planned to detect at least 30% reduction in the primary outcome with 90% power and type I error 5%.

Results
From 2012 to 2018, 206,111 pregnant women were screened; 712 (0.35%) had primary CMV infection; of whom, 399 (56%) were enrolled at 17 centers. The trial was stopped for futility at the recommendation of the Data and Safety Monitoring Committee due to a planned interim analysis that revealed complete enrollment was unlikely to demonstrate a significant outcome. Mean gestational age at randomization was 16.2 and 15.6 weeks in the HIG and placebo groups, respectively. Primary outcome data were available for 394 participants (98.7%). The primary outcome rate was 22.7% in the HIG group and 19.4% in the placebo group (relative risk [RR], 1.17; 95% confidence interval [CI], 0.80 to 1.72; p=0.42). Overall, there was no significant difference in the proportion of women with a side effect; however, those receiving HIG had a higher rate of headache (P = 0.05) and shaking chills (P = 0.03). The rate of preterm birth was 12.2% in the HIG group and 8.3% in the placebo group (RR, 1.47; CI 0.81 to 2.67; P = 0.2) (table). No statistical interactions were found in pre-specified subgroup analyses.

Conclusion
CMV HIG was not effective at decreasing risk of congenital CMV infection or fetal death among women with primary CMV infection in early pregnancy.

Disclosures
Brenna Hughes, MD, Merck (Consultant).