bluuebunny/crossref_metadata_2025_split huggingface dataset:
754. Evaluation of Standardized Dalbavancin Use to Facilitate Early Hospital Discharge for Patients Inappropriate for Outpatient Parenteral Antibiotic Therapy
Authors: Shihadeh Katherine C , Young Heather , Wyles David L , Jenkins Timothy C 
Published: October 2019

Abstract

Background
Patients frequently remain in the hospital for prolonged intravenous (IV) antibiotic therapy for serious infections when outpatient IV antibiotic therapy is unsafe or unfeasible. A protocol was developed to facilitate early discharge by administering one dose of dalbavancin 7 – 10 days prior to the planned end of treatment, allowing patient discharge the same day as the infusion. The purpose of this analysis was to describe the effectiveness, safety, and financial impact by using dalbavancin to facilitate early discharge.

Methods
This is a retrospective observational analysis of all inpatients who received dalbavancin at Denver Health Medical Center from April 2018 to April 2019. One dose of dalbavancin 1,500 mg was administered over 30 minutes to each patient. The medical record was reviewed 30 days after discharge to determine safety (adverse reaction to dalbavancin) and effectiveness (readmission or receipt of additional antibiotics). The estimated cost of one hospital day was $1,800; one dose of dalbavancin costs $3,000.

Results
Sixteen patients (69% male; average age 45 years) received dalbavancin. The majority of patients were homeless (81%), injection drug users (75%), and infected with HCV (56%). One patient was infected with HIV (6%) and none had diabetes, kidney disease, or cirrhosis. Antibiotics administered prior to dalbavancin were vancomycin or cefazolin, based on organism, for a median duration of 25 days (IQR 11–34). Patients were infected with methicillin-resistant S. aureus (n = 8), methicillin-susceptible S. aureus (n = 7), and one co-infection with S. epidermidis and S. pyogenes. The infections included complicated bacteremia (n = 6), uncomplicated bacteremia (n = 4), osteomyelitis (n = 2), right-sided endocarditis (n = 2), and osteomyelitis with bacteremia (n = 2). No adverse reactions were noted. Readmission 30 days from discharge occurred for two patients for reasons unrelated to the infection or dalbavancin. None received additional antibiotics. 115 hospital days were averted (average of 7 days per patient). Cost savings to the hospital were estimated to be $159,000.

Conclusion
A standardized approach to use dalbavancin for serious infections to facilitate early hospital discharge appears to be safe and effective and led to substantial cost savings.

Disclosures
All authors: No reported disclosures.
761. Sepsis Readmissions and Coding in Two Community Hospitals
Authors: Cheruranky Anita , Li Aldon , Faiad Graciela 
Published: October 2019

Abstract

Background
An estimated 1.7 million adults in the United States develop sepsis and nearly 270,000 Americans die because of sepsis annually. A diagnosis of sepsis increases hospitalization costs, antibiotic usage, and mortality. Admissions for sepsis account for a high proportion of 30-day readmissions, creating a major financial burden for the healthcare system. However, reliable measurement of sepsis incidence remains challenging given increasing clinical awareness, changes in diagnosis/coding practices and changing definitions. We thus sought to evaluate sepsis readmissions and coding practices at 2 community hospitals (226, 99 beds).

Methods
A total of 997 hospitalizations occurred at both institutions with a primary diagnosis of sepsis from January 30, 2018–December 31, 2018; out of which 130 were readmitted within 30 days.An Infectious Disease trained physician reviewed all 130 index admissions and readmissions. Sepsis was defined as per the Centers for Medicare and Medicaid Services (CMS) sepsis-1 mandate: 2 of 4 SIRS criteria + suspected infection.

Results
All 130/130 (100%) index hospital admissions had a primary discharge diagnosis of sepsis, out of which only 85/130 (65%) met criteria for sepsis. While coded as sepsis, in 45/130 (35%) cases no infectious etiology was found. Among 130 readmissions 51 (39%) truly met criteria for sepsis. The infectious etiologies of index admissions included urinary tract infections (UTI) (18), pneumonia (16), bacteremia (16), abscess (9), Clostridium difficile infection (CDI) (8), cellulitis (5), neutropenic fever (5), cholecystitis (4), meningoencephalitis (1), candidemia (1). Readmissions that met criteria for sepsis included pneumonia (10), UTI (8), abscess (7), CDI (5), bacteremia (5), osteomyelitis (4), cellulitis (4), neutropenic fever (3), candidemia (2), and cholecystitis (2).

Conclusion
Shockingly 35% of the index admission cases were misdiagnosed as sepsis and as high as 61% on re-admissions. Increasing clinical awareness and compliance with CMS may have led to overdiagnosis and treatment of sepsis. Given the significant treatment and prevention initiatives that are being undertaken; reliable sepsis definition and coding is warranted for accurate surveillance purposes.

Disclosures
All authors: No reported disclosures.
762. Integrating Diagnostics of Tomorrow into Clinical Practice Today: One Infectious Disease Group’s First 90 Days Experience with the Karius® Test
Authors: Stetzler Trisha , Ahmad Sharjeel , Almoujahed Mohammad , Farrell John J , Hong David K , Kasper Douglas , Kim Joseph , Lin Rone , Patel Marlynn 
Published: October 2019

Abstract

Background
Infection disease (ID) groups covering inpatient and office, antimicrobial stewardship, and infection prevention duties may welcome an opportunity to streamline diagnostics via metagenomic next-generation sequencing (NGS). But the appropriate patient profile for NGS has yet to be defined. In 2019, we began using the Karius Test (KT), an NGS test that identifies and quantifies microbial cell-free DNA in plasma.

Methods
On January 10, 2019 our ID group (7 MDs and an APN covering 14 Illinois hospitals) began using the KT (Redwood City, CA). 5 ml of whole blood is collected, spun to plasma, and shipped to Karius for analysis. Following NGS, human sequences are removed and remaining sequences are aligned to a curated pathogen database of >1,000 organisms. Organisms present above a statistical threshold are quantified in DNA molecules per microliter (MPM) and reported.

Results
Over 90 days 45 KTs were ordered on 42 patients (mean age = 46); including 3 repeat tests. Thirty-six were inpatients (8 in the ICU) with a mean 4.7 days to ID consult and length-of-stay of 16 days. 31% (13/42) were immunocompromised: i.e., transplant, oncology, or HIV/AIDS. Fine needle or open biopsies were performed on 13 patients and 13 patients had bronchoscopy; 30.8% (8/26) were diagnostic of infection. A valid KT result was returned in 44/45 tests (mean 3.5 days from ID consult). 56.8% (25/44) of tests were positive for one or more organisms (a single pathogen was detected on 11 KTs). Among positive tests, 56% (14/25 - 10 bacterial and 4 fungal infections) were confirmed by culture, antigen, or PCR. Mean time to diagnosis for culture, PCR, antigen, and KT was 16.4, 3, 5.5, and 3.5 days, respectively. In 3 cases, the KT was the only positive test but correlated with the clinical scenario resulting in antimicrobial changes (Pneumocystis jirovecii pneumonia in AIDS, pulmonary aspergillosis in AIDS, and Fusobacterium nucleatum septic thrombophlebitis).

Conclusion
We identified 4 clinical scenarios where the KT provided value: patients with suspected invasive fungal infections, culture-negative endovascular infections/endocarditis, possible discitis or paravertebral infection, and pulmonary disease in AIDS. Future efforts will include outreach for prevention of invasive diagnostic procedures when a KT is pending or positive.

Disclosures
All authors: No reported disclosures.
778. ID Rocks It: Infectious Disease Remotely Offered Consultative Knowledge and Support via Inpatient Telehealth
Authors: Tande Aaron J , Berbari Elie , Ramar Priya , Ponamgi Shiva , Sharma Umesh , Philpot Lindsey , Ebbert Jon , O’Horo John C 
Published: October 2019

Abstract

Background
Infectious diseases (ID) consultation is associated with improved outcomes for patients hospitalized with infection. Provision of this service is not practical for many smaller hospitals, particularly critical access facilities. We sought to evaluate the impact of an electronic, asynchronous consultative service (“eConsults”) at two rural hospitals without on-site ID support.

Methods
Beginning July 2018, ID physicians at Mayo Clinic, Rochester, began performing asynchronous eConsults for patients hospitalized at Mayo Clinic Health System (MCHS) Albert Lea and MCHS Austin Hospitals. The first 100 consecutive patients receiving eConsults (cases) were compared with patients admitted for infection at the same facilities prior to pilot initiation (controls). Cases were matched to controls using 1:3 propensity match based on age, gender, race, and weighted Charlson comorbidity index. The primary outcome was readmission or death within 30 days after hospital discharge.

Results
Cases (n = 100) were more likely to have been hospitalized in the 6 months prior to the index hospitalization than controls (n = 300) (P < 0.0001). Patients with ID eConsult had a significantly decreased odds of death at 30 days (OR 0.3, 95% CI 0.2–0.7, P = 0.003) and there was a trend toward decreased readmission at 30 days (OR 0.4, 95% CI 0.2–1.1, P = 0.07). The mean length of stay was significantly longer for cases (5.7 days vs. 3.8 days, P =0.003). However, ID eConsult did not occur until 2.6 days into hospitalization, on average.

Conclusion
ID eConsultation was associated with lower odds of 30-day mortality. The increased length of stay may be mitigated by encouraging ID eConsults earlier during hospitalization. Inpatient ID eConsults represent a high-value proposition for patients and providers and a feasible means of expanding the reach of ID physicians. This novel care delivery model warrants further investigations.

Disclosures
All authors: No reported disclosures.
780. Inpatient Addiction Medicine Consultations at the Urban/Rural Frontier: Improving Quality of Care and Linkage to Outpatient Services for Patients with Substance Use Disorder in Central Kentucky
Authors: Fanucchi Laura , Oller Devin 
Published: October 2019

Abstract

Background
When persons with opioid use disorder (OUD) are hospitalized with medical complications (e,g. endocarditis, viral hepatitis) they frequently do not receive medications for the underlying OUD. In recent years, a number of hospitals have implemented addiction medicine consultation (AMC) services to help address this treatment gap, though these are all in large urban centers. AMCs provide comprehensive substance use disorder (SUD) assessments, manage SUDs, initiate pharmacotherapy for OUD, and arrange linkage to ongoing treatment. The aim of this study was to describe the initial implementation and outcomes of a new AMC at the University of Kentucky Hospital, a 945-bed tertiary referral center with a large rural catchment.

Methods
The Addiction Consultation and Education Service(ACES) began October, 2018 and was comprised of several physicians and an APRN. A patient navigator assisted with prior authorizations and outpatient linkage. ACES referred to a new bridge clinic at the University for ongoing office-based opioid treatment as well as to community programs and licensed opioid treatment programs. Patient demographics, SUD diagnoses, and comorbidities (including details of the injection-related infections) are collected from the electronic health record, as well as key process metrics including: time-to-consultation and medication initiation, length of stay(LOS), discharge against medical advice(AMA), and details of linkage to outpatient services.

Results
From October-December, 91 patients were seen, 73 met DSM-5 criteria for OUD, 82 had a medical complication of SUD, and 53 lived in rural counties (Rural-Urban Continuum Codes 4–9). Average LOS was 19.5 days. Among OUD patients, 71% underwent buprenorphine/naloxone induction, 9% were started on methadone. Less than 6% of patients started on buprenorphine or methadone left against medical advice.

Conclusion
AMCs are a key part of providing comprehensive care for persons hospitalized with infectious complications of substance use. Initiating medication for OUD likely decreases rates of discharge against medical advice. Compared with other AMCs, a greater percentage of patients seen by ACES resided in rural counties. Establishing a bridge clinic prior to starting an AMC is critical to ensure ongoing care.

Disclosures
All authors: No reported disclosures.
994. Effect on Β-lactam Usage Following Implementation of Clinical Pharmacy Services to Improve Β-lactam Allergy History Documentation
Authors: Harrington Nicole , Drews Victoria , Laude Jillian , Care Julianne , Walsh Donna 
Published: October 2019

Abstract

Background
The purpose of this study was to implement a pharmacy-initiated β-lactam allergy assessment and to determine its impact on antibiotic prescribing patterns. Avoiding the use of β-lactams due to a documented allergy may lead to inferior treatment outcomes, particularly for indications where β-lactams are preferred.

Methods
This performance improvement study was conducted at a large community-based academic healthcare system in Delaware. A β-lactam allergy algorithm was developed to guide allergy assessments and categorize patients as low risk for possible reaction, possible type 1 reaction or insufficient information. Pharmacy residents and clinical pharmacists were educated on how to conduct the assessments, which were then performed on inpatients with a β-lactam allergy that were prescribed a non-β-lactam antibiotic from December 2018 through March 2019. The primary outcome of this study was the percentage of patients ordered a β-lactam antibiotic pre- and post-implementation of the assessment. Secondary outcomes included: allergy assessment classifications, number of patients with an allergy discrepancy, percentage of patients switched to a β-lactam antibiotic, development of a reaction, and the number of allergy consultations ordered. The primary endpoint was analyzed using a Chi-square test.

Results
The percentage of patients prescribed a β-lactam pre- and post-implementation was 59% and 63%, respectively (P = 0.055). A total of101 patients had an allergy assessment performed. Assessments resulted in 45% of patients categorized as low risk, 45% as possible type 1 reaction and 10% as insufficient information. In summary, 33% of patients were changed to a β-lactam following completion of an assessment and zero patients experienced a reaction. Additionally, 69% of patients had an allergy discrepancy in their electronic medical record, and four patients received an allergy consultation.

Conclusion
The use of clinical pharmacy services to perform β-lactam allergy assessments was successful, as the majority of patients with a low-risk allergy classification were changed to a β-lactam antibiotic. The next steps for this project include engagement of infectious diseases and allergy specialists to further optimize clinical practice.

Disclosures
All authors: No reported disclosures.
995. A quality improvement initiative to increase penicillin allergy clarification and decrease aztreonam usage
Authors: rahbani Peggy 
Published: October 2019

Abstract

Background
Penicillin (PCN) allergy is a serious adverse reaction that prevents the use of first-line therapy. 10% of the population reports a PCN allergy; however, less than 1% is truly allergic. Elimination of false allergies significantly impacts patient’s lives and decreases antimicrobial resistance and cost. Inova Mount Vernon Hospital (IMVH) has reported lack of pharmacist’s interventions in allergy clarification and counseling thus leading to an increase in aztreonam usage.
The primary objective of the study was to increase pharmacist’s interventions in patient allergy clarification and counseling. The secondary objective was to decrease aztreonam duration of therapy (DOT) by 10%.

Methods
This project was conducted and monitored M-F on the pharmacy true north board March-December 2018. The initial step was to create a standard work and educate pharmacists on individualized PCN allergy patients interviewing and counseling. Pharmacist’s interventions tracking were made using the electronic reporting system. To quantify aztreonam usage, duration of therapy (DOT/1000) was collected during the study period and compared with data from 2017.

Results
During the study implementation, a total of 551 interventions pertaining to PCN allergy were documented by pharmacists between March-November 2018, compared with only 72 interventions made in March-November 2017 (7x increase, P < 0.005). Pharmacists while intervening clarified the allergy added the severity of the reaction, documented whether patients recently tolerated any PCN-based antibiotics, and de-labeled patients when appropriate. Allergy assessments lead to a decrease in aztreonam DOT/1000 by 12% in 2018 compared with 2017 and the overall antimicrobial stewardship goal was achieved.

Conclusion
Pharmacists interventions in allergy clarification helped with antibiotic de-escalation, improved safety, and de-labeled patients when appropriate. This initiative also increased physician and nursing awareness of the importance of clarifying PCN allergies. After successfully hardwiring this practice the pharmacy is partnering with nursing to implement PCN skin testing service at IMVH.

Disclosures
All authors: No reported disclosures.
1007. A novel approach to evaluate antibiotic utilization across the spectrum of inpatient and ambulatory care and implications for prioritization of antibiotic stewardship efforts
Authors: Frost Holly M , Knepper Bryan C , Shihadeh Katherine C , Jenkins Timothy C 
Published: October 2019

Abstract

Background
Antibiotic overuse remains a significant problem in inpatient and outpatient settings. The objective of this study was to develop a methodology to evaluate antibiotic use across inpatient and ambulatory care sites in an integrated healthcare system in order to prioritize antibiotic stewardship efforts.

Methods
We conducted an epidemiologic study of antibiotic use across an integrated healthcare system on 12 randomly-selected days between October 1, 2017 and September 30, 2018. Inpatients and perioperative patients were recorded as having received an antibiotic if they were administered ≥1 dose of a systemic antibacterial agent. Outpatients were recorded as having received an antibiotic if they were prescribed ≥1 systemic antibacterial agent.

Results
On the study days, 10.9% (95% CI 10.6–11.3%) of patients received an antibiotic. Of all antibiotics administered or prescribed, 54.1% were from ambulatory care (95% CI 52.6–55.7%), 38.0% were from the hospital, (95% CI 36.6–39.5%), and 7.8% (95% CI 7.1–7.8%) were perioperative. The emergency department/urgent care centers, adult outpatient clinics, and adult noncritical care inpatient wards accounted for 26.4% (95% CI: 25.0–27.7%), 23.8% (95% CI: 22.6–25.2), and 23.9% (95% CI 22.7–25.3) of antibiotic use, respectively. Only 9.2% (95% CI: 8.3–10.1%) of all antibiotics were administered in critical care units. Antibiotics with a broad spectrum of Gram-negative activity accounted for 30.4% (95% CI: 29.0–31.9%) of all antibiotics prescribed. Infections of the respiratory tract were the leading indication for antibiotic use.

Conclusion
In an integrated healthcare system, nearly three-quarters of antibiotic use occurred in the emergency department/urgent care centers, adult outpatient clinics, and adult noncritical care inpatient wards. Antibiotics with a broad spectrum of Gram-negative activity accounted for a large portion of antibiotic use. Analysis of antibiotic utilization across the spectrum of inpatient and ambulatory care is useful to prioritize antibiotic stewardship efforts.

Disclosures
All authors: No reported disclosures.
1010. Exploring Antimicrobial Prescriptions in a National Audit of Hematology/Oncology Inpatients Compared with the General Inpatient Population: Targeted Analysis Highlights Key Areas for Targeted Intervention
Authors: Douglas Abby , Hall Lisa , James Rodney , Worth Leon , Slavin Monica , Thursky Karin 
Published: October 2019

Abstract

Background
Little is known about the antimicrobial prescribing practices in hematology and oncology (haemonc) populations. We aimed to explore antimicrobial prescribing practices in haemonc patients compared with other acute inpatients, in order to target areas for intervention.

Methods
In Australia, facilities nationwide participate in an annual point-prevalence survey of antimicrobial prescribing in hospitalized patients (Hospital National Antimicrobial Prescribing Survey (Hospital NAPS)). The results for adult inpatients from 2015–2018 were analyzed. Assessments of appropriateness were undertaken by local antimicrobial stewardship teams according to a structured algorithm, and defined as: 1 (optimal); 2 (adequate); 3 (suboptimal); 4 (inadequate); 5 (not assessable). A score of 1 or 2 is considered to be”appropriate’ and 3 or 4 ‘inappropriate’; those not assessable were excluded. Antimicrobial class, indication and appropriateness were compared between haemonc and other acute inpatient populations. Using logistic regression analysis, factors associated with appropriate prescribing of antibacterials were explored.

Results
The survey comprised 95809 antibiotic prescriptions for 63668 adult inpatients (4097 haemonc, 59571 other inpatients) in 423 acute facilities. The top treatment and prophylactic indications for all classes of antimicrobials were highly disparate between haemonc and other inpatients (table). Of note in the haemonc group, vancomycin use was high, and amphotericin B was used frequently for antifungal treatment. In multivariate analysis, haemonc patients were strongly associated with antibacterial appropriateness compared with other inpatients (adjusted OR 1.72, 95% CI 1.59–1.87, P < 0.001); factors associated with inappropriate prescription included antibiotic allergies and prophylactic indications.

Conclusion
Haemonc patients were more likely to receive appropriate antimicrobials compared with other inpatients. However, we have identified key areas for targeted interventions (prophylaxis use, antimicrobial allergy labels, vancomycin and amphotericin B treatment). Separate analysis of haemonc populations is necessary to identify key areas of concern specific to this patient group.

Disclosures
All authors: No reported disclosures.