bluuebunny/crossref_metadata_2025_split huggingface dataset:
319. Infectious disease healthcare utilization and outcomes of patients discharged to skilled nursing facilities on parenteral antibiotic therapy
Authors: Bailey Rosemary C , Crnich Christopher J , Jolles Sally , Furuno Jon P , Noble Brie , Langenstroer Madeline C 
Published: November 2023

Abstract

Background
Hospitalized patients are frequently discharged to a skilled nursing facility (SNF) for parenteral antibiotic therapy (PAT). While there are studies describing the healthcare utilization and outcomes of individuals receiving post-hospital PAT in non-institutional settings, characterization of the PAT experience among SNF patients remains limited. To address this gap in knowledge, we conducted a retrospective cohort study of hospitalized patients discharged to a SNF on antimicrobial therapy.

Methods
Health records of patients (age ≥18 years) hospitalized in a single hospital who were discharged on systemic antibiotics to a SNF from 1/1/2016 - 12/31/2018 were reviewed. Subjects who received an inpatient ID consultation and were discharged on PAT were included. Information captured included patient demographics, diagnoses, discharge antibiotic regimen and timing, post-discharge encounters, 90-day hospital readmissions, and losses to follow-up. This study was approved by the Institutional Review Board with a waiver for informed consent.

Results
155 patients meeting the inclusion criteria were identified. Post-discharge follow-up with the ID Service was not recommended for 19 patients (12.3%). Patients who followed-up post-discharge had a total of 264 sub-specialty provider (mean: 2.8/patient; range: 0-13) and 170 ID provider (mean: 1.7/patient; range: 0-5) face-to-face encounters within 90 days of discharge. Average time to ID clinic follow-up was 3.2 weeks (range: 1-6 weeks). ID clinic nursing staff conducted 1373 telephone encounters (mean: 13.9/patient; range, 3-40) with SNF nursing staff within 90 days of discharge. The 90-day hospital readmission rate was 37% (36/101 patients) and 47% of readmissions were ID-related. The 90-day mortality rate was 9%; 2 patients died before and 7 after outpatient follow-up was established.

Conclusion
ID clinic follow-up of patients discharged to a SNF on PAT was infrequent, but their care entailed a higher volume of telephone care coordination, and they experienced higher readmission rates relative to patients receiving PAT in ambulatory settings. Further studies to better understand if these findings are driven by patient factors or issues related to SNF care practices are needed.

Disclosures
All Authors: No reported disclosures
320. Heterogeneity in Clinical Presentations of Sepsis
Authors: Biebelberg Brett , Rhee Chanu , McKenna Caroline S , Klompas Michael 
Published: November 2023

Abstract

Background
Sepsis treatment protocols stipulate a uniform care plan for all patients with possible sepsis. Sepsis clinical criteria, however, may capture a wide spectrum of illnesses. We sought to elucidate the heterogeneity of sepsis by characterizing the breadth of infection types, organ dysfunctions, and their differential outcomes in a large cohort of sepsis patients.

Methods
We identified all adults admitted via the ED to 5 Massachusetts hospitals from 2015-2022 with possible sepsis, defined as suspected infection (blood culture orders and intravenous antibiotics) and organ dysfunction using CMS SEP-1 thresholds (drop in systolic blood pressure [SBP] ≥ 40mmHg or hypotension, elevated lactate, invasive or noninvasive ventilation, elevated creatinine or bilirubin, low platelets, or elevated INR/PTT). We identified infection sources using present-on-admission ICD-10 diagnosis codes and analyzed the frequency and mortality of each combination of infection site and organ dysfunction.

Results
The cohort included 74,609 patients with suspected sepsis: median age 67 [IQR 55-79], 47% female, 24% non-white, 36% hypertension, 33% liver disease, and 28% chronic pulmonary disease. The overall in-hospital mortality rate was 9%. Patients varied widely in sources of infection (e.g. 33% pulmonary, 23% genitourinary, 13% intra-abdominal, and 1% obstetric/gynecologic) and organ dysfunctions (e.g. 57% drop in SBP ≥ 40mmHg, 9% hyperbilirubinemia, and 6% thrombocytopenia). Similarly, mortality rates varied from 3-13% across infection types (Figure 1) and from 3% (drop in SBP alone) to 27% (invasive ventilation) across organ dysfunctions (Figure 2). Combining infection types and organ dysfunctions further extended the spectrum of mortality from 0% for obstetric/gynecologic infections with thrombocytopenia to 35% for bacteremia with elevated INR or PTT (Figure 3).Figure 1:Scatter plot of frequency vs mortality of infectious sources in patients presenting with suspected sepsisFigure 2:Scatter plot of frequency vs mortality of organ dysfunction patterns in patients presenting with suspected sepsisFigure 3:Heat map describing mortality rates for each combination of infectious source and organ dysfunction in patients with suspected sepsis

Conclusion
Sepsis encompasses a wide spectrum of illnesses including multiple infection sites and organ dysfunctions that vary in crude mortality rates from 0-35%. The heterogeneity of sepsis begs the question whether “one-size-fits-all” bundles are suitable. Care tailored to each patient’s presentation may be more appropriate.

Disclosures
Chanu Rhee, MD, MPH, Cytovale: Advisor/Consultant|Pfizer: Advisor/Consultant|UpToDate, Inc.: Honoraria Michael Klompas, MD, MPH, UpToDate, Inc.: Royalties for chapters on pneumonia
322. Improving Assessment of Beta-Lactam Allergies by Embedding a Questionnaire in Best Practice Advisory Alerts Across a Large Health System
Authors: Boger Michael S , Boger Michael S , Jaffa Rupal K , Kiliany Rebecca , Shah Ekta , Morris Lee , Davidson Lisa 
Published: November 2023

Abstract

Background
Penicillin (PCN) allergy is commonly reported. Yet most patients labeled allergic can tolerate beta-lactams (BLs), the antibiotics of choice for many infections. Documentation of reaction details is important to identify low risk patients who can safely receive BLs, but it is often incomplete. A May 2018 point prevalence study from the electronic medical record (EMR) using a one-week sample of Atrium Health Greater Charlotte Market (AH) PCN allergy patients showed that 52% had no reaction documented.

Methods
This was a retrospective, observational study in thirteen hospitals in the AH system. To improve BL allergy assessment, a BL allergy questionnaire was developed during the launch of a new AH wide EMR. During the initial roll-out, a best practice advisory (BPA) fired for nursing when entering a BL allergy, prompting a link to a separate BL allergy questionnaire for nursing completion. After all sites were live, we assessed questionnaire completion rates. During the optimization phase, the questionnaire was incorporated directly in the BPA and simplified from ten to three questions, allowing completion in one step (Fig 1). The answers are then automatically sent to flowsheets where they are available for reference and feed into assessment algorithms that provide the allergy level of risk and clinician treatment guidance upon antibiotic order entry (Fig 2). The BPA fires daily as a reminder until questionnaire completion.Figure 1.Beta-Lactam Allergy Questionnaire Best Practice Advisory (BPA).Figure 2.Beta-Lactam Allergy Assessment Algorithm.

Results
Pre-optimization: Over a ten month period from December 2021 through October 2022, 4118 inpatient questionnaires were completed. Beginning in August 2022, when all facilities were live on the new EMR, the average monthly questionnaire completion was 833 (Fig 3). Post-optimization: In November 2022, completion increased 38.9%, resulting in an additional 4743 questionnaires over four months (average of 1186 per month). The number of questionnaires completed thereafter decreased as the number of patients with previously completed questionnaires increased.

Conclusion
The creation of a targeted BL allergy questionnaire in the EMR improved BL allergy documentation across a large, diverse health system. The effect was enhanced through workflow optimization incorporating the questionnaire into a one-step BPA.

Disclosures
All Authors: No reported disclosures
326. Meeting an unmet need - impact of a Complex Fungal Infection Clinic in the UK
Authors: Dominic Catherine , Houston Hamish , Das Abhishek , RH Stone Neil 
Published: November 2023

Abstract

Background
The WHO recently set out priority fungal pathogens of global importance which were previously neglected in terms of awareness & funding(1). Accurate diagnosis of fungal infection is a challenge & mortality remains high(2) as expertise and dedicated mycology services are lacking globally. Our centre provides one of the UK’s first complex fungal infection clinics, established in 2019. We sought to describe the patients attending this clinic, as a step towards understanding the landscape of clinical mycology in the UK.

Methods
Electronic health record systems were searched for all patients attending our clinic over 4 years from 01/04/19-01/04/23. Patients referred for consideration of a fungal diagnosis were included in the analysis. Invasive fungal infections (IFIs) were classified as per EORTC/MSGERC guidance.(3)

Results
80/407 patients attending our clinic were referred for consideration of a fungal diagnosis. 31 (39%) were male. Median age was 53 (IQR 38-62). Most referrals (59/80; 74%) were received from within our institution. 41 (51%) had a fungal diagnosis confirmed prior to review. 28 were treated for invasive fungal infections (IFIs), 9 for chronic mycoses (including 5 chronic pulmonary aspergillosis & 2 mycetoma), 28 for superficial mycoses (20 recurrent mucocutaneous infections & 8 onychomycoses) & 15 had no evidence of fungal infection. Of the IFI: 16 were proven; 8 probable; 2 possible IFI & 2 did not meet diagnostic criteria. 7 IFI were caused by Aspergillus, 8 by Cryptococcus & 2 each by Coccidiodes, Candida & Histoplasma. The IFIs mainly affected the upper & lower respiratory tract (17/28). 20/80 (25%) were immunosuppressed (commonest causes: diabetes; HIV; steroids; malignancy & chemotherapy). On average (median), patients visited clinic 4 times (IQR 2-7) & received 2 different antifungal drugs (IQR 1-3). The most common side-effects prompting a change in therapy were visual changes, rash & diarrhoea.

Conclusion
Our data illustrate the need for dedicated follow-up for patients with complex fungal infections. With several new antifungal drugs currently undergoing clinical trials, complexity in therapeutic decision-making will only increase.(4) Establishing centralised complex fungal infection clinics helps to build diagnostic & clinical capacity in mycology.

Disclosures
Hamish Houston, BA MBBCh, Gilead Sciences: Grant/Research Support Neil RH Stone, MD PhD, Gilead: Advisor/Consultant|Gilead: Grant/Research Support|Gilead: Honoraria|Pfizer: Honoraria|Shionogi: Honoraria
328. One-Day Holiday: An Approach to Managing Daptomycin-Induced CK Elevations in OPAT
Authors: Fabricio Julia B , Swartwood Michael , Oosterwyk Teresa M , Schranz Asher J , Farel Claire E , Mavrogiorgos Nikolaos , Bowman M C , Kinlaw Alan C , Boerneke Renae 
Published: November 2023

Abstract

Background
Daptomycin can be ideal for outpatient parenteral antimicrobial therapy (OPAT) due to its once-daily dosing, tolerability, and lack of nephrotoxicity compared to vancomycin. Though infrequent, skeletal myopathy with associated elevation of serum creatinine kinase (CK) is a clinically significant adverse effect associated with daptomycin. Risk factors associated with CK elevations include initial dose, obesity, chronic kidney disease, and statin use.
Based on a case series by Burdette et. al, the UNC OPAT Program manages asymptomatic mild-to-moderate CK elevations by either a one-day dose holiday with continuation of the same dose or one-day daptomycin holiday followed by dose reduction. We assessed the effectiveness of this strategy for allowing continuation of daptomycin in our patient population.Figure 1:Daptomycin and CK Elevations FlowchartTable 1:Baseline Demographics

Methods
A total of 396 patients received daptomycin in the OPAT Program from March 2015 to January 2023. We analyzed associated baseline risk factors for patients with CK elevations above 500 U/L and management strategies (e.g., one-day holiday, dose reduction, and/or drug discontinuation). CK elevations were defined as mild (500-999 U/L), moderate (1000-1999 U/L), or severe (≥ 2000 U/L).

Results
Of the 396 patients on daptomycin, 36 (9%) experienced a CK elevation &gt; 500 U/L. 34 (94%) patients required further management. 58% of patients were asymptomatic, with 55% having mild CK elevation. Most reported symptoms were muscle/joint pain. On average, CK elevations occurred 18 days (± 9) into therapy, with a shorter time to CK elevation for severe (11 days ± 2) and moderate elevation (14 days ± 6). Lab abnormalities were managed within one day. Of the 7 patients that had a one-day holiday only, 5 experienced CK improvement. Of the 8 patients with a one-day holiday + dose reduction, 6 showed CK improvement. No patient with dose reductions had readmission during treatment course and one had infection recurrence within 90 days.

Conclusion
The one-day holiday +/- dose reduction adjustment strategy for management of CK elevations allowed for continuation of daptomycin without compromising treatment or leading to hospital readmission. Timely evaluation of safety labs and dose adjustment strategies are key in managing CK elevations for OPAT patients receiving daptomycin.

Disclosures
Asher J. Schranz, MD, MPH, WoltersKluwer: Honoraria Alan C. Kinlaw, PhD, Genentech: Grant/Research Support
336. A 6-Sigma Approach for Follow-up Evaluation of Outpatient Parenteral Antimicrobial Therapy (Project SAFE-OPAT) To Improve Documentation and Post-Discharge Care
Authors: Keri Vishakh C , Ali Sajjad , Elattma Ahmed , Monday Lea M 
Published: November 2023

Abstract

Background
Outpatient Parenteral Antimicrobial Therapy (OPAT) is challenging to implement safely and difficult for infectious diseases (ID) physicians to monitor in centers without a dedicated OPAT staff. We utilized a 6-Sigma framework to evaluate our OPAT process and define opportunities for improvement.

Methods
In a retrospective cohort study, we screened 5 months of ID consult data for patients who left on OPAT from an urban hospital system (Fig 1). Primary outcome was incidence of adverse event (AE), a composite of either emergency department (ED) visit or all-cause 30-day readmission. Clinical characteristics and completeness of ID documentation were compared between patients with and without an AE. Complete documentation included antibiotic dose, duration, stop date, and a scheduled ID appointment. We simultaneously conducted a 6-sigma analysis involving stakeholders (physicians, case managers, nurses) in focus groups, to generate a process map, Ishikawa diagram, 5-Why’s analysis, and identify heterogeneity in our OPAT process (Fig 2).

Results
Fifty of 441 patients (11.3%) were discharged on OPAT and incidence AE was 30%. Neither type of infection (Fig 3), nor demographics, clinical characteristics, or discharge location differed between groups (Table 1). Only half (50%) of the patients had complete documentation. Median time from discharge to clinic was 21 days, however, AE’s occurred in a median time of 12 days. Patients without an AE were more likely to have been seen in the clinic post-discharge (51% versus 20%, p=0.039). ID clinic appointments were made for 60% of patients, with a show rate of 63%. (Fig 4). Two additional unscheduled patients initiated their own visit (Fig 4). The 6-Sigma analysis identified process heterogeneity at discharge location and over-reliance on human memory for complete documentation. Interestingly, focus groups revealed numerous assumptions not supported by the objective data (Fig 5 in conclusion).

Conclusion
Almost 1 in 3 patients leaving on OPAT experienced an adverse event. A 6 Sigma analysis identified heterogeneity in our process and incorrect assumptions among stakeholders (Fig 5). Next steps should focus on improving ID documentation and ensuring all patients leaving on OPAT have an ID clinic visit scheduled within 14 days after discharge.

Disclosures
All Authors: No reported disclosures
338. ChatGPT Conveys Incorrect Information about the FDA’s Antibiotic Boxed Warnings
Authors: Linfield Rebecca , Parsonnet Julie 
Published: November 2023

Abstract

Background
Chat Generative Pre-training Transformer (ChatGPT) is a popular artificial intelligence-based chatbot that rapidly provides responses to online inquiries. As a language-processing – rather than a scientific – tool, ChatGPT does not guarantee accuracy. The United States Food and Drug Administration (FDA) labels medications with significant risk of serious or life-threatening adverse effects with boxed warnings (BW). We sought to assess the accuracy of ChatGPT regarding FDA BW for antibiotics.

Methods
FDA labels for commonly-used antibiotics were categorized through the DailyMed database of the National Library of Medicine (Table 1). ChatGPT-3.5 was then queried regarding FDA BWs using the following query: “Are there any boxed warnings on the FDA label for XX [medication] and if so, what are they?” Responses were sorted into 3 categories:(1) “Matching”: ChatGPT accurately reported both existence and content of BW or its absence;(2) “Inaccurate”: ChatGPT accurately reported a BW but erred on some aspects of the content; and(3) “Incorrect”: ChatGPT misidentified existence of BW, or listed incorrect adverse effects (AE)Table 1:FDA Boxed Warnings for Commonly Used Antibiotics

Results
Of the 41 antibiotics queried, 9 have FDA BWs and ChatGPT correctly identified the existence of all 9. However, ChatGPT correctly matched the AE of the FDA BW in only 3 instances (33%); in five instances (56%), ChatGPT listed inaccurate AEs (either under- or overinclusive) and in one (11%), ChatGPT listed an incorrect AE. For the 32 antibiotics without an FDA BW, ChatGPT reported that 23 (72%) had a BW (Figure 1). Figure 2 provides some examples of incorrect ChatGPT claims regarding AEs.Figure 1:ChatGPT Responses about FDA Boxed WarningsFigure 2:Examples of Incorrect ChatGPT claims

Conclusion
ChatGPT reported inaccurate and incorrect information about FDA BW for antibiotics. Clinicians should be aware of this new source of information for patients.

Disclosures
All Authors: No reported disclosures
346. Evaluation of the Safety Profile of Cefazolin Monotherapy in Outpatient Parenteral Antibiotic Antimicrobial Therapy at a Large Academic Medical Center
Authors: Poux Nicolas , Gillett Eric M , Franklin Catherine , Estano Mark J , Dewan Charles , Sheedy Kate , Dionne Brandon , Kubiak David W , Pearson Jeffrey C , Chan Brian T 
Published: November 2023

Abstract

Background
The Infectious Diseases Society of America recommends serial safety lab monitoring during outpatient parenteral antimicrobial therapy (OPAT) to assess treatment response and prevent adverse events. However, these recommendations do not address the safety profile of specific antimicrobial agents or the ideal frequency of monitoring. Previous studies, using cohorts of fewer than 300 patients, report adverse event rates of less than 5% with outpatient cefazolin. It is possible that serial lab monitoring for patients on cefazolin monotherapy may represent unnecessary work and increase costs with minimal patient benefit.

Methods
A retrospective chart review was performed on patients treated with cefazolin monotherapy in the OPAT program of Brigham and Women’s Hospital (Boston, MA, USA) from February 2018 to February 2023. Data from weekly safety labs were examined during OPAT for the following abnormalities: change in creatinine (absolute increase of 0.5 mg/dL or relative increase ≥50%), ALT &gt; 100 units/L, neutropenia (absolute neutrophil count &lt; 1000 cells/mm3), eosinophilia ( &gt;500 cells/mm3), and thrombocytopenia (&lt; 100K/uL or relative decrease ≥50%). Other treatment complications adjudicated from chart review included antibiotic treatment changes, readmission, or mortality during OPAT.

Results
Among the 420 patients receiving cefazolin in OPAT, the median age was 62 (IQR: 49-71) years; 168 patients (40%) were women, and 62 (15%) were referred from oncology or transplant services. Twenty-four (6%) patients had at least one lab abnormality. Of these, 13 (3%) required a treatment change or had readmission or death. Eight (2%) cases were related to a lab abnormality, while five were due to other factors either unrelated to antibiotic therapy or apparent on clinical examination (e.g., rash).

Conclusion
In an OPAT program at a large academic medical center, weekly lab monitoring altered clinical decision-making for 2% of patients on cefazolin monotherapy. It may be reasonable to reduce the frequency of or eliminate routine lab monitoring for these patients to reduce the cost of healthcare services. Future studies are indicated to evaluate the clinical impact of less frequent lab monitoring for OPAT patients on cefazolin monotherapy.

Disclosures
David W. Kubiak, PharmD, BCPS, BCIDP, FIDSA, Astellas Pharma, Inc.: Advisor/Consultant|AVIR Pharma Inc: Advisor/Consultant|Cidara Therapeutics: Advisor/Consultant|Shionogi Inc: Grant/Research Support
349. The impact of Vancomycin dosing by area under the curve over minimal inhibitory concentration (AUC/MIC) versus Trough levels on cumulative Vancomycin dosage and incidence of Acute Kidney Injury (AKI) in patients admitted to intensive care units (ICU)
Authors: Sahu Aniruddha , Wang Kevin K , Jurasinski Philip , Kulkarni Salil , Weihs Sayo , Mizusawa Masako , Bamberger David 
Published: November 2023

Abstract

Background
Higher Vancomycin trough levels (15-20 mcg/ml) are associated with increased risk of AKI. IDSA recommends dosing Vancomycin as per AUC/MIC reduces the risk of nephrotoxicity. The aim of this study was to determine if AUC/MIC dosing could reduce the incidence of nephrotoxicity patients in admitted to intensive care unit (ICU). This has not been previously studied.

Methods
This was a retrospective pre and post chart review study including all admitted patients to ICU at Truman Medical Center Hospital Hill, Kansas City, Missouri from 10/1/2020 to 10/1/2021. The pre intervention period (trough monitoring) was 10/1/2020-3/29/2021.The post intervention period was 4/1/2021-10/1/2021, included patients who received Vancomycin dosing via using a Bayesian derived AUC monitoring software program targeting AUC of 400-600 mg*hour/L (Insight Rx). All patients who were admitted to ICU and received Vancomycin for &gt;48 hours were included. Exclusion criteria includes Vancomycin use for &lt; 48 hours, end stage renal disease and who received continuous renal replacement therapy within 48 hours of starting Vancomycin.

Results
119 patients received Vancomycin dosing by AUC/MIC and 122 patients by Vancomycin trough. Patients received 23.51 ± 2.13 mg/kg/day(mean ± standard error) Vancomycin in AUC/MIC and 25.28 ± 1.71 mg/kg/day in trough group (p = 0.18). The incidence of AKI was 25.21%(n=30) in AUC/MIC group and 17.21%(n=21) in trough group (p = 0.13). Vancomycin was used for 5.61 ± 0.68 days in AUC/MIC group and 4.92 ± 0.48 days in trough group (p = 0.10). The incidence of AKI in patients who received concomitant intravenous contrast was 26.22%(n=16) in AUC/MIC group and 10.90%(n=6) in trough group (p = 0.04*). Average length of stay (LOS) in ICU was 11.56 ± 2.65 days in AUC/MIC group and 8.66 ± 1.61 days in trough group (p = 0.06). All-cause mortality during hospitalization was 29.41%(n=35) in AUC/MIC group and 22.13%(n=27) in trough group (p = 0.20). AKI was noted in 19.82% patients receiving Piperacillin tazobactam and Vancomycin versus 22.4% receiving Vancomycin without Piperacillin tazobactam(p = 0.63).

Conclusion
There was no difference in cumulative vancomycin dose, incidence of AKI, LOS and All-cause mortality during the hospitalization while using Vancomycin dosing by AUC/MIC vs trough in ICU patients.

Disclosures
All Authors: No reported disclosures