bluuebunny/crossref_metadata_2025_split huggingface dataset:
989. Role of Bone Biopsy and Deep Tissue Culture for Antibiotic Stewardship in Diabetic Foot Infections
Authors: Hockney Sara M , Steker Danielle , Krueger Karen M , Bhasin Ajay , Williams Janna L , Galvin Shannon 
Published: December 2022

Abstract

Background
Bone biopsy is the gold standard for identifying the etiology of infectious osteomyelitis (OM) but is not always done in the setting of diabetic foot infections (DFIs), even in settings where resistant organisms are common. This study aimed to describe organisms most frequently identified on bone biopsy or deep tissue culture and determine how culture data impacted antibiotic management in patients with DFIs.

Methods
We retrospectively reviewed all patients admitted with a DFI between 2018 and 2020 and selected for patients diagnosed with infectious OM of the lower extremity for whom bone biopsy or deep tissue culture was obtained. Statistics were performed in R version 4.2.0.

Results
Of 305 patients with DFI, 47 patients received 41 deep tissue cultures and 29 bone biopsies for a total of 70 cultures. Of 45 (64%) positive cultures, 36 (80%) had gram positive organisms and 24 (34%) had gram negative organisms. Multidrug resistant organisms were isolated in 7 (14.9%) patients, including 5 cases of MRSA (10.2%) and 2 cases of ESBL-producing organisms (4.3%). Pseudomonas aeruginosa was isolated in 3 (6.4%) patients. Culture data resulted in antibiotic changes in 41 (87.2%) patients. Therapy was narrowed in 29 (61.7%) patients and broadened due to inadequate empiric coverage in 4 patients (8.5%). Culture-directed therapy was started in 4 (8.5%) patients in which it had initially been withheld. Culture data from 18 (40%) patients showed sensitivity to an oral treatment regimen with high bioavailability. There was no significant difference in rates of antibiotic utilization at discharge between patients who underwent bone biopsy or deep tissue culture relative to those who did not (80% vs 75%, p=0.857). There was a trend towards utilization of less MRSA coverage (38.2% vs 50.5%, p=0.16) and Pseudomonas coverage (34.0% vs 41.9%, p=0.36) in patients undergoing bone biopsy or deep tissue culture, but this did not reach statistical significance. Table 1:Bacteria isolated from deep tissue culture or bone biopsy and effect on antibiotic therapyFigure 1:Empiric antibiotics in hospital vs culture directed antibiotics on discharge

Conclusion
In patients with DFIs, deep tissue and bone biopsy cultures were infrequently obtained but resulted in targeted therapy changes in most patients. While culture data usually allowed for narrowing of antibiotics, it revealed inadequate empiric coverage in a subset of patients.

Disclosures
Janna L. Williams, MD, Abbvie: COVID19 Infection Prevention Consultant Shannon Galvin, MD, Gilead: Grant/Research Support.
993. “I feel like they’re actually listening to me”: A Pilot Study of Hospital Discharge-Decision Making for Patients with Injection Drug Use-Associated Infections
Authors: Thakarar Kinna , Kohut Michael R , Stoddard Henry , Burris Debra , Sikka Monica K , Solomon Daniel A , Kershaw Colleen , Eaton Ellen , Chessa Frank , Hutchinson Rebecca , Fairfield Kathleen , Friedmann Peter , Thomas J 
Published: December 2022

Abstract

Background
Conversation guides have the potential to transform care for patients hospitalized with injection drug use (IDU)-associated infections. This study’s objectives were to 1) pilot a structured conversation guide for hospital discharge decision making in patients with IDU-associated infections 2) investigate the guide’s feasibility and acceptability and 3) examine patient and provider experiences, patient outcomes, and lessons learned.

Methods
We developed a conversation guide and conducted semi-structured interviews with physicians and patients at a tertiary care center in Maine. We interviewed physicians after each piloted the guide with two patients. We interviewed patients less than one week after the conversation and again after 4-6 weeks. Two analysts indexed transcriptions and used the framework method to identify and organize relevant information. We conducted retrospective chart review to corroborate and contextualize qualitative data.

Results
Eight patients and four infectious disease physicians piloted the conversation guide. All patients (N=8) completed antimicrobial treatment and 88% were discharged on medication for opioid use disorder (Table 1). All providers and most patients stated that the conversation guide was important for incorporating patient preferences and antimicrobial treatment options. Patients appreciated more autonomy and their voices being included in their care. Providers felt the guide facilitated their understanding of patient values. Values and preferences between patients and providers were aligned. Participants identified the length of the guide, discussion of pain management, and addressing post-discharge needs such as housing as areas for improvement (Table 2).

Conclusion
The use of a conversation guide to inform hospital discharge decision making for patients with IDU-associated infections incorporates patient preferences and values into treatment decisions. While we identified areas for improvement, overall patients and providers believed that this novel conversation guide helped to improve patient care and autonomy.

Disclosures
Kinna Thakarar, DO, MPH, Maine Medical Center: Board Member|NIH: Grant/Research Support|University of New England: Board Member Monica K. Sikka, MD, F2G: Site research investigator Ellen Eaton, MD, MSPH, Gilead: Grant/Research Support.
1008. Implementation of Clinical Pathway for Management of Fever in Nursing Home Residents in Singapore
Authors: Smitasin Nares , Jagdishchandra Garvi , Salada Brenda Mae , Karunakaran Bindu , Fisher Dale 
Published: December 2022

Abstract

Background
Ageing population is a major health care problem all over the world. In Singapore, as of 2020, senior citizen (65 years and above) consists of 15.2 % of total population. By 2030, one in five Singaporeans will be more than 65 years old. Thus, nursing home (NH) is an important pillar of a health care system.
Nursing home staff are in the front line to manage common infections. However, the inexperience and the lack of guidance have led to inappropriate transfer to acute hospitals.
Infectious Diseases Community Program (IDCP) is the project to enhance partnerships with NHs. We work with NHs to develop, adapt, and implement appropriate processes related to infection control, prevention, and management. One of our objectives is the enhancement of assessment and appropriate evaluation of fever. The aim is to reduce the inappropriate admissions to acute hospitals.

Methods
Fever and desaturation pathway (figure 1) was developed by IDCP team. Six participating NHs adopted the pathway and trained their staff. The study was approved by NHG domain specific review board (DSRB). Hospital records were reviewed. We compared the rate of inappropriate admission from 2015-2017 which serve as a baseline and 2019-2020. The wash-out period was 2018 when NHs were implementing the pathway.
Inappropriate admission is defined as
&lt; ! 1. Admission is against advanced care planning / preferred plan of care
or
2. Criteria in the pathway are not met on admission, 48 hours later and no other medical reason for admission. Figure 1

Results
Total number of fever transfers was 950 in 2015-2017 and 688 in 2019-2020. Number of inappropriate admissions was 115 in 2015-2017 and 50 in 2019-2020. Inappropriate admission was 12.11% in 2015-2017 and 7.27 % in 2019-2020 (table 1). Figure 2 shows the rate of inappropriate admissions of six participating NHs from 2015-2020. There is a decreasing trend after the pathway has been implemented in 2018. Table 1
Figure 2

Conclusion
Adopting fever and desaturation pathway has reduced the rate of inappropriate admission in six participating NHs in Singapore. However, there is an increasing trend in inappropriate admission in 2020. This could be due to the lack of isolation facility in the NHs during the COVID-19 pandemic. We are continuing the implementation of the pathway to the rest of the NHs in the western region of Singapore.

Disclosures
All Authors: No reported disclosures.
1009. Integrating a Lean Six Sigma DMAIC approach to improve transitions of care in patients discharged on outpatient parenteral antimicrobial therapy
Authors: Monday Lea M , Joshi Seema , Goteti Ravitej , Saba Janan , Weinmann Allison J 
Published: December 2022

Abstract

Background
Outpatient Parenteral Antimicrobial Therapy (OPAT) programs aim to facilitate early discharge and improve patient care; however, rates of readmission remain high. After discharge, safe monitoring and follow-up is logistically heterogenous and prone to error. We aimed to utilize a Six Sigma framework to evaluate our OPAT process and define opportunities for improvement in patient care.

Methods
A define, measure, analyze, improve, control (DMAIC) approach was used by a multidisciplinary group to evaluate errors and opportunities in the OPAT discharge process (Fig 1). Baseline analysis of 6-months of OPAT discharges revealed an all cause 30-day readmission rate of 19.7%, and less than half of all patients (45%) were seen in the infectious diseases (ID) clinic within 28-days. The group created a process map and identified potential opportunities for error and heterogeneity in the process.

A define, measure, analyze, improve, control (DMAIC) approach was used by a multidisciplinary group to evaluate errors and opportunities in the OPAT discharge process

Results
Process mapping revealed process heterogeneity depending on patient discharge location (Fig 2). Reliability of ordering labs and transporting patients to appointments varied by location (Skilled nursing facility (SNF) versus home infusion, etc.). Furthermore, the OPAT note was not included in the discharge summary and the process was reliant on an ID team member emailing the clinic to request follow-up. An Ishikawa diagram identified numerous factors contributing to OPAT related adverse events (Fig 3). Main opportunities for improvement included (1) the OPAT note, (2) delegation of laboratory ordering for monitoring patient after discharge, (3) patient follow-up scheduling and monitoring, and (4) skilled nursing facility (SNF) communication and expectations. Interventions resulting included working with information technology to update the OPAT note to include appointment dates, attaching OPAT note to discharge summary, and bridging communication and ensuring task completion by delegating certain reliable SNFs as centers of excellence.

Process mapping revealed significant process heterogeneity depending on patient discharge location, that the OPAT note was not included in the discharge summary, and the process was heavily reliant on an ID team member emailing the clinic to request follow-up and ensure future laboratory tracking.

An Ishikawa diagram identified numerous factors contributing to OPAT related adverse events including numerous system and individual factors

Conclusion
The DMAIC approach was useful in identifying opportunities to improve transitions of care in patients discharged on OPAT and developing interventions for targeted process improvement. Other centers may use a similar strategy to analyze and improve the care of OPAT patients.

Disclosures
All Authors: No reported disclosures.
1013. Outpatient parenteral antimicrobial therapy (OPAT)-related peripheral eosinophilia as a predictor of hypersensitivity reactions.
Authors: Khalaf Suha Abu , Jubair Fahed , Nolan Nathanial S , Jegede Olujimi 
Published: December 2022

Abstract

Background
The administration of outpatient parenteral antimicrobial therapy (OPAT) has significantly increased in recent decades. OPAT offers many benefits to patients and the health care system. Best practices suggest patients on OPAT require active monitoring for adverse effects of therapy. Asymptomatic eosinophilia is common finding in patients receiving OPAT and could be benign or herald allergic drug reactions. Little is known about the practice patterns of OPAT providers in their management of asymptomatic eosinophilia. This study aimed to assess the opinions and practice patterns regarding asymptomatic eosinophilia among providers managing patients on OPAT in the United States.

Methods
This is a cross-sectional study of data collected from a one-time, anonymous, self-administered survey to providers who care for patients receiving OPAT. The survey was posted in the discussion forums of the Infectious Diseases Society of America (IDSA) and shared via emails to twenty ID departments in the US. Data was collected from June to July 2021. Survey responses were analyzed using Python for statistical analysis.

Results
Sixty-five respondents completed the survey. Thirty-six percent of respondents reported that eosinophilia occurs in up to five percent of their patients, with an average time of 1-2 weeks between antibiotic exposure and the development of eosinophilia Fig (1). Sixty-nine percent of respondents reported that they do not change their laboratory monitoring frequency in patients with asymptomatic eosinophilia. Fifty-two percent of respondents would discontinue/switch antibiotics only if the patient developed complications Fig (2). The risk of subsequent hypersensitivity reaction/end-organ damage was less frequently noted, as seventy-five percent encountered it in &lt; 10% of eosinophilia cases Fig (1). Fig. 1Reported OPAT associated eosinophilia and subsequent hypersensitivity reaction per respondents
Fig. 2 Practice patterns among survey respondents to eosinophilia

Conclusion
Per our survey results, OPAT-related eosinophilia is common though subsequent hypersensitivity/life-threatening reactions are not. Most surveyed ID providers monitor asymptomatic eosinophilia without changing antibiotics. Further prospective studies are needed to understand the course and best practice for asymptomatic eosinophilia among patients on OPAT.

Disclosures
All Authors: No reported disclosures.
1014. Patient perspectives on pharmacy experiences for antiretroviral refills
Authors: Havens Josh , Liu Yadi , Furl Renae 
Published: December 2022

Abstract

Background
Control and prevention of HIV infection require sustained adherence to antiretroviral therapy (ART) for patients with HIV (PWH) or those on pre-exposure prophylaxis (PrEP). ART is increasingly designated by payers as a specialty medication and often mandates specialty mail-order pharmacy for refills. Little is known about patient perspectives of pharmacy choice preferences for ART.

Methods
A 20-question survey was distributed to patients (PWH and PrEP) of the Specialty Care Center in Omaha, NE. Participants &gt;19 years, retained in care for &gt;6 months, and experience with ART/PrEP refills at both local and mail-order pharmacies were considered for study participation. The survey was designed in 3 parts: perspectives on both pharmacy settings, ranking of pharmacy attributes, and pharmacy preference. Descriptive analyses were performed for all survey questions.

Results
Surveys were completed by 61 participants (N=156; 39.1%). Median age was 52 years, 85% White, 13% Black, 5% Latinx, and 80% commercially insured. Forty-eight participants (79%) reported insurance mandates to use a specialty mail-order pharmacy with 28 (58%) believing the mandate impacted their medical care. Forty-one participants (67%) preferred refilling prescriptions through a local pharmacy. Participants ranked “ease of refilling” as the most important attribute (Figure 1) and favored local pharmacies vs mail-order pharmacies for all pharmacy attributes (Figure 2).

Scoring scale, 1=strongly disagree to 5=strongly agree.

Conclusion
Midwest PWH and PrEP patients generally preferred local pharmacies to refill their antiretroviral therapies versus mail-order pharmacies for nearly all pharmacy attributes. Further, many participants felt specialty pharmacy mandates negatively impacted their medical care. Insurance payers should consider removing restrictive specialty pharmacy mandates for ART/PrEP prescriptions.

Disclosures
All Authors: No reported disclosures.
1017. Residual Infusion Performance Evaluation (RIPE): A Single-Center Evaluation of Residual Volume Post-Intravenous Eravacycline Infusion
Authors: Baumann Alysa J , Cleveland Kerry O , Gelfand Michael S , Perkins Nicholson B , Covington Angela D , Hobbs Athena L V 
Published: December 2022

Abstract

Background
Intravenous (IV) fluid manufacturers report an acceptable volume of overfill range for a 250 mL bag of normal saline from 265-285 mL. This overfill can contribute to residual drug that is not administered to patients. Frequent instances of incomplete eravacycline infusions were noticed by infectious disease providers.
Residual Eravacycline Volume Following IV Infusion

Methods
This single-center, retrospective, quasi-experimental study evaluated residual volume after the completion of IV eravacycline infusion in patients admitted during the pre-intervention period (July 1 – 30, 2021) vs. post-intervention period (November 1 – 30, 2021). The intervention (August 1 – October 31, 2021), consisted of updating drug labels to add the drug diluent to total volume and a comment in the administration section to “infuse at current rate until bag is empty.” Nursing education was provided to encourage administration of the entire drug volume. The primary outcome compared residual antibiotic volume before and after implementation of the intervention. The secondary outcomes evaluated amount of drug lost (total mg and percent of total dose) in the pre- and post-intervention periods and cost of facility drug waste.
Nursing Education Distributed During Intervention Period

Results
There was an average residual volume of 38.0 mL (range 6 – 85 mL) for pre-intervention (n=9, total of 46 doses) vs. 12.2 mL (range 0 – 37 mL) for the post-intervention (n=7, total of 21 doses) population (p&lt; 0.0001). Residual volume accounted for an average of 15.2% of the total bag volume compared to 4.7% for the pre- and post-intervention groups, respectively (p&lt; 0.0001). The pre-intervention residual volume contained an average of 13.5 mg (15.3% of total dose) of eravacycline, versus 4.7 mg (4.7% of total dose) in the post-intervention (p&lt; 0.0001). Cost analysis used average wholesale price for 50 mg vials. Residual volume in the pre-intervention period estimated $893.45 ($10,721.40 annualized) vs. $161.04 ($1,932.48 annualized) in the post-intervention period.
Pre- and Post-Intervention Comparison
Clinical Analysis of Residual Antibiotic Volume
Facility Waste

Conclusion
Average residual volume and amount of discarded drug was significantly reduced after the interventions. Following the results of this study, interventions were expanded to all admixed antimicrobials. Further studies are needed to determine the potential clinical impact when patients do not receive the complete antibiotic infusion due to residual volume.

Disclosures
Kerry O. Cleveland, MD, AbbVie: Honoraria|Cumberland: Honoraria|Merck: Honoraria|Pfizer: Honoraria Michael S. Gelfand, MD, AbbVie: Expert Testimony|La Jolla: Expert Testimony.
1018. Shifting Antimicrobial Practice to Minimize Length of Stay in Orthopedic Infections: Analysis from an Academic Tertiary Care Center
Authors: Stern Rebecca A , Wada Paul Y , Freiberg Jeffrey , Gibas Kevin , Cihlar Jennifer , Fiske Christina T , Wright Patty W , Staub Milner B 
Published: December 2022

Abstract

Background
Increased hospital length of stay (LOS) has been associated with increased rates of readmission, nosocomial infections, and cost during hospitalizations for orthopedic-related infections (HOIs). We hypothesized that Infectious Diseases (ID) consultation is associated with increased LOS for HOIs due to pending culture results delaying final recommendations. We assessed patient and care factors affecting LOS, including duration and timing of ID consultation, and identified process improvements to expedite discharge for HOIs.

Methods
We performed retrospective chart review of HOI admissions with ID consultation at Vanderbilt University Medical Center from May-August 2021. Differences in HOIs discharged &lt;1 vs. &gt;1 day after ID final recommendations were examined using Fisher’s exact, Chi-squared, and Wilcoxon rank sum testing. Clustering by patient for those with &gt;1 admission was performed. We used multivariable and propensity score weighted negative binomial regression models to estimate adjusted rate ratios (aRR) and 95% confidence intervals (CI) for number of days followed by an ID consultant and LOS.

Results
HOIs discharged &lt;1 day after ID final recommendations (69/105) had shorter median LOS (3 vs. 8 days, p&lt; 0.001) (Figure 1), more oral-only antibiotic regimens (41% vs. 17%, p=0.003), and more frequent discharge to home (91% vs. 53%, p&lt; 0.001). HOIs discharged &gt;1 day after ID final recommendations were more likely to undergo multiple surgeries (28% vs. 12%, p=0.019) and peripherally inserted central catheter (PICC) placement (69% vs. 43%, p=0.013). For each additional day of ID consultation, there was associated increase in LOS (multivariable aRR 1.12, 95% CI 1.02-1.23; weighted aRR 1.12, 95% CI 0.99-1.26). Figure 1.Length of Stay after ID Final Recommendations

Conclusion
ID consultation is unlikely to be the primary barrier to hospital discharge but may be a marker for more complicated HOIs and increased LOS. Most patients with prolonged stays were discharged &gt;1 day after ID final recommendations. Implementation of protocols to promote prompt ID consultation, streamline PICC placement, and coordinate outpatient intravenous antibiotics may accelerate transitions of care and discharges.

Disclosures
Milner B. Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds.