Infectious Disease Physicians Research Articles

Telemedicine Offers Solutions for the Rural Disparities in Infectious Disease (ID) Care Delivery

Abstract In the US, there is a growing shortage of infectious diseases (ID) physicians that highlights disparity between rural versus urban ID expertise resulting in a healthcare gap with significant consequences for patients unable to have ID directed care available to them. Telemedicine is a crucial modality of healthcare that can be used to bridge that gap by providing quality care consistent with outcomes for inpatient ID service models, while also serving as a tool for much greater geographic coverage by a single ID physician. As a specialty, we must embrace telemedicine for the good of our patients, whose local communities may not have access to ID care, and to create the incentive of broader community impact for potential entrants into the ID field.

P-2168. The Intervention of Infectious Diseases Physicians Might Enhance the Value of Broad-Range 16S rRNA Gene Polymerase Chain Reaction in the Clinical Aspect

Abstract Background Evaluation of Broad-Range 16S rRNA gene polymerase chain reaction (BRPCR) has been reported to aim in diagnosing infection by detecting and identifying bacterial genes in clinical specimens from patients with suspected infections. However, collecting the right specimens at the right time and determining whether the bacteria detected by BRPCR are the true cause or contamination requires infectious disease expertise. We investigate whether there is an association between the detection of bacteria that caused infection using BRPCR and intervention by Infectious Diseases (ID) physicians. Methods We reviewed the patients who underwent BRPCR at Osaka City General Hospital between April 2017 and March 2024. The collected items are age, sex, bacteria detected by BRPCR, determination of whether the bacteria if detected, caused infection, or were contaminated, and with or without the intervention of ID physicians (consultation to ID physicians). Then we analyzed the correlation between the intervention of ID physicians and the identification of the bacteria that caused the infection by BRPCR using Fisher's exact test. We also investigated whether the BRPCR results had affected the final diagnosis. Results There was a total of 149 clinical specimens from 138 patients. Of these, 84 (60%) were male, with a median age of 48 years (IQR 6-72). Bacteria were identified in 101 (67.7%) clinical specimens. In 70 specimens of them, the identified bacteria were presumed to have caused the infection. Of the 70 specimens, 56 had interventions by ID physicians. Whereas there were 79 specimens in which bacteria were identified but were presumed to be contaminants, and in which bacteria were not identified, of which 49 had intervention by ID physicians. The results showed an association between the intervention of ID physicians and the identification of the bacteria that caused the infection by BRPCR (p=0.0196). In 29 (19.4%), the final diagnosis changed from infectious to non-infectious based on the results of BRPCR. Conclusion Interventions by ID physicians might relate to identifying the bacteria causing an infection using BRPCR, and that might lead to enhancing the value of BRPCR. Disclosures All Authors: No reported disclosures

P-1885. Continuous Infectious Diseases Coverage by Merging with a Hospitalist Practice in a Small Community Hospital System

Abstract Background There is a severe shortage of infectious diseases (ID) physicians in the United States, with > 80% counties without an ID physician. Insufficient compensation is a contributing factor, with many internal medicine graduates practicing as hospitalists. Based on community needs, we merged the ID practice into the hospitalists group to create an ID-Hospitalist position. Methods Corewell Health South is based in Berrien County, which is in Southwest Michigan, population 152,261, and includes large rural populations and several federally funded clinics. The hospital includes 2 acute care facilities, including 220-bed and 76 bed hospitals. In 2002, the ID physicians began seeing patients as hospitalists at a Long-Term Acute Care Hospital. An ID physician assumed the role of Hospitalist Director in 2005 and second physician became co-director in 2008. At that time, the ID service adopted a 7 day on-7 day off schedule and included primary hospitalist patients. Results Since 2011, the ID-Hospitalist group has had continuous coverage with at least 3 Full time and 1 part-time ID-Hospitalists. Coverage (2.63/100,000) exceeds the national average of 1.79/100,000 by 84%. All service weeks are based on a 7 day on-7 day off schedule. In 2013, the outpatient ID clinic was resumed after a 5-year hiatus and is Ryan White Funded. A clinic day is built into the 7-day work week. Over the last 22 years, the group has included 6 ID physicians, which include 5 American graduates and 1 international graduate. In surveying the group, 83% expressed that pay was a factor in working as an ID/Hospitalist. 67% reported more free time and improved work-life balance. 67% preferred doing ID only, although the majority enjoyed hospitalist practice. Perceived weaknesses included overextension of responsibilities and a de-emphasis on the ID service in favor of hospitalist responsibilities. Another limitation included inconsistent coverage at the smaller hospital, increasing the reliance on telephone consultations. Conclusion Merging an ID practice into a hospitalist group has been effective in sustaining an ID service. Strengths included stable salary support and ability to perform other administrative or clinical tasks. Weakness included a multitasking of duties. This may serve as a model for resource limited settings. Disclosures All Authors: No reported disclosures

P-1880. An Innovative Infectious Diseases Hospitalist Model - Supporting Lean ID Teams

Abstract Background Two-thirds of the US population live in counties with no or below-average ID physician (ID/P) coverage. This workforce shortage is exacerbated by emerging ID threats and an inadequate fellowship match. In response to these demands, we developed an innovative ID hospitalist (ID/H) model. Subspecialty hospitalists have been increasing since the early 2000s, and ID/Hs may provide support to a stretched ID workforce and mitigate burnout. Methods Setting: Cambridge Health Alliance (CHA) is an academic, community, safety-net healthcare system in Massachusetts with two hospitals and multiple outpatient clinics. It serves >140,000 patients in Boston’s metro-north region. Intervention: CHA’s ID Division is composed of 4 attending physicians (2 FTE total in ID), 1 physician’s assistant (PA), and 1 ID pharmacist. Inpatient consultations are usually performed by 2 ID/Ps (1 at each hospital campus) with partial PA support. During high volume and low staffing weeks from 7/2021 to 4/2023 with only 1 ID/P available, a new staffing model was created. An ID/H provided in-person consultations at one campus (with over-the-phone discussion with the ID/P), while the ID/P provided in-person consultations at the other campus. Outcomes were evaluated via surveys to the ID/Ps, chart review analyzing recommendations, and financial modeling of compensation rates at CHA and locum agencies. Results An ID/H completed 59 clinical encounters during 21 shifts over 9 weeks in the study period. All ID/Ps had high/highest satisfaction working with an ID/H when ranked on a Likert scale. ID/Ps characterized the impact of the ID/H in Table 1. Qualitative themes included an increase in staffing flexibility and timely patient care. There was a high adoption rate of consult recommendations (58/59= 98.3%). The majority of consults were sought by the Medicine service (49/59= 83.1%). ID Consults are characterized in Table 2. This model was cost-effective for department finances compared to utilization of ID moonlighters or locums. Locums are compensated at a much higher hourly rate and due to delays with insurance processing, the institution may not receive reimbursement for their work. Conclusion An ID/H model is a novel way to support lean ID teams. Future research is needed to explore if this will attract more physicians to ID. Disclosures All Authors: No reported disclosures

P-1705. Infectious Diseases Pharmacist Curbsides: Questions Infectious Diseases Providers Ask Infectious Diseases Pharmacists

Abstract Background Infectious Diseases (ID) consult services, typically led by ID physicians, benefit significantly from the support of ID pharmacists. These pharmacists, with specialized training in ID pharmacotherapy through post-graduate residencies or fellowships, play a crucial role in advising on the selection, dosing, duration, and monitoring of antimicrobials. While the contribution of ID pharmacists to antimicrobial stewardship programs is well described, their impact in supporting ID consult services remains underdocumented. This report explores the clinical inquiries made by ID physicians and advanced practice providers (APP) to ID pharmacists on consult services, detailing how these interactions influence patient treatment and monitoring plans.Figure 1ID Pharmacist Curbside Question Categories (Categories with 2+ Submissions) Methods Ten ID residency- or fellowship-trained clinical pharmacists practicing in various practice settings documented questions they received from ID providers (attendings, fellows, and APPs) for patients on their respective ID consult service over a 6-month period. The impact of the conversations was documented if the pharmacist recommending a new drug, dose, duration, or monitoring plan which resulted in a change in care. Additional information was captured on the time spent answering questions, category of question, and pertinent microbiology or organism phenotype to describe areas of highest need for ID pharmacist support.Figure 2Questions Leading to Therapeutic Change Results Over the first three months of documentation, 782 questions were asked by ID providers to ID pharmacists. Total direct time spent answering questions was 8,937 minutes. The top three question categories were gram-negative resistance, antifungal therapy, and antimicrobial allergies. Seven hundred and three (89.8%) questions resulted in a clinical change in management as recommended by the ID pharmacist. The most common clinical change category was recommending a new dose which occurred in 57.4% of questions followed by new antimicrobial 50.4%, new monitoring plan 24.2% and new duration of therapy 8.8%. Conclusion ID pharmacists offer critical support that frequently changes management on ID consult services. Integrating their expertise into a multidisciplinary ID team is essential for achieving optimal patient safety and treatment outcomes. Disclosures Wesley D. Kufel, Pharm.D., BCPS, BCIDP, Merck & Co.: Grant/Research Support|Shionogi, Inc: Grant/Research Support Jennifer Ross, PharmD, BCIDP, Shionogi Inc.: Advisor/Consultant Frank Tverdek, PharmD, Merck: Advisor/Consultant

P-1890. Implementation and outcomes of a fully remote tele-ID and tele-OPAT program at a regional medical center

Abstract Background Infectious diseases (ID) consult services and outpatient parenteral antimicrobial therapy (OPAT) programs have traditionally been restricted to well-equipped academic medical centers. However, the integration of telehealth technologies into ID specialty care now allows for the expansion of ID expertise to underserved medical communities, including non-academic medical centers, and community and rural hospitals. Our initiative pioneered a comprehensive tele-ID service, encompassing both inpatient consultations and a tele-OPAT service for post-discharge management. Herein, we describe the program structure and outcomes from the first year of our integrated tele-ID and tele-OPAT program, implemented at a 144-bed community hospital in Vermont. Methods The program featured an inpatient tele-ID consult service supported by local nurse tele-presenters who would facilitate physical exams for a remote ID physician using videoconferencing technology. Patients deemed appropriate for OPAT were referred to the remote tele-OPAT team which consisted of a nurse coordinator, an ID pharmacist, and the current ID physician attending the inpatient service. The nurse coordinator's responsibilities included communicating with the local case management team, home health, and post-discharge facilities to ensure orders were placed, and communications were triaged for the tele-OPAT team. The ID pharmacist reviewed OPAT regimens for appropriateness and monitored outpatient labs for safety and dose adjustments. Tele-OPAT patients were seen locally by the ID physician in a pre-existing clinic with the assistance of a nurse tele-presenter. Results Ninety patients were enrolled in the tele-OPAT program in the first twelve months. Of these, 62 (68.9%) completed therapy without adverse event (AE) or 30-day readmission. 30-day readmission occurred in 14 patients (15.6%) and 20 patients (22.2%) had a documented AE during therapy, with 10 patients (11.1%) experiencing line-related issues. Conclusion Our telehealth initiative successfully expanded ID expertise to an underserved community hospital, with a majority of patients completing therapy without AEs or readmissions, demonstrating the efficacy and safety of remote ID consultations and tele-OPAT services. Disclosures All Authors: No reported disclosures

P-2070. SARS-CoV-2 Vaccination Rates Among a Cohort of Pediatric Solid Organ Transplant Recipients

Abstract Background SARS-CoV-2 vaccination has been shown to prevent severe disease and subsequent secondary infections in immunocompromised patients. This study assessed the rate of SARS-CoV-2 vaccinations among pediatric solid organ transplant (SOT) recipients at a single transplant center.Figure 1.SARS-CoV-2 vaccination status among pediatric solid organ transplant recipients for all ages and by age group. Methods We retrospectively reviewed medical records of pediatric recipients of heart, kidney, and liver transplants at Mayo Clinic, Rochester, MN between January 2011 and December 2023. All SARS-CoV-2 vaccine doses administered on or before April 1, 2024 were recorded. Up-to-date (UTD) status was based on current CDC recommendations for immunocompromised patients for each age group. Deceased patients, those no longer following at Mayo Clinic and whose vaccine records were unavailable were excluded. We also assessed whether patients had been seen by an ID physician in the year prior to collection stop date. Results The study included 136 patients: 48 kidney, 58 heart and 30 liver transplant recipients; 52.9% were male. Two patients subsequently received organs of a different type. Mean age was 16.1 years. Since authorization in 2020, 90 patients (66.2%) received at least one SARS-CoV-2 vaccine. This varied by age group, with 72.8% of > =12 year olds, 40.0% of 5-11 year olds and 62.5% of under 5 year olds (p = 0.007 [Figure 1]). Seventy-three patients (53.7%) completed at least three doses. Based on current recommendations that include the 2023-2024 formulation, 30 patients (22.0%) were UTD. This did not differ between age groups (p = 0.717) or by transplanted organ type (p = 0.21). Patients that saw ID were significantly more likely to be UTD (p = 0.001). Among partially immunized patients, 95% (n = 57) needed one additional dose to be UTD. Conclusion Despite simplified guidelines with fewer doses needed, a third of pediatric SOT recipients remain unvaccinated against SARS-CoV-2 and only 22% are UTD based on current recommendations. The proportion of unvaccinated patients was highest in the 5-11 year old age group and lowest in the oldest. Those that recently saw ID were significantly more likely to be UTD. Our data suggest that continued care provided by ID physicians may increase vaccine uptake, but reasons for undervaccination and strategies to counteract this should be further explored within this vulnerable population. Disclosures All Authors: No reported disclosures

P-928. The Second Heart Program: A Peer-focused, Multidisciplinary Harm Reduction Intervention to Improve Outcomes for People Who Inject Drugs After Admission for Infective Endocarditis

Abstract Background Infective endocarditis (IE) is a severe and highly prevalent injection-related infection among people who inject drugs (PWID). IE is estimated to account for 5-10% of deaths among PWID. The long-term outcomes among PWID with infective endocarditis are poor, with 5-year mortality rates over 50%. Most long-term complications are related to ongoing drug use (re-infection). However, most PWID with IE are not offered treatment for their underlying substance use disorder while in hospital. The Second Heart (SH) program is the first interdisciplinary team in Canada designed specifically to meet the unique needs of PWID with IE and which transitions with patients from the hospital into the community. The six components of the SH team are: peer support worker, systems navigator, addiction medicine physician, infectious disease physician, cardiologist/cardiac surgeon, and family physician. Methods The Second Heart Program was a non-randomized clinical trial enrolling PWID with infective endocarditis at three tertiary care hospitals in Hamilton. It was a mixed methods study utilizing both qualitative and quantitative methods. Five quantitative surveys, two qualitative interviews, and chart review were completed over the 12-month study period. Results Participants felt that their involvement with SH supported their physical, mental, and social recovery from IE, improved their trust in the healthcare system, and increased their engagement with their care. Out of 20 enrolled participants, all were consulted with an addictions medicine provider during initial hospitalization, 16/20 were set up with a family doctor post-discharge, 9/20 completed their 1-month follow-up survey, one participant died within 12 months of enrolment, and 12/19 completed their 12-month follow-up survey. Conclusion The early success in this pilot project has led to the successful application of funding for an expanded version of the multidisciplinary intervention for people who have any injection-related infection, including Hepatitis and HIV. Disclosures All Authors: No reported disclosures

P-2221. Clinical utility and sensitivity of plasma metagenomic microbial cell-free DNA sequencing in children with complicated pneumonia

Abstract Background Etiological diagnostics for children with complicated bacterial pneumonia remain limited and insensitive, and pleural fluid (PF) testing is invasive. Plasma metagenomic microbial cell-free DNA (mcfDNA) sequencing, available by Karius, Inc., is a potentially comprehensive, non-invasive, and efficient diagnostic tool for pediatric pneumonia. However, rigorous studies comparing the real-world performance of mcfDNA to other testing modalities are lacking. Methods We compared the performance of the Karius Test (KT) to blood culture, PF culture, and in-house PF PCR assays targeting the most common pathogens in complicated community acquired pneumonia (cCAP), including Streptococcus pneumoniae (Spn), group A Streptococcus (GAS), and Staphylococcus aureus, in immunocompetent children hospitalized with cCAP requiring pleural effusion or empyema drainage at Children’s Hospital Colorado from 2022-2024. We calculated percent agreement across tests and sensitivities using both a composite reference standard and clinical truth. Bacterial pathogens were adjudicated by three infectious disease physicians as probable, possible, or unlikely cCAP pathogens. DNA virus detections on KT were not considered causative of cCAP. Results In our cohort of 32 children with cCAP (Table 1), 84.4% (27/32) had at least one probable pathogen identified by KT alone vs. 75% (24/32) by all other testing combined (Table 2). GAS (37.5%) and Spn (31.3%) were the most commonly detected pathogens, and 15.6% had > 1 probable pathogen detected. Compared to a composite reference standard, KT had the highest sensitivity (91.1%), followed by targeted PF PCR assays (67.6%), PF culture (26.5%), and blood culture (12.5%), with similar trends by clinical truth. Positive agreement between KT and PCR + culture was 88.9%. Most KT samples were collected within 5 days of starting effective antibiotic therapy, but KT remained positive even up to 10 days on therapy (Figure 1). Conclusion Compared to culture and PF PCR-based testing, KT had higher sensitivity and excellent positive agreement for etiological diagnosis of pediatric cCAP. Early use of KT may be a promising diagnostic strategy, especially in the setting of antibiotic pre-treatment. Further studies are needed to determine KT specificity and clinical impact. Disclosures Edwin J. Asturias, MD, Hillevax: Advisor/Consultant|Merck: Advisor/Consultant|Moderna: Advisor/Consultant|Pfizer: Grant/Research Support Molly Butler, PhD, Pfizer: Conference Attendance Samuel R. Dominguez, MD, PhD, BIofire Diagnostics: Advisor/Consultant|BIofire Diagnostics: Grant/Research Support|DelveBio: Grant/Research Support|Karius: Advisor/Consultant|Karius: Grant/Research Support|Pfizer: Grant/Research Support

P-2367. Qualitative Analysis of Barriers to Outpatient Antiviral Treatment for COVID-19 and Influenza Patients Observed by Infectious Disease Specialists in North America, 2024

Abstract Background Antiviral medications for COVID-19 and influenza can mitigate disease severity in high-risk outpatients if taken early in the course of illness yet are underutilized. We sought to understand barriers to providers prescribing these medications. Table Thematic summary from infectious disease specialists outlining barriers to outpatient antiviral treatment for COVID-19 and influenza patients, United States, 2024 Methods We conducted an on-line survey regarding knowledge, attitudes, and practices of prescribing antiviral treatment for outpatients with COVID-19 and influenza. Respondents were asked about perceived barriers among providers treating COVID-19 and influenza outpatients in their institutions. Questions were structured using a Likert scale and were analyzed using a thematic analysis approach in Microsoft Excel. Results Of 1,898 infectious disease specialists across the United States and Canada who received the survey between 1/10/24 to 2/5/24, 565 (30%) responded, of whom 93% were infectious disease physicians and 7% were healthcare professionals. Surveyed physicians worked in university (45%), non-university teaching (24%), community (20%), city/county (4%), outpatient (0.4%), and veteran affairs hospital settings (6%) and 144 (25%) provided free text responses. The primary barrier to prescribing antivirals was provider skepticism (47%), due to patient symptoms deemed too mild for treatment and needing more evidence about effectiveness. This was followed by perceptions of limited accessibility (31%) related to high cost, limited hospital access, and difficulty administering some medications. Pharmacologic limitations (18%) were concerns about drug interactions, side effects, and incomplete medical history. Other barriers were timeliness of treatment within a short therapeutic window (15%) and patient skepticism (13%). Additional free text responses described successful hospital protocols and suggestions for encouraging antiviral prescribing. Conclusion These themes demonstrate a need for better education of providers about antiviral risks and benefits as well as improved access and coverage of life-saving medications. Infectious disease specialists provided useful insights which can help to shape clinical recommendations, future research for antiviral therapeutics, and public health messaging for improved patient care. Disclosures Philip M. Polgreen, MD, Eli Lily: Advisor/Consultant|Pfizer: Grant/Research Support

P-736. No Air Don’t Care: Lack of gas on imaging is associated with a longer time to surgical intervention in patients with necrotizing fasciitis

Abstract Background Although necrotizing fasciitis is a life-threatening infection, initial symptoms may be non-specific. The presence of gas on plain X-ray or computed tomography scan can be diagnostic, but is missing in up to 1/4 of cases.Figure 1.Stratification of patients with necrotizing fasciitis Methods We performed a retrospective cohort study of adult patients admitted in 2022-2023 with necrotizing fasciitis (diagnosis code M72.6) at an urban level 1 trauma center, who received surgical intervention, and at least 1 dose of linezolid or clindamycin in addition to other antibiotics. Patients transferred from an outside hospital, who had no imaging results, or no surgical intervention were excluded. Patients with and without gas on initial imaging result were compared (Fig1). Primary outcome was whether a lack of gas on imaging correlated with longer time to surgical intervention. Time 1 was defined as the time radiographic images were attested, or the time of surgery consult (whichever was later). Time 2 was the documented operating room (OR) surgical start time. Clinical and microbiologic outcomes were also recorded.Table 1:Characteristics of patients with necrotizing soft-tissue infection with and without gas on initial imaging Results 79 patients were included in the analysis (60 and 19 patients with and without gas on imaging, respectively). Cohorts were evenly matched in terms of illness severity and comorbidities, except that patients without gas on imaging were more often female (P=0.014) with higher rates of CPK elevation (P=0.033) (Table 1). Site of infection did not differ between groups (Fig2), nor did microbiologic OR culture results (figure not included, P=0.105). Patients without gas on imaging had significantly longer time to OR compared to those with gas (median 15.7 verses 4.3 hours, respectively, P=0.0128) (Figure 3a). Length of stay, repeat trips to OR, and mortality did not differ between groups, however, patients without gas had high rates of readmission (P=0.041) (Fig3b). Conclusion Almost a quarter of necrotizing fasciitis patients presented without gas on initial imaging result. Despite having a similar degree of illness and poor prognostic laboratory parameters, these patients had a significantly longer time to OR compared to those with gas on initial imaging. Infectious diseases physicians should strive to provide valuable insight to our surgical colleagues for a syndromic approach to this illness regardless of the imaging results. Disclosures All Authors: No reported disclosures

P-1517. Assessing the novel combinations against Carbapenem resistant Acinetobacter baunmannii (CRAB): ceftazidime-avibactam and ampicillin-sulbactam

Abstract Background Carbapenem-resistant Acinetobacter baumannii (CRAB) poses a serious threat to public health, as treatment options are becoming limited. IDSA Guidance has advocated combination therapies to combat CRAB. Sulbactam (SUL), a β-lactamase inhibitor with inherent antibacterial activity against CRAB, is recognized as an important component of combination therapy. Pairing avibactam (AVI) inhibitor with ceftazidime (CAZ), has also been successful in restoring its antibiotic efficacy against many Gram-negative pathogens but has not proven effective against CRAB when used alone. In vitro assays combining SUL and AVI have shown promise against CRAB with different genetic backgrounds. Our aim is to assess the in vitro efficacy of combining ampicillin-SUL (AMS) and CAZ-AVI (CZA) against CRAB. Figure 1 Methods Three different methodological strategies were used. 89 strains underwent MIC evaluation (agar dilution) against SUL plus AVI, AMS (2:1) plus AVI, and AMS plus CZA, with a constant concentration of AVI (4 mg/L) and CAZ (8 mg/L). Additionally, 30 CRAB strains with different genetic backgrounds were used to assess AMS/CZA (14 μg and 50 μg) synergy by the disk stacking method and MTS synergy. Results AVI reduced SUL MIC values to < =4 mg/L in 96.8% of the tested isolates, excluding NDM producers. For MBLs producers, SUL-AVI MIC values less < =4 mg/L were tested in 14.3% strains (Fig. 1A). The inclusion of AMP or CAZ in the SUL-AVI combination did not result in any alterations in MIC values (98% of strains with identical values). Using stacking assay, 59% of isolates showed >3 mm increase in halo diameter for AMS with both CZA disks (Fig. 1B). Additionally, we calculated the FICI by using gradient strips (MTS) obtaining a synergistic or additive effect in 69% and 2% of strains, respectively. Antagonism was only seen in two tested NDM-1 positive isolates. Conclusion Our results demonstrated synergy between AMS and CZA in geographically diverse CRAB, including extensively drug-resistant isolates, such as those producing widespread oxacillinases. Some methods, mainly disk-based, may underestimate the true extent of AMS-CZA synergy. These findings could facilitate the implementation AMS/CZA in clinical settings and provide a potential alternative in regions where the latest approved drugs are not accessible. Disclosures David Paterson, Infectious Diseases Physician, AMR Action Fund: Board Member|Aurobac: Advisor/Consultant|bioMerieux: Grant/Research Support|bioMerieux: Honoraria|CARB-X: Advisor/Consultant|Entasis: Expert Testimony|Menarini: Honoraria|Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Shionogi: Grant/Research Support|Shionogi: Honoraria

P-1701. Impact of a Clinical Pharmacist-Led Antimicrobial Stewardship Program on Antibiotic Utilization and Resistance Patterns in a Medical Intensive Care Unit: A Cohort Study

Abstract Background Antimicrobial resistance presents a formidable challenge in medical intensive care units (MICUs), where the overuse of broad-spectrum antibiotics is closely associated with the rise of drug-resistant bacteria. This study aimed to evaluate the impact of implementing a robust Antimicrobial Stewardship (AMS) program in a medical ICU setting. Methods From February 2022, an AMS program was initiated in the medical ICU which involved consistent involvement from both a clinical pharmacist and an infectious disease physician who conducted ongoing assessments and offered feedback. To gauge the effectiveness of the AMS program, outcomes were compared between the AMS period and the six months preceding its implementation (pre-AMS period). Primary metrics included the utilization of antibacterial agents, such as broad-spectrum beta-lactam antibiotics effective against Pseudomonas aeruginosa. Results The study included a total of 275 patients during both the AMS and pre-AMS periods, ensuring a balanced comparison. There were no significant disparities between the groups regarding disease severity and mortality rates. Noteworthy findings during the AMS period included a substantial decrease in the empirical use of broad-spectrum beta-lactam antibiotics targeting Pseudomonas aeruginosa (42.18% during AMS vs. 63.27% pre-AMS, p < 0.001) and in multi-drug resistant organism (MDRO) infections (10.18% during AMS vs. 17.82% pre-AMS, p < 0.001). Additionally, there was notable improvement in appropriate antimicrobial de-escalation for MDRO-positive patients during the AMS period (37.45% during AMS vs. 20.36% pre-AMS, p = 0.001). The utilization of polymyxin also decreased during the AMS period (17.09% during AMS vs. 34.55% pre-AMS, p = 0.034). Furthermore, there was a significant increase in the susceptibility of Gram-negative Bacilli isolates to broad-spectrum beta-lactam antibiotics effective against Pseudomonas aeruginosa during the AMS period. Conclusion The implementation of a comprehensive clinical pharmacist-led AMS program resulted in a substantial reduction in antibacterial agent utilization within a medical ICU setting. Disclosures All Authors: No reported disclosures

P-157. Molecular epidemiology of carbapenemase genes among carbapenem-resistant Klebsiella pneumoniae (CR-Kp) from the Philippines: implications for surveillance and treatment

Abstract Background In the Philippines, the proportion of carbapenem-resistant Klebsiella pneumoniae (CR-Kp) has doubled in the past decade and now exceeds 15%. However, the prevalence of different carbapenemase genes remains unknown. Unlike the United States and China where blaKPC predominates, blaOXA-48-like serine carbapenemases and metallo-β-lactamases (MBL) blaNDM, -IMP, and -VIM frequently occur among CR-Kp in the Asia-Pacific region. In order to better inform empiric treatment strategies and assist with infection prevention, we investigated the carbapenemases present in CR-Kp from the Philippine General Hospital (PGH), a 1,500-bed tertiary care national referral center in Manila, Philippines.Table 1.Carbapenemase genes detected with Xpert® Carba-R among carbapenem-resistant Klebsiella pneumoniae isolates from the Philippine General Hospital in Manila, Philippines. Methods CR-Kp from clinical samples were identified in the clinical microbiology laboratory at PGH using the VITEK® 2 platform (bioMerieux, USA). These isolates were collected and underwent rapid molecular testing with Xpert® Carba-R (Cepheid, USA) at the central laboratory of the Philippine National Institutes of Health. Molecular test results were typically available within 24 hours from the time of identification. These results were relayed to the treating physicians to guide clinical decision-making. Results A total of 81 CR-Kp isolates were collected from February to May 2024. Isolates were obtained from respiratory (n=44, 54.3%), blood (n=24, 29.6%), urine (n=9, 11.1%), and tissue/wound (n=4, 4.9%) samples. Table 1 summarizes the carbapenemase genes detected with Xpert® Carba-R among CR-Kp isolates from PGH, including multiple genes present in some samples. Conclusion Among CR-Kp from PGH, blaNDM was the predominant carbapenemase, followed by blaOXA-48-like and blaKPC genes. A third of the isolates co-harbored blaNDM and a serine carbapenemase, usually blaOXA-48-like. These findings suggest that there is molecular heterogeneity and likely plasmid spread among CR-Kp in the Philippines. These findings also underscore the importance of molecular surveillance programs that can rapidly characterize resistant strains, highlight the emergence of novel genotypes, and inform empiric and definitive therapy for CR-Kp. Disclosures Federico Perez, MD, MS, Merck: Grant/Research Support David Paterson, Infectious Diseases Physician, AMR Action Fund: Board Member|Aurobac: Advisor/Consultant|bioMerieux: Grant/Research Support|bioMerieux: Honoraria|CARB-X: Advisor/Consultant|Entasis: Expert Testimony|Menarini: Honoraria|Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Shionogi: Grant/Research Support|Shionogi: Honoraria

P-1738. Effectiveness of Clinical Pharmacist-Driven Antimicrobial Stewardship (ASP) in Bacteremic Patients in India

Abstract Background Antimicrobial resistance is a prevalent problem, especially in low-middle-income countries. Infectious disease physicians are a scarce commodity and are unable to fully shoulder the complete responsibility of antimicrobial stewardship implementation in a health care setting. Thus, we set out to assess the utility of a Clinical pharmacist-led ASP in optimising antimicrobial use in bacteremic patients. SOURCE OF INFECTION Methods This is a prospective audit and feedback of bacteremic patients led by a clinical pharmacist with minimal input and sign-off from an ID specialist. A month of observation (July 2023) was followed by a 3-month intervention period from August to October 2023 in the medical and surgical speciality departments of a large tertiary care hospital in Southern India. RECOMMENDATION ACCEPTANCE RATE Results 103 and 218 patients were noted to be bacteremic during baseline and intervention, respectively. The mean age was 48.2, and 66% were male. The majority of positive blood cultures were from Haematology (19%), Hepatology(15%), Nephrology(14%) and others (52%). The average length of stay was 19 days and 16.6 days in baseline and intervention phases, respectively. The predominant organisms were carbapenem-resistant and extended-spectrum beta-lactamase-producing enterbacteriaceae and coagulase-negative staphylococci (CoNS). The common sources of bacteremia were central line-associated bloodstream infection (CLABSI) and gut translocation during febrile neutropenia. (Table 1). The DOT in the observation phase was 1517/1000 Patient-Days (PD), and the intervention phase's average DOT was 1326/1000PD, and there was a significant reduction in antibiotic utilisation in the intervention (P=0.003). The length of therapy was 16.6 and 11.06 days, with in-hospital mortality of 13.6% and 8% in the observation and intervention phases, respectively. Clinical pharmacist recommendations were either fully or partially accepted in 75% of the cases in the intervention phase (Table 2). Conclusion A clinical pharmacist-led ASP showed a reduction in significant antimicrobial use with 75% acceptance of recommendation and no difference in mortality even in bacteremic patients. Disclosures All Authors: No reported disclosures

P-510. Describing the Cohort of Women Veterans Prescribed HIV PrEP at the Veterans Health Administration

Abstract Background Pre-Exposure Prophylaxis for HIV (PrEP) is a highly effective option available to women in the Veteran’s Health Administration (VHA). However, PrEP uptake among VHA patients has remained modest, particularly among women. To better understand PrEP uptake for women Veterans, we used VHA administrative data to describe the cohort of women Veterans prescribed PrEP and their prescribers at the VHA. Methods We conducted a cross-sectional study of women enrolled in VHA care between January 1, 2012 and June 30, 2022 who were prescribed HIV PrEP for at least 30 days. Results PrEP initiation increased gradually over the study years, with most patients receiving initial prescriptions after January 1, 2020. Among the cohort of 417 women, 48% lived in the South, and most were aged 18-39 years. In terms of racial demographics, 53% identified as white and 40% as Black, while ethnically Hispanic women constituted 12% of the group. Eleven percent were homeless. Nearly half of the cohort were noted to have military sexual trauma. There was a high prevalence of mental health disorders, with 85% experiencing depressive disorder. Regarding prescriber profiles, 22% were advanced practice providers, 20% were clinical pharmacists, and 58% were physicians, 87% of whom specialized in infectious diseases. Conclusion These findings indicate an increase in prescriptions over time and significant geographic disparities among a vulnerable population of women Veterans. Although most patients lived in the South, this region has a lower rate of PrEP prescription to HIV incidence than in other regions. Most prescribers were infectious disease physicians, in contrast to estimates amongst general and commercially insured populations. Many patients in the study were prescribed PrEP via clinical pharmacists, and although data is lacking to compare to the general population, this suggests that Clinical Pharmacist Practitioners, who possess a scope of practice within the VHA which includes medication prescriptive authority and serving as a direct care provider, are an important tool to enhance PrEP uptake among women Veterans. More research is needed to identify barriers and strategies to overcome them for PrEP service implementation among women Veterans. Disclosures All Authors: No reported disclosures

P-81. A Decade of Culture-Negative Native Vertebral Osteomyelitis: Insights from the Mayo Clinic

Abstract Background Culture-negative native vertebral osteomyelitis (CN-NVO) is increasingly common, rising from 0.3 to 1.8 cases per 100,000 between 1995 and 2008. The lack of microbial identification complicates optimal treatment and creates prognostic uncertainties. We describe our decade-long clinical experience with CN-NVO, focusing on patient characteristics, treatment, and outcomes. Patient Characteristics Methods We retrospectively analyzed adult patients with radiographic evidence of NVO between January 1, 2011, and July 31, 2021. CN-NVO required clinical indicators such as back pain and fever, elevated inflammatory markers, and negative cultures from at least one spine biopsy. Patients with infected instrumentation were excluded. Diagnostic Evaluation Values represent median, lower quartile, and upper quartile for continuous variables unless otherwise specified, 2 whereas frequencies and percentages are presented for categorical variables. ^ All results returned negative *Biopsies number two and three did not result in additional findings or change clinical management. Results Seventy-two patients were included. Their characteristics are presented in Table 1. Most (77.8%) had received antibiotics within the 4 weeks preceding the biopsy. Disc space enhancement on MRI was the primary finding, with the lumbar spine being the most frequently involved (Table 2). Blood cultures were positive in 39.4% of the patients within 3 months of symptom onset. Streptococcus spp. (n=9, median time between positive culture and diagnosis: 6.5 days [IQR 2.25, 26.75]) and Staphylococcus aureus (n=7, 40 days [IQR 37.5, 51.5]) were most common. Definitive antibiotics were administered in 98.6% of the cases, primarily IV β-lactam + vancomycin. Oral antibiotics (PO) were used in 46.5% of the patients, primarily as step-down therapy (91%) (Table 3). Surgery was required in 8.5% of the patients for abscess drainage or relief of spinal cord compression. Treatment failure occurred in 9.4% of patients, and 37.5% died during the median follow-up of 568.5 days, with two deaths related to the infection. Treatment and Outcomes ^ defined as requiring another course of antibiotics and/or surgery for suspected ongoing infection ¶ Clinical findings include back pain or fevers; laboratory findings indicate abnormal or uptrend in inflammatory marker values # Defined as MRI findings concerning ongoing or worsening infection as per the interpretation of the Radiologist, Infectious Disease physician, and/or Orthopedic Surgeon Conclusion Patients with CN-NVO often require prolonged antibiotic therapy, typically combination regimens, with favorable treatment outcomes. Our treatment failure rate is similar to other studies, although comparability may be limited by heterogeneity in definitions. Mortality rates in the range of 6 and 36% have been reported, with the higher end driven mostly by comorbidities. Enhanced diagnostics and standardized treatment protocols are needed to further improve patient outcomes. Disclosures All Authors: No reported disclosures

P-78. Observational Comparison of In-Person vs. Remote Care for Bone and Joint Infections

Abstract Background Telemedicine can overcome barriers to accessing subspecialty expertise including for infectious disease (ID). A common need for ID expertise is bone and joint infections (BJI), which are associated with substantial morbidity and mortality. Access to BJI expertise in underserved locations could be increased through ID telemedicine (Tele-ID). Here, we compare patients, and outcomes of Tele-ID vs in-person ID care of BJI.Table 1:Characteristics of the Study Population Methods We conducted a retrospective study of BJI patients who received Tele-ID (live audio-video) care at hospital #1 vs. in-person ID care at hospital #2 between 2015-2019. Both hospitals are affiliated with a larger academic institution and have care provided by the same ID physicians. Demographic data, comorbidities, diagnostic and microbiological data, treatment, and outcomes were assessed.Table 2:Primary Outcomes of the Study Population Results Of the first 100 patients, half received Tele-ID care at hospital #1 and the other half received in-person ID care at hospital #2. Both groups had similar patient characteristics (Table 1), except for higher frequency of same site infection at hospital #2 (68 vs 26%). Patients cared for via Tele-ID were more often transferred to an alternative tertiary-care facility (30% vs. 0%) for surgical specialty services not available at hospital #1 (Table 2). For Tele-ID patients transferred vs in-person care, LOS was longer and discharge to home occurred less often compared with those not transferred. Readmission for the same infection within 30 days and mortality were not different (Table 2). The most common BJI managed by Tele-ID was diabetic foot osteomyelitis without any hardware, whereas joint infections with hardware were most commonly seen by in-person ID (Figure 1). Amongst patients with OR procedures, most OR cultures were negative, with Staphylococcus aureus being isolated most frequently at both hospitals (Figure 2).Figure 1:Type of Infection by Hospital Conclusion This initial observational study suggests that clinical outcomes are similar for patients with BJI cared for by in-person vs. Tele-ID, although hospital transfer for surgical interventions was more common at the Tele-ID site. Further comparison in a larger number of patients at each hospital is ongoing. This preliminary experience suggests that Tele-ID could provide appropriate care for BJI where in-person ID expertise is not available.Figure 2:OR Culture Organism(s) by Hospital Disclosures Seema Mehta Steinke, MD, MS, Pearl Diagnostics: Advisor/Consultant Rima Abdel-Massih, MD, Infectious Disease Connect: CEO & co-founder|Infectious Disease Connect: Ownership Interest John W. Mellors, MD, Infectious Disease (ID) Connect, Inc.: Share Options

P-570. Infectious Disease Physician Office-Based HIV Program Results in Successful Adherence of Therapy in Patients Receiving Long-Acting Cabotegravir and Rilpivirine

Abstract Background The long-acting (LA) formulation of cabotegravir (CAB) and rilpivirine (RPV) demonstrated efficacy in Phase 3 studies and was approved in the US for HIV-1 in 2021. CAB+RPV LA offers treatment advantages over daily oral therapy with 1-2 month injections administered by a health care provider. However, onboarding of therapy and drug access for patients has proven challenging for physicians. We describe real-world implementation of a standardized Infectious Disease (ID) office-based CAB+RPV LA program with evaluation of adherence and virologic effectiveness. Methods The ID in-office CAB+RPV LA program was implemented in July 2023 in a national network of ID practices. The program involved creation of standardization for drug orders and approval, nurse training and appointment management. The first 100 patients treated in the program were followed. Data included demographics, prior therapy, baseline laboratory data, adherence to schedule and follow-up laboratory indices. Adherence was defined as injections received +/- 7 days from target date. Results Overall, 100 patients have entered the program in 20 practices nationally from July 2023 to March 2024. Median age is 49 years (IQR: 49-59), 81% male. Median weight and BMI are 89.8 kg (IQR: 80.8-101.6) and 29.2 kg/m2 (IQR: 27.1-31.9), respectively. Median duration of HIV disease is 7 years (IQR 4, 13) and patients received 1 (IQR: 1-2) oral regimen prior to CAB+RPV LA. A total of 55 patients initiated CAB+RPV LA in the ID physician office and 45 transferred care to their ID physician office. Median baseline viral load prior to any CAB+RPV LA was 30 (IQR: 21-65) and CD4 count was 761 (IQR: 535-1008). The majority (98%) are receiving injections every 2 months. Of 274 injections administered to date, 269 (98.2%) have been adherent to schedule. Fourteen patients eligible for 6 month follow-up labs had viral load undetectable (86%, n=12) or suppressed (14%, n=2). Six patients discontinued therapy, primarily due to financial or payor issues. Conclusion An ID physician office-based CAB+RPV LA program resulted in high levels of injection adherence. Patients eligible for follow-up achieved a 100% level of virologic control. These results suggest that CAB+RPB LA administered through a standardized ID office-based program is effective in managing HIV-1. Disclosures Nikhil K. Bhayani, MD, FIDSA, CorMedix: Advisor/Consultant|Cumberland Pharmaceuticals: Advisor/Consultant|Melinta: Advisor/Consultant|Paratek Pharmaceuticals: Advisor/Consultant Erika M. Young, DO, Cumberland Pharmaceuticals: Advisor/Consultant Brian S. Metzger, MD, MPH, Cumberland Pharmaceuticals: Advisor/Consultant|Ferring Pharmaceuticals: Advisor/Consultant Lucinda J. Van Anglen, PharmD, Cumberland Pharmaceuticals: Grant/Research Support|Ferring Pharmaceuticals: Grant/Research Support|Novartis Pharmaceuticals: Grant/Research Support|Takeda Pharmaceuticals: Grant/Research Support

P-1871. Surge Protector: Characterizing the Challenges of Fluctuating OPAT Volume

Abstract Background Outpatient parenteral antimicrobial therapy (OPAT) is often overseen by multidisciplinary teams in infectious diseases (ID) provider groups. OPAT programs serve an important role in health systems to decrease inpatient length of stay and ensure safe transitions of medically complex patients. The optimal composition and staffing needs of OPAT teams are not defined. To gauge challenges facing OPAT program administration and provide insights for those initiating an OPAT program, we described trajectories in patient volume throughout our OPAT program. Methods We included all UNC OPAT courses from inception in 2015 through 2023. The OPAT team mainly provides care for home infusion OPAT, providing lab monitoring, assessment of adverse events, and care coordination. The OPAT team does not cap enrollment and currently accepts patients seen by general ID providers who require >14 days parenteral antimicrobials. OPAT team staffing has varied since inception. It is currently primarily administered by a nurse and a pharmacist, with support from a scheduler and an ID physician. We calculated the average monthly census of patients followed by the OPAT team over time. Census was defined as the number of outpatients followed by the OPAT team at a time. To gain granular detail we also trended the average weekly OPAT census in 2022 and 2023. Results 2,878 OPAT courses were cared for by the OPAT team. Median days on OPAT was 35. The most common diagnoses were osteomyelitis (43%), bacteremia (20%) and diabetic foot infection (12%). Average monthly OPAT census overall increased since inception (Fig 1) and demonstrated marked monthly variation across the entire period. In 2022-2023, the weekly census ranged from 32 to 60 patients, with a median weekly census of 45 patients (IQR, 41-50) (Fig 2). Conclusion We found our OPAT census underwent frequent, wide fluctuations in volume, which was met with adjustments in task prioritization and approach to accommodate surges. Of note, the OPAT team provides assessment and transition management for referred patients prior to discharge. These patients are not counted in census but are a key area to improve safety and stem readmission. Our results demonstrate that OPAT workload can be volatile and needs robust, expert staffing to meet unpredictable demands and patient needs. Disclosures Asher J. Schranz, MD, MPH, UpToDate: I receive fees for authorship of an UpToDate article.