Final Culture Results Research Articles

Diagnostic Stewardship Opportunities for Emergency Department Evaluation of Children with Suspected Urinary Tract Infection

Background: Among children who start antibiotics for suspected urinary tract infection (UTI) in emergency departments (EDs), 40-60% have negative urine cultures or other results inconsistent with UTI. Practices contributing to excess antibiotic exposure are not well understood. The goal of this study was to understand diagnostic and post-encounter follow-up processes in children who received antibiotics, in order to define targets for intervention. Methods: We identified encounters by children evaluated in two pediatric EDs, over 2 months in the first ED and 9 months in the second ED, to balance different visit volumes. Children 2 months-17 years old were included if they had a urinalysis (UA) and/or urine culture performed, were assigned a primary or secondary diagnosis code for UTI, and initiated antibiotics. Patients were excluded if they received antibiotics prior to the encounter, had prior urologic surgery or device placement, or were immunocompromised or pregnant. Data abstracted by chart review included demographics, documented symptoms, test results, and documented urine culture review and management. Possible UTI symptoms per pediatric criteria included fever, dysuria, urinary frequency, urgency, or hesitancy, suprapubic, abdominal or flank pain, foul smelling urine, or new urinary incontinence. In both EDs, nurses review urine cultures and document changes to treatment plans. Final urine culture results were considered inconsistent with UTI if there was 1) no growth or 2) only mixed growth reported with quantity < 1 00,000 colony forming units/ml. Results: Of 150 eligible children, 146 (97%) had at least one UTI symptom and 146 (97%) had abnormal UA Results: Urine cultures were not performed in 27 (18%) children. Of 123 encounters with urine cultures performed, 71 (58%) had results inconsistent with UTI. Though 67/71 cultures were marked as reviewed, 43/67 (64%) of the patients who could have stopped antibiotics per guideline recommendations did not have documented plans to stop. In those who had documented plans to stop antibiotics, nurses reached 20/23 (87%) caregivers by phone to communicate these recommendations. Conclusion: Many children suspected to have UTI at the time of ED evaluation do not meet criteria for UTI. We found that the most frequent departures from evidence-based practice recommendations were 1) not sending urine cultures, and 2) not stopping antibiotics when culture results did not support the suspected UTI diagnosis. Further investigation should explore barriers and facilitators to these evidence-based practices to develop population- and context-specific diagnostic stewardship strategies.

The potential role of through the needle PIVC insertion in reducing early catheter contamination.

Over-the-needle (OTN) PIVC devices are at inherent risk of insertion related skin contamination. Through-the-needle (TTN) catheter deployment resulted in no measurable contamination in this study. OTN catheters were 1.67 times more likely to be contaminated than TTN in this study. To compare a traditional over-the-needle peripheral intravenous catheter device to a through-the-needle (TTN) peripheral intravenous catheter device for early bacterial contamination during insertion. Five TTN test devices (OspreyIV 20 g SkyDance Vascular, Inc) and 5 OTN comparative devices (Insyte Autoguard 20 g Becton Dickinson) were aseptically inserted through targeted zones inoculated with 1 mL aliquot suspension of approximately 1 × 10 CFU of Staphylococcus aureus among 3 healthy sheep. Immediately after insertion, each study catheter was surgically removed from the surrounding tissue and cultured for the presence of Staphylococcus aureus inoculum that may have been transferred to the catheter during insertion. Final culture results of the 5 test articles found no bacterial colonies. Final culture results of the 5 comparative articles revealed 2 of 5 were contaminated with bacterial colonies. The absolute risk reduction is 40%, or a 40% rate of contamination drops to a 0% rate of contamination when the TTN catheter deployment was used. The risk ratio achieved was 1.67, indicating catheters placed using the OTN deployment were 1.67 times more like to be contaminated than the TTN deployed catheters. In this present ovine study, the data revealed that use of a novel TTN approach resulted in less contamination than the more traditional OTN approach. Traditional OTN devices, developed over 70 years ago, are at inherent risk of insertion-related contact contamination. The results of this research, as well as previously published studies, point toward considering physical catheter protection strategies such as TTN devices as a potential alternative to OTN devices.

Evaluating the impact of emergency department clinical pharmacist integration within a discharge urine culture follow‐up program

AbstractIntroductionPatients are often discharged from the emergency department (ED) prior to final culture results, leading to the development of post‐ED discharge urine culture review programs (UCRPs) to ensure appropriate management. The purpose of this study was to evaluate the impact ED pharmacists have on antibiotic management and determine areas for improved antimicrobial stewardship efforts.MethodsThis was a single‐system, retrospective, quasi‐experimental study of patients who visited the ED for evaluation of a urinary tract infection comparing no pharmacist involvement in a culture review to a process when ED pharmacists were involved. Patients included those discharged from the ED requiring review under a UCRP. Incarcerated patients and those admitted to an inpatient service from the ED were excluded. The primary outcome was the receipt of guideline‐appropriate management. Secondary outcomes included unplanned admission or ED revisit within 14 and 30 days related to the initial ED visit, all‐cause hospital admission or ED revisit within 14 and 30 days, and acceptance rate of pharmacist recommendations.ResultsA total of 142 patients were included (before pharmacist integration = 70, after pharmacist integration = 72). Receipt of guideline‐appropriate management occurred at 33% without pharmacist integration and 85% in the arm with pharmacist integration, p < 0.001. Pharmacist recommendations were accepted in 97% of cases. No difference was noted between ED revisit within 14 and 30 days with a chief complaint directly related to the initial ED visit, 14 and 30 day admission related to the initial encounter, and all‐cause hospital admission or ED revisit within 14 and 30 days. In patients with asymptomatic bacteriuria, there was a higher receipt of inappropriate management 67% (20/30) in the time before pharmacist integration versus 19% (9/48) after pharmacist integration (p < 0.001).ConclusionThere was a significantly higher number of patients with appropriate antimicrobial management after pharmacist involvement in UCRP review.

Will Preoperative Synovial Fluid Antigen Testing Change Our Clinical Practice?

Commentary In their article, Toler et al. evaluated the diagnostic performance of a recently launched synovial fluid antigen test for the preoperative diagnosis of periprosthetic joint infection (PJI). The test is of great interest because identifying the causative microorganism prior to the surgical procedure is important in guiding surgical decision-making and starting targeted antimicrobial treatment as soon as possible. Toler et al. demonstrated a high concordance between synovial fluid culture and the antigen test. Moreover, in culture-negative synovial fluids, the test identified a microorganism in 49% of cases. However, from a clinical point of view, there are important limitations that should be taken into consideration. With regard to how the test will guide antibiotic treatment, the following shortcomings should be taken into account. A limited number of species (i.e., Staphylococcus, Enterococcus, and Candida species) are included in the test, as noted in the article, and it is important to keep in mind that the reference test used to calculate the diagnostic accuracy was a positive synovial fluid culture for the included species. A comparison with intraoperative tissue cultures was not performed, and, because the sensitivity of synovial culture is poor, an infection cannot be ruled out in the case of a negative antigen test. Therefore, empirical antibiotic treatment should still be administered in the case of a negative antigen test when a PJI is suspected. In the case of a positive test, it is important to realize that, in addition to the inclusion of a limited number of species that can be detected, the test only identifies species on a genus level. Because the antibiotic treatments for methicillin-sensitive staphylococci compared with methicillin-resistant staphylococci and for Enterococcus faecalis compared with Enterococcus faecium are different, their identification on a genus level cannot fully target antibiotic treatment. Other tests that overcome this limitation are available, such as the recently launched multiplex polymerase chain reaction (PCR) for bone and joint infections1. The BioFire Joint Infection PCR Panel provides a rapid diagnosis (i.e., within 1 hour), includes more genera and identifies pathogens on a species level, and detects resistance genes, which may better guide antimicrobial treatment1. Also, other microorganisms not detected by the PCR test may be involved. According to the literature, around 30% to 40% of PJIs are polymicrobial in nature, with an even higher incidence observed in early postoperative and chronic infections with a sinus tract2,3. Consequently, empirical antibiotic treatment cannot be easily narrowed in the case of a positive antigen test either. With regard to how the test will help us in surgical decision-making, some experts in the field have advocated a 2-stage exchange instead of 1-stage exchange for PJI caused by difficult-to-treat microorganisms such as enterococci and Candida4,5. Therefore, isolating these species prior to the surgical procedure may guide surgical decision-making. However, in the total cohort in the study by Toler et al., Candida species already grew on synovial fluid culture in 338 cases and Enterococcus species grew on culture in 465 cases. More rapid identification that the antigen provides is not needed in chronic infections, as one has time to wait for the final culture results. In the remaining preoperative samples with negative synovial fluid cultures, the antigen test detected Candida in an additional 142 cases and enterococci in an additional 188 cases. If these extra cases were to be considered to represent real infections, rather than false-positives as stated by Toler et al., only 0.3% of candidal infections and 0.4% of enterococcal infections from the total cohort of patients will have been missed when solely relying on preoperative cultures of synovial fluid. This low percentage of missed infections makes one wonder whether the number needed to test is really justified. Last but not least, Toler et al. analyze their results according to whether the preoperative diagnosis, according to the 2018 International Consensus Meeting, was positive or negative, but the inconclusive cases (7.5% of the total cohort) are not included in the final analysis, although these are the cases that are most clinically challenging. Based on the above-mentioned limitations and the way that the results are analyzed, it seems that the evaluated antigen test will not change our daily clinical practice in a large number of cases. Additional analyses, particularly comparisons with the final postoperative diagnosis and intraoperative culture results, are needed to define the role of this test in the diagnostic workup.

The Potential Role of through the Needle PIVC Insertion in Reducing Early Catheter Contamination

HighlightsAbstractAim:To compare a traditional over-the-needle peripheral intravenous catheter device to a through-the-needle (TTN) peripheral intravenous catheter device for early bacterial contamination during insertion.Methods:Five TTN test devices (OspreyIV 20g SkyDance Vascular, Inc) and 5 OTN comparative devices (Insyte Autoguard 20g Becton Dickinson) were aseptically inserted through targeted zones inoculated with 1 mL aliquot suspension of approximately 1 × 10 CFU of Staphylococcus aureus among 3 healthy sheep. Immediately after insertion, each study catheter was surgically removed from the surrounding tissue and cultured for the presence of Staphylococcus aureus inoculum that may have been transferred to the catheter during insertion.Results:Final culture results of the 5 test articles found no bacterial colonies. Final culture results of the 5 comparative articles revealed 2 of 5 were contaminated with bacterial colonies. The absolute risk reduction is 40%, or a 40% rate of contamination drops to a 0% rate of contamination when the TTN catheter deployment was used. The risk ratio achieved was 1.67, indicating catheters placed using the OTN deployment were 1.67 times more like to be contaminated than the TTN deployed catheters.Conclusion:In this present ovine study, the data revealed that use of a novel TTN approach resulted in less contamination than the more traditional OTN approach. Traditional OTN devices, developed over 70 years ago, are at inherent risk of insertion-related contact contamination. The results of this research, as well as previously published studies, point toward considering physical catheter protection strategies such as TTN devices as a potential alternative to OTN devices.

Opportunities for Antibiotic Reduction in Pediatric Patients With Urinary Tract Infection After Discharge From the Emergency Department.

The aim of this study was to evaluate how often antibiotics are adjusted by providers, specifically discontinued or de-escalated to a more narrow-spectrum agent, based on final culture and susceptibility results, when treating patients diagnosed with a urinary tract infection (UTI) in the pediatric emergency department (ED). This was a retrospective study of pediatric patients younger than 18 years who were discharged home from the ED with a diagnosis of UTI between January 1, 2018, and December 31, 2019. Patients were included if a urine culture was sent as part of their UTI workup and were excluded if they had been pretreated with antibiotics before the diagnosis. Discontinuation was considered possible if the urine culture had no or insignificant bacterial growth. De-escalation was defined as changing to a more narrow-spectrum antibiotic based on susceptibility testing. Empiric antibiotics were prescribed in 131 of 136 UTI episodes. Cefdinir (39%) and cephalexin (36%) were most commonly prescribed, but agents and durations were inconsistent. Discontinuation occurred in only 4 of 52 possible episodes (8%), resulting in a median of 6 extra days of unnecessary antibiotics per episode. For 62 of the 78 cases (79%) with culture confirmation, the prescribed empiric antibiotic was active against the isolated pathogen. A narrower agent could have been used in 29 of 62 (47%) of these cases. However, de-escalation was never attempted. Lack of de-escalation in these episodes resulted in a median of 7 extra days of unnecessary broad-spectrum antibiotic exposure. Inconsistent empiric antibiotics and inaccurate diagnosis result in excess antibiotic exposures for pediatric patients diagnosed with UTI. Postdischarge antimicrobial stewardship interventions are needed to reduce unnecessary antibiotic exposure in children.

Clinical characteristics and risk factors for visual prognosis according to the types of infectious endophthalmitis.

Endophthalmitis is a fatal ophthalmological emergency that needs prompt diagnosis and treatment. This study aimed to evaluate the clinical characteristics and investigate risk factors for the visual prognosis of the different types of endophthalmitis. This retrospective study included 239 eyes diagnosed with endophthalmitis at the Pusan National University Hospital between January 2006 and December 2020. All patients were classified into six groups based on the etiology of endophthalmitis: post-cataract surgery, post-vitrectomy, post-glaucoma surgery, post-intravitreal injection, endogenous, and post-trauma. Demographics and clinical characteristics such as age, sex, laterality, initial symptoms, the interval between the primary causable event and diagnosis of endophthalmitis, initial and final visual acuity, management, and culture results were reviewed and statistically analyzed. Risk factors for poor visual prognosis were also analyzed according to the type of endophthalmitis. Of the 239 cases of endophthalmitis, the most common cause was post-cataract surgery, that occurs within two weeks post-surgery. Gram-positive Staphylococcus was cultured most frequently. Fusarium was characteristically cultured from delayed post-cataract surgery endophthalmitis (14 days-6 weeks post-surgery). Post-vitrectomy endophthalmitis occurred within 3.3 days post-surgery, but post-glaucoma surgery endophthalmitis developed a long period after surgery, averaging 2,742 days. Post-intravitreal injection endophthalmitis occurred most frequently following bevacizumab injection, and Staphylococcus was most commonly isolated. For endogenous endophthalmitis, the pyogenic liver abscess was the most common underlying disease, and Klebsiella was isolated most frequently. Post-traumatic endophthalmitis mostly occurred in young men. Advanced age and poor initial visual acuity were risk factors for poor visual prognosis (P = 0.041, odds ratio = 1.024 and P < 0.001, odds ratio = 3.904, respectively, using logistic regression analysis). Advanced age and initial visual acuity were risk factors for poor visual prognosis in cases of endophthalmitis caused by various etiologies. Early diagnosis and treatment of endophthalmitis are required, especially in older patients.

Little Utility of Fungal Blood Cultures in Surgical and Burn Intensive Care Units.

ABSTRACTCritically ill patients are at risk for fungal infections, but there is a paucity of data regarding the clinical utility of dedicated fungal blood cultures to detect such infections. A retrospective review was conducted of patients admitted to the surgical and burn intensive care units at Parkland Memorial Hospital between 1 January 2013 and 31 December 2017 for whom blood cultures (aerobic, anaerobic, and/or fungal cultures) were sent. A total of 1,094 aerobic and anaerobic blood culture sets and 523 fungal blood cultures were sent. Of the aerobic and anaerobic culture sets, 42/1,094 (3.8%) were positive for fungal growth. All fungal species cultured were Candida. Of the fungal blood cultures, 4/523 (0.76%) were positive for growth. Fungal species isolated included Candida albicans, Aspergillus fumigatus, and Histoplasma capsulatum. All 4 patients with positive fungal blood cultures were on empirical antifungal therapy prior to results, and the antifungal regimen was changed for 1 patient based on culture data. The average duration to final fungal culture result was 46 days, while the time to preliminary results varied dramatically. Two of the four patients died prior to fungal culture results, thereby rendering the culture data inconsequential in patient care decisions. This study demonstrates that regular aerobic and anaerobic blood cultures sets are sufficient in detecting the most common causes of fungemia and that results from fungal cultures rarely impact treatment management decisions in patients in surgical and burn intensive care units. There is little clinical utility to routine fungal cultures in this patient population.IMPORTANCE This study demonstrates that regular aerobic and anaerobic blood culture sets are sufficient in detecting the most common causes of fungemia, and thus, sending fungal blood cultures for patients in surgical and burn intensive care units is not a good use of resources.

A RARE CASE OF DISSEMINATED BLASTOMYCOSIS IN IMMUNOCOMPETENT PATIENT COMPLICATED BY SUPERIOR MESENTERIC ARTERY SYNDROME

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Blastomycosis is a fungal infection, endemic to the Mississippi and Ohio River valleys. Here we report a case of disseminated blastomycosis in an immunocompetent patient with severe systemic symptoms but delayed diagnosis resulting in superior mesenteric artery syndrome (SMA) CASE PRESENTATION: A 25-year-old male presented with 3 months of intense lower back pain that progressively worsened and a 35lbs unintentional weight loss. He had been previously evaluated at an outside hospital and discharged on pain regimen with no improvement. CT Chest AP demonstrated fine miliary nodules on bilateral lungs, multiple paravertebral abscesses, osteolytic lesions throughout the axial skeleton, and most surprisingly, an incidental finding of dilation of the descending and transverse portions of the duodenum. Initial AFB smear, HIV, hepatitis, and other immunodeficiency workup was unremarkable. Patient underwent IR guided abscess aspiration of paravertebral abscess with a final culture result of BLASTOMYCES DERMATITIDIS. General Surgery was consulted due to the abnormal upper GI findings, a final diagnosis of SMA syndrome due to significant and fast weight loss from systemic disease was made. The patient ultimately required a loop duodenojejunostomy to bypass the obstruction. DISCUSSION: SMA syndrome is an uncommon cause of Upper GI obstruction, to our knowledge, this is the first case reported in association with disseminated blastomycosis. Our patient was started on Amphotericin B and later transitioned to Itraconazole long-term with marked improvement of symptoms. CONCLUSIONS: A high degree of suspicion and prompt diagnosis for blastomycosis is important, particularly in immunocompetent patients. Delayed diagnosis might represent significant morbidity such as in our patient. DISCLOSURE: Nothing to declare. KEYWORD: blastomycosis

Antimicrobial resistance in Escherichia coli and Pseudomonas aeruginosa before and after the coronavirus disease 2019 (COVID-19) pandemic in the Dominican Republic.

To describe antimicrobial resistance before and after the COVID-19 pandemic in the Dominican Republic. Retrospective study. The study included 49 outpatient laboratory sites located in 13 cities nationwide. Patients seeking ambulatory microbiology testing for urine and bodily fluids. We reviewed antimicrobial susceptibility reports for Escherichia coli isolates from urine and Pseudomonas aeruginosa (PSAR) from bodily fluids between January 1, 2018, to December 31, 2021, from deidentified susceptibility data extracted from final culture results. In total, 27,718 urine cultures with E. coli and 2,111 bodily fluid cultures with PSAR were included in the analysis. On average, resistance to ceftriaxone was present in 25.19% of E. coli isolated from urine each year. The carbapenem resistance rates were 0.15% for E. coli and 3.08% for PSAR annually. The average rates of E. coli with phenotypic resistance consistent with possible extended-spectrum β-lactamase (ESBL) in urine were 25.63% and 24.75%, respectively, before and after the COVID-19 pandemic. The carbapenem resistance rates in urine were 0.11% and 0.20%, respectively, a 200% increase. The average rates of PSAR with carbapenem resistance in bodily fluid were 2.33% and 3.84% before and after the COVID-19 pandemic, respectively, a 130% percent increase. Resistance to carbapenems in PSAR and E. coli after the COVID-19 pandemic is rising. These resistance patterns suggest that ESBL is common in the Dominican Republic. Carbapenem resistance was uncommon but increased after the COVID-19 pandemic.

Effectiveness of an Electronic Automated Antibiotic Time Out Alert in the Setting of Gram-Negative Bacteremia.

To minimize complications associated with over-utilization of antibiotics, many antimicrobial stewardship programs have incorporated an antibiotic time out (ATO); however, limited data are available to support its effectiveness. This was a single-center retrospective cohort study assessing the impact of the automated electronic ATO in the setting of Gram-negative bacteremia. The primary outcome was the proportion of patients who received a modification of therapy within 24 h of final culture results. Secondary outcomes included modification at any point in therapy, time to modification of therapy, time to de-escalation, and days of therapy of broad-spectrum antibiotics. There was a total of 222 patients who met inclusion criteria, 97 patients pre-ATO and 125 patients post-ATO. The primary outcome of modification of therapy within 24 h of final culture results was not significantly different (24% vs. 30%, p = 0.33). The secondary outcome of modification of therapy at any point in therapy was not significantly different between the two groups (65% vs. 67%, p = 0.73). All other secondary outcomes were not significantly different. The ATO alert was not associated with a higher rate of antibiotic modification within 24 h of culture results in patients with GNB. Further efforts are needed to optimize the ATO strategy and antibiotic prescribing practices.

Influence of microbiological culture results on antibiotic choices for veterans with hospital-acquired pneumonia and ventilator-associated pneumonia.

We examined the impact of microbiological results from respiratory samples on choice of antibiotic therapy in patients treated for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP). Four-year retrospective study. Veterans' Health Administration (VHA). VHA patients hospitalized with HAP or VAP and with respiratory cultures between October 1, 2014, and September 30, 2018. We compared patients with positive and negative respiratory culture results, assessing changes in antibiotic class and Antibiotic Spectrum Index (ASI) from the day of sample collection (day 0) through day 7. Between October 1, 2014, and September 30, 2018, we identified 5,086 patients with HAP/VAP: 2,952 with positive culture results and 2,134 with negative culture results. All-cause 30-day mortality was 21% for both groups. The mean time from respiratory sample receipt in the laboratory to final respiratory culture result was longer for those with positive (2.9 ± 1.3 days) compared to negative results (2.5 ± 1.3 days; P < .001). The most common pathogens were Staphylococcus aureus and Pseudomonas aeruginosa. Vancomycin and β-lactam/β-lactamase inhibitors were the most commonly prescribed agents. The decrease in the median ASI from 13 to 8 between days 0 and 6 was similar among patients with positive and negative respiratory cultures. Patients with negative cultures were more likely to be off antibiotics from day 3 onward. The results of respiratory cultures had only a small influence on antibiotics used during the treatment of HAP/VAP. The decrease in ASI for both groups suggests the integration of antibiotic stewardship principles, including de-escalation, into the care of patients with HAP/VAP.

Study of the effect of added bronchoscopic suction to routine treatment of ventilator associated pneumonia patients in surgical ICU.

Comparing BAL and antibiotic therapy with antibiotic therapy itself for treating VAP patients in ICU. In this randomized clinical trial, the first group was treated using antibiotics and closed-suction was performed daily, using 50 cc of sterile normal saline. The second group was treated with antibiotics and daily closed-suction with 50 cc of sterile normal saline, plus bronchoscopic suction every other day. Patients of both groups were followed and investigated one, 3, 7, and 10 days after initial diagnosis. Mean blood leukocyte count and body temperature was measured in groups one (no bronchoscopy) and two (with bronchoscopy) in first, 3rd, 7th, and 10th days which was higher in the second group. Mean treatment status was also measured using APACHE II index. There was also a statistically significant difference in 3rd day (p-value < 0.05). There was also no difference in final culture result or mortality rate between two groups. According to the results of this study like lower body temperature, higher leukocyte count reduction, and lower APACHE II scores in the second group, treated with bronchoscopic suction, adding bronchoscopy seems to be more useful than normal method.

Implementing an Electronic Screening Tool to Identify Patients at Risk for Candida auris

Background:Candida auris is an emerging fungus that presents a serious threat to healthcare facilities. Because Chicago is a locus of high prevalence, the Illinois Department of Public Health (IDPH) released guidelines for acute-care hospitals to screen and isolate patients who are directly admitted from either a skilled nursing or long-term acute-care facility (SNF or LTAC) with a tracheostomy or on a ventilator. This project was undertaken to evaluate applicability of IDPH criteria to our inpatient population and to develop effective tools to implement a surveillance system. Methods: To assess IDPH criteria, we reviewed local case epidemiology and conducted a point-prevalence survey of all inpatients on May 22, 2019. To implement a new surveillance program, we convened a multidisciplinary team to assess the functionality of the electronic health record (EHR), to create clinician education, and to develop new electronic tools. Results: Between June 2018 and August 2019, 20 unique C. auris patients were admitted to our facility, and only 2 (10%) met IDPH criteria. During the point-prevalence survey, 609 inpatients were assessed, and only 7 (1%) met IDPH criteria (Table 1). Therefore, we created a new surveillance program tailored to our local epidemiology. To do this, we convened a multidisciplinary team with representatives from infection prevention, nursing informatics, patient care, microbiology and information technology (IT). The IT build took 5 months, and the work products included a screening questionnaire integrated into the nurse admission navigator, new microbiology laboratory orders for C. auris culture, a new internal isolation category that we deemed prior location-based isolation (PLI), and an electronic report to automatically aggregate data. To streamline workflow, best-practice alerts (BPAs) were designed to automatically order isolation and laboratory tests based on responses to the admission questionnaire (Fig. 1). Additionally, tools were created catch missed opportunities for isolation and to automatically update isolation status based on final culture results. Conclusions: Local epidemiology must be considered when designing C. auris surveillance programs. Stakeholder engagement and informatics were key to successful program implementation. The EHR must be nimble to address updated recommendations for organisms of concern. Data must be continuously evaluated to measure success of a targeted screening and surveillance program.Funding: NoneDisclosures: None

Prospective evaluating the appropriate use of piperacillin /tazobactam in cardiac center of a tertiary care hospital

BackgroundThe appropriate use of Piperacillin/Tazobactam (Pip/Taz), including the correct dose, escalating and or de-escalation according to the microbiological culture is essential to reduce the antibiotic resistance. Resistant to antimicrobials in a major global problem and contributes significantly to morbidity, mortality and cost of care. Guidelines exists to ensure appropriate use of Pip/Taz. Antibiotics Stewardship guidelines (https://apps.who.int/iris/bitstream/handle/10665/329404/9789241515481-eng.pdf) provides a detailed recommendation with regards to initiation, monitoring and escalation and de-escalation based on final culture results. Appling such guidelines ensures a more proper utilization of the empiric uses of antibiotics used in the hospital-based setting. Use of Pip/Taz in cases of suspected infection postoperatively is common practice in the cardiac surgery ward where this study was conducted.MethodsThis was a prospective cohort study involving all patients who were admitted to the cardiac surgery unit of a tertiary care center. All patient prescribed at least 1 day of Pip/Taz as an empirical therapy were included and prospectively observed. We aimed to evaluate the use of Pip/Taz and its appropriateness based on Antibiotics Stewardship guidelines (ASG). Any deviation from the guidelines in initiation, escalation, de-escalation based on culture and sensitivity results was considered inappropriate use. Four patients died (1.3%) early as result of complications for surgery but included in the analysis. The study was conducted from October 2017 to October 2018.ResultsOf the 300 patients who received Pip/Taz Cultures were done in 250 patients (83%). The overall appropriate use of Pip/Taz was seen in 166 patients (55.3%).ConclusionThe empirical use of Pip/Taz in the surgical cardiac unit was largely inappropriate and not entirely driven by the culture test results. Interventions are needed to optimize the use of Pip/Taz including appropriate culture and sensitivity driven use and timely de-escalation or de-escalation when indicated. This will prevent emergence of resistance and reduce the patient toxicity and financial costs.

Rapid Detection of Airway Pathogens in Lung Transplant Donors

Final culture results are often unavailable at the time of donor organ offers, despite their importance in the evaluation of donor organ quality. We hypothesized that a rapid multiplex molecular assay could improve time to results and facilitate treatment initiation in the donors prior to organ recovery. The "Rapid Detection of Airway Pathogens for Lung Transplantation" trial (NCT03933878) is a prospective observational clinical trial investigating the efficiency and accuracy of the BioFire Pneumonia Panel in the context of donor bronchoscopy. This assay tests the presence and/or quantity for 26 common airway pathogens in 2 hours. Bronchoalveolar lavagewas collected from brain dead donors at the time of lung procurement. Molecular assay results were compared to standard of care cultures. Time to result between molecular assay and standard of care was compared by Wilcoxon signed-rank test. Agreement between assays was assessed by Cohen's kappa. A total of 35 donor samples were included. From the time of sample collection to time to result, the median time was 7.01 hours [6.59-9.18] versus 57.7 hours [44.6-72.6] (p <0.001) for the molecular and standard of care assay results, respectively. Molecular assays detected bacterial pathogens in 21 cases (60%) and viruses in 2 cases (6%), versus 57% and 3% for standard of care assays, respectively. The agreement between assays for bacteria was 0.82 (p <0.001) and 0.65 (p <0.001) for viruses. Molecular detection of lower respiratory pathogens significantly reduces the time to result while maintaining agreement with standard of care clinical cultures in the context of candidate lung allografts. Such data could inform quality assessment and facilitate timely donor management prior to organ recovery.

Clinical Response to Discordant Therapy in Third-Generation Cephalosporin-Resistant UTIs

To describe the initial clinical response and care escalation needs for children with urinary tract infections (UTIs) resistant to third-generation cephalosporins while on discordant antibiotics. We performed a retrospective study of children <18 years old presenting to an acute care setting of 5 children's hospitals and a large managed care organization from 2012 to 2017 with third-generation cephalosporin-resistant UTIs (defined as the growth of ≥50 000 colony-forming units per mL of Escherichia coli or Klebsiella spp. nonsusceptible to ceftriaxone with a positive urinalysis). We included children started on discordant antibiotics who had follow-up when culture susceptibilities resulted. Outcomes were escalation of care (emergency department visit, hospital admission, or ICU transfer while on discordant therapy) and clinical response at follow-up (classified as improved or not improved). Of the 316 children included, 78% were girls and the median age was 2.4 years (interquartile range 0.6-6.5). Children were evaluated in the emergency department (56%) or clinic (43%), and 90% were started on a cephalosporin. A total of 7 of 316 children (2.2%; 95% confidence interval 0.8%-4.5%) experienced escalation of care. For the 230 children (73%) with clinical response recorded, 192 of 230 (83.5%; 95% confidence interval 78.0%-88.0%) experienced clinical improvement. In children with repeat urine testing while on discordant therapy, pyuria improved or resolved in 16 of 19 (84%) and urine cultures sterilized in 11 of 17 (65%). Most children with third-generation cephalosporin-resistant UTIs started on discordant antibiotics experienced initial clinical improvement, and few required escalation of care. Our findings suggest that narrow-spectrum empiric therapy is appropriate while awaiting final urine culture results.

Results of duodenoscope culture and quarantine after manufacturer-recommended cleaning process

Outbreaks of infections transmitted by duodenoscopes have prompted changes to duodenoscope cleaning protocols. However, little is known about effectiveness of clinical cleaning practices. We present culture data after duodenoscope manufacturer-recommended high-level disinfection (HLD) and quarantine. Our institution adopted a combination of manufacturer-recommended cleaning with the Centers for Disease Control and Prevention-recommended culture and quarantine in 2015. Duodenoscopes (models TJF-Q180V, TJF-160, and PJF-160; Olympus, Center Valley, Penn, USA) underwent HLD according to the manufacturer's reprocessing manual protocols after use. Two culture specimens were then obtained using a sterile brush from the distal tip, including elevator mechanism, and by flushing sterile water through the working channel. Duodenoscopes were quarantined until cultures resulted. Positive cultures were defined as >10 colony-forming units (CFUs) of low-concern organisms or any CFUs of high-concern organisms according to Centers for Disease Control and Prevention recommendations. If either culture specimen was positive, the process was repeated until cultures were negative. Data were collected from December 2015 to July2018. There were 140 instances of duodenoscope cleaning with 280 specimens. Twenty-eight of 234 (12%) initial culture specimens (18% of cultured duodenoscopes) were positive. Five of 36 (14%) second cultures were positive. Two of 8 (25%) third cultures were positive. Ninety-eight percent of organisms cultured were gram positive. In 8 instances both culture methods (brushing and flush) were positive; otherwise, only 1 method was positive. In 11 instances (8%) duodenoscopes were removed from quarantine before final culture results. No patient had infections related to ERCP. Eighteen percent of duodenoscopes had a positive culture after initial HLD. Only 3% were gram-negative bacteria. Repeated HLD was 86% and 75% effective at eliminating initial and repeat positive cultures, respectively. Initial HLD per manufacturer recommendations is not always effective at eliminating bacterial contamination. Additional steps are necessary to decrease risks of duodenoscope-transmitted infections.

Listeria Monocytogenes Prosthetic Joint Infection, Case Report and Review of the Literature

Background: Listeria monocytogenes causes bacteraemia in elderly and immunocompromised patients and rarely also in immunocompetent patients. In sporadic setting it can be challenging to diagnose. We present the first case of Listeria monocytogenes infection presenting as an acute infection of a prosthetic joint in an immunocompetent patient. Case summary: An immunocompetent patient presented with acute onset of right hip pain lasting for 3 days. The day before admission the patient had fever of 38.5°C and chills. The patient admitted having eaten raw meat some days prior to onset of symptoms. He had a prosthetic right hip implanted due to secondary arthritis 9 months prior to onset of hip symptoms. He was treated successfully with removal of mobile parts and appropriate antibiotic treatment. Conclusion: Sporadic focal infections with Listeria monocytogenes occur rarely and are often not diagnosed until the arrival of final culture results. Dietary history is also important when clinical history of patients is taken. Food consumption advice is important in immunocompromised, but also immunocompetent patients can get infected when eating raw food. Accurate diagnosis for orthopaedic samples is crucial. In order to successfully treat patients with a prosthetic joint infection, a tight collaboration between several specialists is needed.

2001. Assessment of Real-world Effectiveness of a Rapid Blood Culture Diagnostic Panel at a Veterans Affairs Medical Center

BackgroundRapid blood culture diagnostics can improve patient outcomes, particularly when paired with robust interventions such as 24/7 stewardship coverage. We sought to determine the clinical impact of a rapid blood culture identification (BCID) panel (BioFire® FilmArray Multiplex PCR) in an established antimicrobial stewardship program (ASP). In addition to clinician education, BCID results were reviewed by the ASP team during weekday business hours, for an average of 2 hours daily based on availability.MethodsData on demographics, blood cultures, antimicrobial use, length of stay and mortality were collected on inpatients at the VA North Texas Health Care System with at least one positive blood culture for bacterial or yeast isolates from March 2017 to June 2017 (pre-BCID) and from March 2018 to June 2018 (post-BCID). The primary outcome was a composite of time to optimal therapy from blood culture collection, defined as escalation, de-escalation, discontinuation, or optimization of antimicrobials retrospectively adjudicated based on final culture results. Secondary outcomes included time to effective therapy, total days of therapy (DOT), length of stay, and 30-day mortality and readmission rates.Results195 patients were screened with 130 patients included in the study. No significant differences in baseline characteristics were observed between groups (Table 1). Sixty-one patients were included in the pre-BCID arm and 69 in the post-BCID arm. Median time to optimal therapy was 82.9 hours (IQR; 12.8–99.8) in the pre-BCID arm and 33.9 hours (IQR; 11.2–64.8) in the post-BCID arm (P = 0.005) (Table 2). No significant change in 30-day mortality or 30-day readmission rates was noted. Vancomycin DOT was 4 days (IQR; 2–5) and 3 days (IQR; 1–4) (P = 0.024), and piperacillin–tazobactam DOT was 4 (IQR; 0–5) and 2 (IQR; 0–4) (P = 0.043), in the pre-BCID and post-BCID groups, respectively (Figure 1).ConclusionIntroduction of BCID into the daily workflow of our ASP resulted in a significant reduction in time to optimal therapy for bloodstream infections. DOT for select broad-spectrum antibiotics were also significantly reduced. This study highlights the potential benefit of rapid diagnostics without negative impact to patient care even in settings without resources for 24/7 ASP review. Disclosures All authors: No reported disclosures.