bluuebunny/crossref_metadata_2025_split huggingface dataset:
Patient Self-Referral to Infectious Diseases Clinic: You Don’t Always Get What You Want, But Hopefully What You Need
Authors: Holman Katherine , Wolske Eric , Nance Demeatrice , Olender Jeff , Englund Kristin , Gordon Steven 
Published: October 2017

Abstract

Background
Patients call into the departments at the Cleveland Clinic Foundation (CCF) to request appointments directly for all specialties. The Infectious Diseases (ID) department chose to evaluate these self-referred patients being seen in our clinic due to (1) limited outpatient clinic appointment availability and (2) patients’ perception of need may not align with the subspecialty care provided.

Methods
In spring 2016, all self-referred patients requesting an outpatient ID evaluation were screened by the ID Access Plus program. Patients were called by administrative staff with a request for records from a licensed practitioner, and when received, were reviewed within 72 hours of receipt by a staff ID physician. Requests were either (1) accepted for appointment, (2) declined, or (3) referred to a more appropriate department within the CCF system. Patients who were declined appointments were informed by an administrator via telephone call. All patients were also informed of the ability for urgent referrals to be accepted with an MD to MD discussion.

Results
During a 12-month period a total of 1000 referrals were processed through the ID Access Plus program: 25% were declined for appointments; 45% were tabled as requested records were not received; and 30% had appointments scheduled. The most common patient reported reasons for self-referral to ID clinic were “Lyme disease” (10%) and “parasites” (4%). The “no-show” rate for scheduled self-referred patients was &lt;5%. The median wait period for a new patient ID appointment in the department declined from over 40 days to &lt; 10 days.

Conclusion
A system of prescreening patients self-referred to ID, requiring a review of medical records by ID clinicians, resulted in improved access for patients.

Disclosures
All authors: No reported disclosures.
Follow-up Appointment Adherence of Outpatient Parenteral Antimicrobial Therapy (OPAT) Patients
Authors: Lall Ambika , Hu Angela , Allison Geneve 
Published: October 2017

Abstract

Background
Outpatient parenteral antibiotic therapy (OPAT) is a safe and effective care delivery system that allows patients to receive intravenous (IV) antibiotic therapy outside of the hospital. OPAT patients require frequent follow-up appointments for clinical and laboratory monitoring of common adverse outcomes of any IV antibiotic administration such as line infections, adverse drug events, and reinfection. Despite the known importance of clinical monitoring, patient factors that influence adherence to OPAT appointments are unknown. The objective of this study was to identify factors that influence adherence to OPAT appointments, in order to improve the OPAT program and make adherence easier for patients if possible.

Methods
80 patients undergoing OPAT between December 2014 and January 2016 were interviewed via telephone regarding the following: reasons for not showing up to appointments, when the first follow up appointment was scheduled, whether they received appointment reminders, transit time, and whether they had to make special arrangements to attend their appointments.

Results
Adherence to follow-up appointments was high (83.8%). 52.5% of initial follow-up appointments were made while patients were still in the hospital. 92% of patients received at least one reminder in the form of a letter (32%), call to cell phone (21%), call to landline (22%), email (17%), or other (1%). Participants mostly cited either transportation (23.4%) or other (30.4%), specifically not feeling well, and work as the reason for missing an appointment.

Conclusion
The majority of patients attended all appointments, and of those, almost all received an appointment reminder, suggesting this is an important factor contributing to appointment adherence. These data reveal some of the barriers some patients face. Future studies can examine whether decreased appointment adherence leads to worse clinical outcomes.

Disclosures
G. Allison, Merck: Grant Investigator and Speaker’s Bureau, Grant recipient and Salary
Risk Factors for Readmission in Patients with Outpatient Parenteral Antimicrobial Therapy
Authors: Huang Victoria , Lerner Polina , Ruhe Jorg , Fedorenko Marianna 
Published: October 2017

Abstract

Background
Outpatient parenteral antimicrobial therapy (OPAT) is a practical and effective way of delivering antimicrobial therapy, but may be associated with significant risk for hospital readmission. This study aimed to elucidate risk factors related to 30-day readmissions in patients who were discharged with OPAT at Mount Sinai Beth Israel (MSBI).

Methods
This IRB approved retrospective cohort study included patients who were at least 18 years or older, admitted to MSBI from August 2015 to March 2016, and discharged to receive OPAT. Subjects were identified using the vascular access team’s monthly reports of peripherally inserted central catheter (PICC) and midline insertion; there was no standardized OPAT program at MSBI. Patients with intravenous antibiotics prescribed for chronic suppression or planned readmission within 30 days were excluded. Information on baseline demographic, clinical, and treatment parameters were collected. The main outcome was readmission to the hospital within 30 days from previous hospital discharge. Univariate and logistic regression analyses were performed to determine predictors of 30-day readmission.

Results
There were a total of 200 patients included in the analysis; the median age was 60 years, 66% were male, and the median Charlson score was 2. Diabetes, peripheral vascular disease, and chronic obstructive pulmonary disease were the most common comorbidities. A total of 155 (78%) patients received a PICC line; the remainder was discharged with a midline. The most common medications prescribed for OPAT included cephalosporins (41%), vancomycin (31%), carbapenems (23%), and penicillins (16%). A total of 42 patients (21%) were readmitted within 30 days after previous discharge. Independent predictors of readmission on logistic regression analyses were (P &lt; 0.05): discharge to a skilled nursing facility or subacute rehabilitation center, diabetes without end-organ damage, and PICC line usage.

Conclusion
Readmissions are common in patients discharged with OPAT. Recognizing predictors of readmission may help determine strategies to optimize care.

Disclosures
All authors: No reported disclosures.
Characterization of Readmissions Among Patients Enrolled in an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program Over a 2-Year Period at UNC Medical Center
Authors: Nwankwo Onyeka , Eichholz Anh , Chundi Vahini , Kinlaw Alan , Medlin Tenesha , Fletcher Lisa , Kufel Wesley , Farel Claire , Marx Ashley 
Published: October 2017

Abstract

Background
The UNC Medical Center OPAT program was started in 2015 to provide multidisciplinary management of medically complex patients referred by the infectious diseases (ID) inpatient services and discharged on parenteral antimicrobials. A primary aim of the program is to avert avoidable readmissions during OPAT therapy through protocolized laboratory monitoring, case review and streamlined access to ID urgent care services.

Methods
We abstracted electronic health records for the first 250 patients enrolled in the OPAT program. 223 patients with sufficient recorded data for entire OPAT course were included. All-cause readmission events during OPAT therapy were collected, and cause for readmission was adjudicated by a multidisciplinary committee.

Results
Of the 223 patients, 62% were male with median age 53 years (20–88). 39 (17%) experienced a readmission (Table 1). Most readmissions occurred among patients not seen in our OPAT urgent care for the admitting complaint. 57 patients (26%) experienced at least one adverse drug reaction (ADR), e.g., laboratory abnormality, rash, or diarrhea; 7 of these required readmission. ADR was the most common reason for ID urgent care visit. Almost half of readmissions were unrelated to OPAT therapy or OPAT-related diagnosis. Less than 10% of OPAT patients utilized ID urgent care services; none of these visits resulted in readmission.

Conclusion
Our OPAT program represents a medically complex cohort that may be at higher risk of readmission at baseline. The availability of providers and pharmacists for urgent care services is effective in avoiding readmission for OPAT-related causes. Future interventions to address common causes of readmission include expanded access to urgent care servvices and close interval follow-up after discharge for particularly high-risk patients.

Disclosures
All authors: No reported disclosures.
Experience with High Dose Once-daily Vancomycin for Patients with Skin and Soft-tissue infections in an Ambulatory Setting
Authors: Wong Maggie , Chapman Michael G , Malhotra Sangita , Mirzanejad Yazdan , Deans Gregory D 
Published: October 2017

Abstract

Background
Intravenous (IV) vancomycin is commonly used to treat MRSA (methicillin-resistant Staphylococcus aureus) infections and is typically dosed at 15 mg/kg every 12 hours. Pharmacokinetic studies, animal models, and limited human study suggest that once-daily high dose (30 mg/kg) vancomycin is similar in efficacy for certain types of infection in the hospital setting, but there is little evidence for its use in outpatient antibiotic therapy (OPAT).
We have used a high dose vancomycin regimen for MRSA skin and soft-tissue infections (SSTI) since 2011. We describe our experience with this regimen in an ambulatory setting supervised by Infectious Diseases (ID) physicians and evaluate its efficacy and safety.

Methods
This retrospective observational study included patients treated with vancomycin for SSTI from Jan 1, 2014 to July 31, 2015. Exclusion criteria included noncompliance with treatment. Patients with initial renal impairment were also excluded as they would be given 15 mg/kg vancomycin daily. Patient demographics, response to vancomycin, duration of therapy, readmission to emergency department (ER), and side effects experienced by patients were collected. A successful outcome was defined as no further requirement for IV vancomycin on the last day of therapy with either oral step down therapy or no further antibiotic.

Results
407 charts were reviewed and 208 patients qualified for inclusion. The mean age of included patients was 38 years. Of the 208 patients, 31% were people who inject drugs, 39% had preceding SSTI in the 12 months prior, and 48% had been on antibiotics in the previous 8 weeks. Incision and drainage was done in 50% of the patients. There were 135 positive wound cultures, of which 58% grew MRSA. The average duration of treatment was 4.7 days.
A successful outcome was achieved in 162 patients (79%). Side effects including red man syndrome and phlebitis were seen in 19 patients (9.3%). 42 patients (20.5%) were readmitted to ER within 30 days of initial referral, and 18 of those were related to the original infections.

Conclusion
High dose (30 mg/kg) once-daily vancomycin for SSTI was effective and safe when used for select patients under the supervision of ID physicians in an ambulatory setting.

Disclosures
All authors: No reported disclosures.
Current Use of Intravenous (IV) Long Acting Antibiotic (LAA) Therapy in the Aetna Health Plan among Patients with Acute Bacterial Skin and Skin Structure Infection (ABSSSI)
Authors: Mehta Rajesh , Edwards Alison , Keyloun Katelyn R , Bonine Nicole , Juster Iver 
Published: October 2017

Abstract

Background
In an effort to lower costs and improve quality of care, there is potential to change the treatment landscape for low-risk (i.e., less severe) ABSSSI patients who historically required inpatient management, a costly option. Outpatient IV treatment pathways have been shown to be a cost-saving option for hospitals and insurers. The objective was to quantify the potential opportunity for reducing cost of ABSSSI treatment in an insured Commercial and Medicare Aetna population.

Methods
Adult patients between January 2013 and July 2016 were identified with a primary ABSSSI claim (Table 1) in the Aetna fully-insured Commercial and Medicare insurance claims database. ABSSSI encounters were identified with insurance eligibility for the 7 months prior to and no evidence of ABSSSI in the 30 days prior to the ABSSSI claim. Demographic and clinical data were described, including length of stay (LOS) and allowed cost for inpatient encounters with data. Inpatient encounters without evidence of severity (e.g., codes for major complications or comorbidities) were considered potential candidates for an outpatient LAA pathway. A sensitivity analysis for LOS and cost was run including all ABSSSI patients with LAA dispenses through 2016 (i.e., inclusion/exclusion criteria did not need to be met).

Results
194,023 ABSSSI encounters were identified, most receiving non-IV treatment (90%). 18,603 received IV treatment, where 83% initially presented to the emergency room and the majority were admitted (97%). Of the 28 encounters with LAA use, 7 were inpatient. Of all current inpatient encounters (N = 9,019 after Jan 1, 2015), the majority (N = 7,005; 78%) where considered potential LAA pathway candidates. Comparing inpatient encounters with vs. without LAA use, mean LOS and cost differed (Table 2: 4.1 days and $14,295 vs. 9.0 days and $23,194, respectively). A sensitivity analysis supported similar mean LOS and cost for all inpatient LAA dispenses.

Conclusion
Current use of LAA in an inpatient population is limited but resulted in potential cost-savings. Most of the inpatient population was identified as potential candidates for an outpatient LAA pathway. Research on utilization and quality of care for outpatient IV treatment pathways with LAA is warranted.

Disclosures
K. R. Keyloun, Allergan: Employee, Salary N. Bonine, Allergan: Employee, Salary
Peripherally Inserted Central Catheter Complications in Rural vs. Uban Children Receiving Long-Term Parenteral Antimicrobial Therapy
Authors: Beachum Natasha , Dehority Walter 
Published: October 2017

Abstract

Background
Peripherally inserted central catheters (PICC) are used for treating infections requiring prolonged intravenous antibiotic therapy (IVAT) in children. Given the lack of data on rural PICC use as well as the rural nature of our state, we studied the safety of home PICC use for treating infections in children living in rural settings.

Methods
We identified children &lt;18 years admitted from January 1, 2005 to March 1, 2014 to the University of New Mexico Hospital (UNMH) through analysis of 43 different ICD-9 and CPT codes indicative of PICC placement, with analysis of the medical record to identify patients discharged on IVAT. All data were entered into REDCap and analyzed on Stata. We recorded demographic data, the antibiotic used, the duration/indication for the PICC, and the type/timing of complications. To classify rural vs. urban residence, we used the rural-urban continuum code (RUCC) from U.S. Census data, and the driving time in hours (h) to the nearest level 1,2 or 3 trauma center and UNMH using MapQuest. All patients had either weekly home health or clinic visits, but none utilized an outpatient parenteral antimicrobial therapy (OPAT) clinic. Linear regression models assessed for differences between outcome and response variables.

Results
Of 866 subjects with a PICC, 221 were discharged on IVAT. 134 (60.6%) were boys and 87 (39.4%) were girls (mean age 9.8 years). The mean driving time to the nearest level 1, 2, or 3 trauma center was 0.6 hours (range 0.1–3.0 hours), while the mean driving time to UNMH was 1.3 hours (range, 0.1–5.0 hours). PICCs were utilized for a mean of 26.1 days at home. The most common antibiotics used were tobramycin (n = 41) and nafcillin (n = 40). Osteoarticular infections and cystic fibrosis exacerbations were the most common indications for PICC use (68.8%). 47 children (21.3%) experienced complications associated with their PICC at a mean of 24.7 days from insertion, most commonly occlusion (n = 13, 27.7%) or accidental removal (n = 13, 27.7%). 40 PICC’s (18.1%) were removed prematurely due to a complication. No association was found between RUCC’s or driving times to UNMH or the nearest level 1, 2 or 3 trauma center with any of these complications nor with complications overall (P = 0.11 to 0.96).

Conclusion
Our study demonstrates that home IVAT with a PICC is safe in children in rural locales.

Disclosures
All authors: No reported disclosures.
Implementation of a Standardized Protocol for Hospitalized Patients Who Inject Drugs and Require Long-Term Antibiotics Reduces Length of Stay Without Increasing 30-Day Readmissions
Authors: Rolfe Robert J , Mathews Ronnie E , Rodriguez J Martin , Paddock Cayce S , Lane Peter S , Taylor Benjamin B , Lee Rachael A 
Published: October 2017

Abstract

Background
Injection drug use (IDU) is a growing epidemic, and persons who inject drugs (PWID) are at high risk for infection. IDU is a barrier to outpatient parenteral antimicrobial therapy (OPAT) and provider experience and knowledge may lead to variation in patient care. Recognizing this problem, a multi-disciplinary team implemented a protocol for management of PWID requiring IV antibiotics. The main goals were to standardize the evaluation and risk assessment of PWID with infections and to provide substance abuse counseling and treatment in order to decrease length of stay (LOS).

Methods
A protocol was developed outlining the evaluation, diagnosis, risk-assessment, treatment, maintenance, and follow up of PWID requiring prolonged IV antibiotics (Figure 1). Patients meeting inclusion criteria were identified and the multidisciplinary team assessed the patient. ID confirmed the diagnosis and outlined the treatment plan, and addiction medicine performed a 9-point risk assessment. Low-risk patients were discharged to complete OPAT. Medium risk and high-risk patients remained hospitalized and were offered group therapy, opioid replacement therapy if applicable, and were reassessed weekly for discharge. These patients were compared with previously identified PWID requiring antibiotics prior to the protocol implementation.

Results
37 patients pre-protocol were compared with 34 patients following implementation. Demographics were similar except 56% of the post-implementation group were diagnosed with a concomitant psychiatric disorder vs. 27% in the pre-implementation group (P = 0.01). There was no statistical difference between the number of patients who left AMA in either group (13.5 % pre; 23.5% post; p 0.28) or the number of readmissions (51.4% pre; 32.4% post; P = 0.10). However, the median LOS was significantly reduced in the post implementation group (18. days vs. 42 days; P &lt;0.001). There have been 418 hospital days saved post implementation.

Conclusion
Implementation of a standardized protocol with a multidisciplinary team and risk stratification to determine appropriate patients for discharge has led to improvement in LOS as well as improved addiction care for hospitalized PWID requiring long-term antibiotics.

Disclosures
All authors: No reported disclosures.
Adverse Drug Reactions Among Patients Enrolled in an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program 2015–2016 at UNC Medical Center
Authors: Chundi Vahini , Eichholz Anh , Nwankwo Onyeka , Kinlaw Alan , Kufel Wesley , Medlin Tenesha , Fletcher Lisa , Marx Ashley , Farel Claire 
Published: October 2017

Abstract

Background
The UNC Medical Center OPAT program was started in 2015 to provide multidisciplinary monitoring and management of patients discharged on parenteral antimicrobials. We examined characteristics of incident adverse drug reactions (ADRs) observed in our initial cohort of OPAT patients.

Methods
We abstracted electronic health records for the first 250 patients enrolled in the OPAT program. 223 patients with sufficient recorded data for entire OPAT course were included in the analysis. ADRs meeting criteria as detailed in Table 1 were collected and further stratified by antimicrobial regimen.

Results
57 patients (26%) experienced at least one ADR during OPAT therapy. The frequency of specific ADRs associated with OPAT therapies are provided in Figure 1. Β-lactam regimens were most frequently associated with liver dysfunction, while combinations of β-lactams and vancomycin were associated with kidney dysfunction. Median days on OPAT regimen was 19 days (IQR: 10–29) for patients who experienced an ADR compared with 39 (IQR: 30–44) for patients who did not experience an ADR.

Conclusion
ADRs were most commonly observed within the first three weeks of therapy, particularly for patients receiving vancomycin and a β-lactam antimicrobial in combination. These results underscore the critical role of a multidisciplinary team in providing laboratory monitoring and response to abnormal results for OPAT patients. In addition, closer monitoring within the first three weeks of therapy may provide opportunities for regimen changes or dose adjustment to avoid toxicities.

Disclosures
All authors: No reported disclosures.
Adverse Events Releated to Antibiotic Use in Patients with Myasthenia Gravis
Authors: Zeitler Kristen , Jariwala Ripal , Montero Jose 
Published: October 2017

Abstract

Background
Myasthenia gravis is a medical condition involving the neuromuscular junction, characterized by weakness and fatigue of voluntary muscles. While the understanding of myasthenia gravis has progressed over the years, questions remain regarding which antimicrobial agents can be administered safely to these patients. Traditionally, aminoglycosides and fluoroquinolones have been avoided in this patient population, while other antimicrobials may be prescribed with caution. With minimal literature to guide practice, our aim was to review antimicrobial prescribing in patients with myasthenia gravis at our institution.

Methods
We conducted a retrospective chart review of adult patients 18 years of age and older with a diagnosis of myasthenia gravis who were admitted from January 2012 through December 2015. Charts were reviewed for the receipt of any antimicrobial during the course of hospitalization and any adverse events related to receipt of antimicrobial agents.

Results
205 patients with a diagnosis of myasthenia gravis were admitted to our institution during the study period. 132 (64.4 %) patients were female and ages ranged from 20 to 98 with a median age of 59 years. 159 (77.6 %) patients received at least 1 dose of an antimicrobial agent during their hospitalization. It was notable that 12.2 % and 11.7 % of patients received at least 1 dose of ciprofloxacin or levofloxacin, respectively. Additionally, 3.9 % of patients received at least 1 dose of an aminoglycoside (gentamicin or tobramycin). Five patients experienced a worsening of their myasthenia gravis symptoms with antibiotic use; 2 cases involved levofloxacin and 1 case each involved ciprofloxacin, cefazolin, or clindamycin. Of note, the average duration of therapy prior to symptoms being noted was 2.6 days.

Conclusion
This study highlights the wide variation in antimicrobial prescribing for patients with myasthenia gravis. Our chart review identified few adverse reactions exacerbating disease symptoms related to antimicrobial use. As it is still unclear the exact mechanism for the development of reactions in select patients with myasthenia gravis, further research may be needed to elucidate this information.

Disclosures
All authors: No reported disclosures.