bluuebunny/crossref_metadata_2025_split huggingface dataset:
Using Preventive Health Alerts in the Electronic Health Record Improves Testing Rates for Infants Perinatally-Exposed to Hepatitis C
Authors: Hojat Leila , Bhardwaj Amrita , Bar-Shain David , Greco Peter , Abughali Nazha 
Published: October 2017

Abstract

Background
Perinatal exposure to hepatitis C virus (HCV) is a major public health issue, as testing rates are poor and many infected patients remain unidentified. We sought to use the electronic health record (EHR) to improve testing rates among infants born to HCV-infected mothers in an urban, safety-net hospital system.

Methods
Our study population was identified using our EHR database (Hyperspace Epic 2014, EpicCare Systems, Verona, WI). Children were included in the study if they had perinatal HCV exposure, were between the ages of 18 months to 18 years, and had at least one encounter in primary or urgent care during the study period. Our study included retrospective (October 2011-Febrary 2015) and prospective (February 2015-May 2016) arms. Our EHR-based intervention, which we initiated in the prospective arm, linked the patient to a one-time HCV antibody test on or after the age of 18 months using a preventive health forecasting engine. The preventive health forecasting engine activated a point of care clinical advisory alert for all children with perinatal hepatitis C exposure. This alert was associated with an order for a HCV antibody test and would occur in all well child or urgent care encounters during the study period.

Results
5.6% (7/125) of the patients with perinatal HCV exposure had a HCV antibody test performed on or after 18 months of age during the retrospective arm. After initiation of our EHR-based intervention, this proportion significantly increased to 18.7% (28/150) (P &lt;0.002; CI, 1.6 to 9.2; OR, 3.9).

Conclusion
Among patients with perinatal HCV exposure, using a point of care clinical advisory within the EHR significantly increased the rate of HCV antibody testing in accordance with American Academy of Pediatrics recommendations. However, a significant number of infants continue to not be appropriately tested. More EHR-based interventions combined with increased physician awareness of appropriate HCV testing in perinatally-exposed infants is imperative.

Disclosures
All authors: No reported disclosures.
2015–2016, Georgia Department of Public Health Districts, Evaluating Oral Health Services in Ryan White Part B Clinics
Authors: Rabold Elizabeth , Felzien Gregory , Coker Michael 
Published: October 2017

Abstract

Background
Poor dental health adversely affects overall health, and people living with HIV/AIDS (PLWHA) have a higher prevalence of dental disease than the general population. This study evaluated dental care access and utilization among PLWHA who receive services at Ryan White Part B (RWPB) Clinics in Georgia using three different measurement instruments.

Methods
Of the 19 Georgia Department of Health (GA-DPH) districts, HIV coordinators from all 16 districts that receive RWPB funding completed a web-based dental care needs assessment survey in October 2016, evaluating July 2015 to June 2016 (FY16). We compared findings to metrics obtained from two other sources: CAREWare, a national HIV electronic health system; and manual chart audits, performed using a weighted analysis of 32–42 clients per district. We analyzed the survey data and compared the three instruments descriptively.

Results
Of the 9,461 total active clients with HIV in the 16 DPH districts evaluated in the survey, 20% had at least one dental visit during FY16. All 16 districts had established relationships with dental providers. The average waiting period to see a dentist was &lt;4 weeks in 13 (81%) of districts. Coordinators most frequently identified lack of transportation, health literacy, and high cost as important barriers to care. Though the overall average of clients with at least one dental visit during FY16 was similar between the survey, CAREWare, and audit data (20%, 16%, and 19%, respectively), the three instruments demonstrated notable variability within sites. Proportion of clients with dental visits across Georgia showed regional variation, with fewer visits reported centrally and more dental visits reported in the northeastern and southeastern areas.

Conclusion
Even though all DPH districts had access to dental providers with short waiting periods, PLWHA served by RWPB received limited dental services and faced many barriers to care during FY16. Three measurement tools demonstrated poor consistency between and across districts, highlighting the challenges in reporting and evaluating data in this population. By developing targeted quality improvement initiatives, GA-DPH will use these finding to improve annual dental visit rates, reduce barriers to care, and more accurately measure specific health outcomes for PLWHA.

Disclosures
All authors: No reported disclosures.
Outpatient Parenteral Antimicrobial Therapy (OPAT) Practices at a Veterans Affairs Hospital: Potential for Pharmacist Impact
Authors: Yang Catherine , Nguyen Nancy N , Chary Aarthi , Nakasone Trisha S 
Published: October 2017

Abstract

Background
The Infectious Diseases Society of America (IDSA) OPAT Practice Guidelines and Handbook recommend multidisciplinary team involvement as a key element to the success of OPAT. Studies have demonstrated that OPAT pharmacist oversight can improve monitoring of intravenous (IV) antibiotics and achieve clinical cure in 77% of patients. Pharmacists at the Veterans Affairs Palo Alto Health Care System are currently not routinely involved with the management of OPAT patients.

Methods
A retrospective analysis was performed to determine the rate of adherence to IDSA recommendations on antibiotic laboratory and clinical monitoring in veterans discharged with OPAT between July 1, 2015 and June 30, 2016. Secondary outcomes assessed were rates of clinical cure, treatment failure, readmission, and OPAT complications. Data was analyzed using descriptive statistics.

Results
Of 83 patients evaluated, 91 IV antibiotics were administered and 70 patients completed OPAT. The most common infections were osteomyelitis (n = 33, 40%), bacteremia (n = 13, 13%), and skin and soft-tissue infection (n = 9, 11%). Cephalosporins (n = 41, 45%) were most commonly used, followed by vancomycin&#x2028;(n = 18, 20%) and penicillins (n = 12, 13%). Appropriate monitoring of complete blood count, basic metabolic panel, and liver function occurred 45%, 45%, and 25% of the time, respectively, based on IDSA guidance. An increase in treatment failure was observed when less than 25% of weekly lab monitoring was conducted. Twenty-six patients (31%) met the IDSA recommendation for follow-up visits within 7–14 days of discharge and 51 patients (61%) received follow-up visits upon OPAT completion. Clinical cure was achieved in 52 patients (63%). There were more 90-day readmissions related to infection, adverse drug reactions, catheter-related complications, and C. difficile infections reported in the treatment failure group compared with the clinical cure group.

Conclusion
In most cases, IDSA recommendations on OPAT management were not appropriately followed and lack of monitoring was associated with treatment failure. Fewer patients achieved clinical cure compared with rates documented in the literature, strongly suggesting the need for an OPAT pharmacist to achieve optimal monitoring and follow-up.

Disclosures
All authors: No reported disclosures.
Early ID Outpatient Follow-up of OPAT Patients Reduces 30-day Readmission
Authors: Saini Ena , Ali Mohammad , Du Ping , Crook Tonya , Zurlo John 
Published: October 2017

Abstract

Background
Although weekly outpatient follow-up for patients discharged on outpatient parenteral antimicrobial therapy (OPAT) has been recommended, few practitioners follow this recommendation. No studies have examined the relationship between outpatient follow-up and patient outcomes for this population. We examined the association between outpatient ID follow-up and the risk for 30-day readmission for patients discharged on OPAT.

Methods
We conducted a retrospective cohort study using EMR data comprising 1102 OPAT patients treated between January 2012 and December 2014 at a major tertiary care medical center. We sought to determine whether ID outpatient follow-up was associated with a lower risk of 30-day readmission, after adjusting for patient demographics, infection diagnosis, outpatient antibiotics, and comorbidities (mainly diabetes mellitus, renal failure and immunosuppression).

Results
Of 1102 cases, 201 of 1102 (18%, 95 females, 106 males) were readmitted within 30 days, of whom 133 (66%) were re-admitted in the first 2 weeks post discharge. 837 (76%) were seen in ID outpatient follow-up within 30 days of discharge, of whom 396 (47%) were seen in first 2 weeks. By univariate analysis OPAT patients seen in ID outpatient follow-up within 2 weeks of discharge were less likely to get readmitted within 30 days of hospital discharge (OR: 0.6, CI: 0.4–0.9, P &lt; 0.02). Patients with immunosuppression (OR: 1.9, 95% CI: 1.3–2.7, P &lt; 0.0001) or discharged on 3 or more antimicrobials (OR: 2.1, 95% CI:1.4–3.2, P &lt; 0.0001) were more likely to have 30-day readmission. By multivariate analysis patients seen in outpatient ID follow-up within 2 weeks (OR: 0.6, CI: 0.4–0.9, P &lt; 0.006) or those receiving ceftriaxone alone (OR: 0.6, CI: 0.3–0.9, P &lt; 0.015) were less likely to have 30-day readmission. Patients who were immunosuppressed (OR: 1.9, CI: 1.3–3.0, P &lt; 0.003) or those discharged on 3 or more antimicrobials (OR: 2.1, CI: 1.4–3.2, P &lt; 0.001) were more likely to have 30-day readmission.

Conclusion
Infectious disease outpatient follow-up within 2 weeks for patients discharged on OPAT reduces all-cause 30-day readmission. Early outpatient follow-up is especially important for patients who are immunosuppressed and those receiving multiple antibiotics.

Disclosures
All authors: No reported disclosures.
Emergency Department Visits During Outpatient Parenteral Antimicrobial Therapy: A Cohort Study
Authors: Kim So Lim , Everett Angela , Rehm Susan J , Gordon Steven , Shrestha Nabin 
Published: October 2017

Abstract

Background
Outpatient parenteral antimicrobial therapy (OPAT) carries risk of vascular access complications, antimicrobial adverse effects, and worsening of infection. Both OPAT-related and unrelated events may lead to emergency department (ED) visits. The purpose of this study was to describe adverse events that result in ED visits and risk factors associated with ED visits during OPAT.

Methods
OPAT courses between January 1, 2013 and December 31, 2016 at Cleveland Clinic were identified from the institution’s OPAT registry. ED visits within 30 days of OPAT initiation were reviewed. Reasons and potential risk factors for ED visits were sought in the medical record.

Results
Among 11,440 OPAT courses during the study period, 603 (5%) were associated with 1 or more ED visits within 30 days of OPAT initiation. Mean patient age was 58 years and 57% were males. 379 ED visits (49%) were OPAT-related; the most common visit reason was vascular access complication, which occurred in 211 (56%) of OPAT-related ED visits. The most common vascular access complications were occlusion and dislodgement, which occurred in 99 and 34 patients (47% and 16% of vascular access complications, respectively). In a multivariable logistic regression model, at least one prior ED visit in the preceding year (prior ED visit) was most strongly associated with one or more ED visits during an OPAT course (OR 2.96, 95% CI 2.38 – 3.71, p-value &lt; 0.001). Other significant factors were younger age (p 0.01), female sex (p 0.01), home county residence (P &lt; 0.001), and having a PICC (p 0.05). 549 ED visits (71%) resulted in discharge from the ED within 24 hours, 18 (2%) left against medical advice, 46 (6%) were observed up to 24 hours, and 150 ED visits (20%) led to hospital admission. Prior ED visit was not associated with hospital admission among patients who visited the ED during OPAT.

Conclusion
OPAT-related ED visits are most often due to vascular access complications, especially line occlusions. Patients with a prior ED visit in the preceding year have a 3-fold higher odds of at least one ED visit during OPAT compared with patients without a prior ED visit. A strategy of managing occlusions at home and a focus on patients with prior ED visits could potentially prevent a substantial proportion of OPAT-related ED visits.

Disclosures
All authors: No reported disclosures.
Outpatient Parenteral Antibiotic Therapy (OPAT) Serial Readmissions and High Utilizers: Drilling Down on Readmission Following Discharge on Intravenous Antibiotics
Authors: Andrews Mary-Margaret , Gallagher Megan , Gentry Mary 
Published: October 2017

Abstract

Background
OPAT discharges (d/c’s) are at high risk for hospital readmission. We observed that a subgroup of OPAT patients (patients) had multiple 30 day readmissions (30DRs) and wanted to define both global and global minus serial readmitter (SR) or high utilizer (HU) 30DR rates to improve the d/c process and resource utilization.

Methods
Our program tracks all d/c’s on IV antibiotics (excluding Cystic Fibrosis patients) and reviews unsuccessful d/c’s and 30DRs (to DHMC only). OPAT patients include those d/c to home or to facilities. We studied d/c’s from 2014 to 2016 and the 30DRs linked to those index d/c’s (through January 2017). 30DRs linked to non-OPAT d/c’s were not included. Around each index d/c, we quantified: LOS; ID diagnosis; d/c disposition; underlying disease; insurance status; # of 30DRs (emergent, urgent, and elective per current Medicare reporting; excluding deaths and against medical advice d/c’s); readmit cause. SRs were defined as having &gt;2 30DRs following an index d/c; HUs were defined as having &gt;4 OPAT d/c’s over a rolling 12-month period. We compared the entire d/c cohort with the subgroups of SRs and HUs. Statistical analysis was performed using SPC Excel.

Results
1189 unique patients had 1454 OPAT d/c’s and 267 unique 30DRs. The ALOS for all d/c’s was 10.1 days (range 0–113); 65.4% were d/c to home (54% to home infusion). Medicare patients comprised 52.3%. The average monthly 30DR rate was 20.4% (range 3.6% to 40.6%), compared with DHMC all cause 30DR rate of 10.5% (FY2016). 8 SRs had &gt;2 30DRs (range 3–6) around 14 index d/c’s (0.9 % of total). 10 HUs had &gt;4 d/c in 12 consecutive months, accounting for 54 d/c’s (3.7% of total). If SRs were excluded, the average 30DR rate fell to 19.0%; if HUs were excluded, the rate fell to 18.4%. Rates were not combined since 4 patients were both SRs and HUs. Underlying diseases of HUs included: cirrhosis, DM, IBD, cancer, renal transplant. HUs ID diagnoses included recurrent bacteremias from occult TIPS infection, IVC’s for TPN, UTIs and osteomyelitis.

Conclusion
OPAT patients have high 30DR rates that exceed overall and population specific 30DR rates in our hospital. By excluding SRs and HUs, 30DR rates may more closely typify an average OPAT experience and be a better program process measure. More understanding about drivers for OPAT d/c for SRs and HUs is needed.

Disclosures
All authors: No reported disclosures.
Impact of Obesity on Acute Kidney Injury Incidence Among Patients Treated with Piperacillin–Tazobactam and Vancomycin
Authors: Rutter W Cliff , Hall Ronald , Burgess David S 
Published: October 2017

Abstract

Background
Obesity is associated with worse patient outcomes in a variety of clinical scenarios. It is unclear from previous research if obesity is associated with increased acute kidney injury (AKI) among patients receiving concomitant piperacillin-tazobactam (TZP) and vancomycin (VAN).

Methods
Clinical and demographic data were collected from the University of Kentucky Center for Clinical and Translational Science Enterprise Data Trust. Patients who received TZP+VAN for at least 48 hours in combination were included. Patients with CKD, a baseline creatinine clearance (CrCl) &lt; 30 mL/minute, CF, or missing height and weight information were excluded from analysis. AKI was defined using the Risk, Injury, Failure, Loss, End-stage (RIFLE) criteria. A weight cutoff point of 91 kg was determined by finding the most predictive bivariable logistic regression model with weights varying from 70 kg through 120 kg via minimization of the Akaike information criterion. Basic descriptive statistics were performed and bivariable and multivariable logistic regressions were performed.

Results
In total, 8125 patients were included in the final analysis. A total of 2452 (30.2%) of patients weighed ≥91 kg. Patients weighing less 91kg were less likely to receive concomitant nephrotoxins and had higher baseline CrCl (97.3 [70.1–128.1] mL/minute vs. 91.8 [68.1–116.5] mL/minute, &lt;0.00001). Baseline severity of illness was similar between groups; however, diabetes (38.9% vs. 20.8%, P &lt; 0.00001), hypertension (63.5% vs. 46.7%, P &lt; 0.00001), and heart failure (14.8% vs. 12.5%, P = 0.007) were more common among the 91kg+ patients. Median daily VAN doses were less in the sub-91kg patients (2000 [1250–2500] mg vs. 3000 [2000–3500] mg, P &lt; 0.00001); however, weight-based doses were lower in the ≥91kg group (25.5 [16.3–31.5] mg/kg/day vs 27.9 [18.7–34.2] mg/kg/day, P &lt; 0.00001). AKI was more common in the patients weighing ≥91kg (23.8% vs. 17.8%, P &lt; 0.00001; adjusted odds ratio 1.46 [95% CI 1.28–1.66]).

Conclusion
Obesity appears to increase the incidence of AKI among patients treated with TZP+VAN, independent of clinically important confounders, with an important breakpoint occurring at 91 kg.

Disclosures
R. Hall, Genentech: Scientific Advisor, Consulting fee Merck: Grant Investigator, Grant recipient
Safety and Efficacy of Telavancin at an Outpatient Parenteral Antibiotic Therapy (OPAT) Unit in New York City
Authors: Rodriguez George D , Polo Lorena , Urban Carl , Turett Glenn , Prasad Nishant , Warren Nathan , Tsapepas Demetra , Ghimire Rabindra , Segal-Maurer Sorana 
Published: October 2017

Abstract

Background
Telavancin is an intravenous (IV) lipoglycopeptide with concentration-dependent bactericidal activity against a broad spectrum of gram-positive organisms and is approved for the treatment of skin and skin structure infections and nosocomial pneumonia; however, post-marketing data is limited. At a hospital-based Outpatient Parenteral Antibiotic Therapy (OPAT) unit, telavancin is used to treat patients due to its convenient daily dosing, its lack of need for therapeutic drug monitoring and its potent in-vitro gram-positive activity. We sought to evaluate the safety and efficacy of telavancin in the OPAT setting.

Methods
We performed a two-year, IRB-approved, retrospective evaluation of all adult patients admitted to the OPAT unit treated with telavancin. Primary outcome was clinical success defined as completion of telavancin and documented clinical resolution. Secondary outcomes included time to initial clinical improvement, 30-day infection related readmission, frequency and time to acute kidney injury (AKI) per RIFLE criteria and incidence of adverse drug reactions (ADRs).

Results
A total of 43 patients were evaluated. Median age was 51 years, 56% were male, and 84% were admitted from the hospital. Baseline demographics differed between clinical failure and success in BMI (38.1 vs. 31 P = 0.168), rates of diabetes mellitus (47% vs. 25% P = 0.148) and chronic vascular insufficiency (33% vs. 11% P = 0.104). Clinical success was observed in 28/43 patients (Figure 1). Successfully treated patients were more likely to be treated for abscesses (21% vs. 0% P = 0.076) and dosed using actual body weight (79% vs. 60% P = 0.196). AKI occurred in 4.7% of all patients, at a median of 7 days after starting (Figure 2). ADRs occurred in 9 patients, of whom 7 led to discontinuation (Figure 3). No difference in time to clinical resolution and 30-day infection-related readmission was observed.

Conclusion
Our study shows real-life experience with telavancin in an OPAT setting, demonstrating tolerability, efficacy, and potential factors which may predispose one to clinical failure (BMI, vascular insufficiency, and dosing weight). Further investigation is warranted to better individualize patient selection and optimize dosing and management of ADRs.

Disclosures
All authors: No reported disclosures.
To Add or Not to Add: Would the Addition of Dalbavancin to Formulary Decrease Admissions for Acute Bacterial Skin and Skin Structure Infections (ABSSSI)?
Authors: Freshwater Dustin , Murphy Nina , Hecker Michelle T 
Published: October 2017

Abstract

Background
One of the major advantages of dalbavancin is that it may be administered as a single dose for the treatment of acute bacterial skin and skin structure infections (ABSSSI). Our objective was to determine the number (%) of patients with an ABSSSI diagnosis whose admission to a county hospital could have been avoided if dalbavancin was on formulary.

Methods
From November 2016 to April 2017, we reviewed encounters for adult patients seen in the emergency department or inpatient setting with a primary ABSSSI diagnosis. For those admitted, potential candidates for dalbavancin included those with ≥2 local signs/symptoms of ABSSSI AND ≥1 systemic sign of infection AND none of the exclusion criteria used in the DISCOVER 1 and 2 trials. Potential candidates were classified as qualifying for dalbavancin if they received IV antibiotics for ≥3 days but &lt;14 days, had no Gram-negative or anaerobic organisms isolated, had no operative intervention nor ≥2 incision and drainage procedures, had a contraindication to linezolid, and did not require hospitalization for management of other comorbidities.

Results
Of 1203 patients with a primary diagnosis of ABSSSI, only 219 (18%) were admitted, of whom only 11 (5%) were classified as potential candidates for dalbavancin. The most common reasons admitted patients were excluded as potential candidates were not meeting signs and symptoms criteria (n = 147), age &lt;18 years (n = 13), being admitted to the hospital for &gt;14 days (n = 11), periorbital or joint cellulitis (n = 9), deep seated infection (n = 5), required admission for another reason (n = 5), and diabetic foot ulcer (n = 4). Of the 11 potential candidates, one qualified for dalbavancin based on our criteria.

Conclusion
At our hospital only a minority of patients with a primary diagnosis of ABSSSI were admitted and one ultimately met our criteria for dalbavancin use. Adding dalbavancin to our formulary would not have resulted in fewer admissions for patients with ABSSSI.

Disclosures
All authors: No reported disclosures.