ID Specialists Research Articles

1330. Diagnosis and Management of NTM Lung Disease: Effect of Online Educational Interventions on Infectious Disease Specialist Knowledge

BackgroundDiagnosis and management of nontuberculous mycobacterial (NTM) lung disease is challenging for clinicians due to its rarity and the need for complicated, multidrug antibiotic regimens. The objective of this study was to determine whether online educational interventions can effectively address knowledge gaps among ID specialists regarding diagnosis and treatment of patients with NTM lung disease.MethodsTwo educational interventions, consisting of a text-based activity with interactive questions, and a video-based discussion between two experts, were developed and made available online. Educational impact of each intervention was assessed using a 3-question repeated pairs pre-/post-assessment study design. Data from a sampling of learners were collected from September 11, 2017 through January 17, 2018. Statistical analyses included a paired (within-physician) two-tailed t-test and McNemar’s χ2 statistic, with Cramer’s V to determine the overall effect of each intervention.ResultsOverall, a total of 1,273 ID specialist learners participated in the two activities from launch through April 30, 2018. Analysis demonstrated a significant improvement (P < 0.05) in overall knowledge with considerable educational impact (V = 0.195 and 0.259). Improvements in specific areas included (figure). Despite gains in knowledge, additional gaps were also identified: (1) Regarding treatment of M. abscessus lung disease, 18% were unable to discern between guideline recommended therapies for M. abscessus and MAC complex NTM, and an additional 14% would treat with a less aggressive, noncurative regimen (n = 211), and (2) regarding treatment of fibrocavitary MAC complex NTM; nearly one-third (31%) would treat a using a thrice-weekly regimen, despite an indication for a daily regimen (n = 114).ConclusionParticipation in interactive text-based as well as video-based activities improved the ability of ID specialists to make evidence-based decisions in the care of NTM lung disease. The findings also uncovered educational needs that warrant further education in selecting appropriate therapeutic regimens particularly in cases where aggressive therapy is indicated. Disclosures E. Jackson, Medscape: Employee, Salary. P. Chatterjee, Medscape: Employee, Salary. S. Smith, BioFire Diagnostics: Independent Medical Education, Educational grant. K. Badal, Medscape: Employee, Salary. D. E. Griffith, Aradigm Corporation: Advisor/consultant and Speaker’s Bureau, Consulting fee and Speaker honorarium. Bayer Healthcare Pharmaceuticals: Advisor/consultant, Consulting fee. Grifols: Advisor/consultant and Speaker’s Bureau, Consulting fee and Speaker honorarium. Insmed Incorporated: Advisor/consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Grant recipient and Speaker honorarium.

1325. HIV, Aging, and Comorbid Conditions: Case-Based, Online Education Improves HIV/ID Specialists’ Management Strategies

BackgroundOver half of people living with HIV are over 50 years of age. Clinicians must balance HIV care with the management of age-related comorbidities such as, cardiovascular disease, diabetes, liver and kidney disease, and cancer.MethodsTo improve HIV/ID specialists’ ability to develop a comprehensive care strategy for aging men and women living with HIV, a CME/CE/CPE-certified educational intervention comprising two patient case scenarios was developed. It launched on a website dedicated to continuous professional development on March 23, 2018. The interactive, text-based, “test and teach” approach elicited cognitive dissonance; clinicians were presented with multiple-choice questions to evaluate their application of evidence-based recommendations. Each response was followed by detailed, referenced, feedback to teach. Educational effectiveness was assessed with a repeated pairs pre-/post-assessment study design, in which each individual served as his/her own control. Responses to three multiple-choice, knowledge questions, and one self-efficacy confidence question were evaluated. A chi-squared test assessed changes pre- to post-assessment. P values of <0.05 are statistically significant. Effect sizes were evaluated using Cramer’s V (<0.05 modest; 0.06–0.15 noticeable effect; 0.16–0.26 considerable effect; >0.26 extensive effect). Data were collected through April 27, 2018.Results4,130 HCPs, including 795 physicians, participated in the activity. Data from HIV/ID specialists (n = 76) who answered all pre-/post-assessment questions during the study period were analyzed. Significant improvements were observed overall (P < 0.0001; V = 0.496) and in several specific areas of assessment (figure). Following activity participation, the % of ID specialists who answered all assessment questions correctly increased dramatically: 9% (pre) vs. 88% (post). Additionally, 77% of HIV/ID specialists indicated a commitment to incorporate one or more changes into practice.ConclusionParticipation in this online, interactive, case-based educational intervention significantly improved ID specialists’ ability to care for aging patients living with HIV. These findings highlight the positive impact of well-designed online education. Disclosures S. Hurst, ViiV Healthcare: Independent Medical Education, Educational grant. S. Smith, ViiV Healthcare: Independent Medical Education, Educational grant.

594. The Prevention and Management of HIV: Online Education as a Tool to Improve Knowledge and Confidence Among HIV/ID Specialists

BackgroundTo optimize care for patients at risk for HIV acquisition and individuals living with HIV, healthcare providers (HCPs) must not only remain current with the data, but critically evaluate the clinical implications of such.MethodsA CME/CE/CPE-certified, 60-minute, video-based activity was developed to increase knowledge of the latest clinical-trial and real-world data for the prevention and treatment of HIV. The activity posted online on March 26, 2018 and featured four experts. Segmented into three sequentially linked presentations, each presentation featured a moderator and panelist who summarized the latest data and evaluated potential clinical implications with regard to, HIV prevention strategies, including PrEP; Existing and emerging HIV ARV regimens; and the management of HIV/HCV coinfection.Educational effectiveness was assessed with a repeated-pairs pre-/post-assessment study design, in which each individual served as his/her own control. Responses to three multiple-choice, knowledge questions and one self-efficacy confidence question were analyzed. A chi-squared test assessed changes pre- to post-assessment. P-value < 0.05 is statistically significant. Effect sizes were evaluated using Cramer’s V (<0.05 modest; 0.06–0.15 noticeable effect; 0.16–0.26 considerable effect; >0.26 extensive effect). Data were collected through April 25, 2017.Results4,485 HCPs, including 954 physicians have participated in the activity. Data from HIV/ID specialists (n = 50) who answered all pre-/post-assessment questions during the study period were analyzed. Significant improvements were observed overall (P = 0.0039; V = 0.166) and in several specific areas of assessment (figure). Following activity participation, 22% of ID specialists indicated increased confidence in answering patients’ questions about new ARV agents and regimens and 90% of HIV/ID specialists indicated a commitment to incorporate one or more changes into practice.ConclusionParticipation in this online education consisting of segmented video interviews on new clinical data significantly improved ID specialists’ knowledge and confidence with regard to key advances in HIV prevention, treatment, and the management of HIV/HCV coinfection. These findings highlight the positive impact of well-designed online education. Disclosures S. Hurst, ViiV Healthcare: Independent Medical Education, Educational grant. S. Smith, ViiV Healthcare: Independent Medical Education, Educational grant.

1960. Antibiotic Challenge Dose Testing Improves Patient Care and Lowers Costs in a Community Hospital: A 2-Year Prospective Study

BackgroundPenicillin allergy is reported in 10% patients in the US Patients with penicillin allergies are treated with broader spectrum antibiotics, often leading to more antibiotic-resistant infections, including C. difficile, increased risk of surgical site infections, and increased healthcare costs.MethodsAfter informed consent, Medical-Surgical patients with documented allergies to penicillin (P) or cephalosporins (C) were given challenge doses through a standardized 2-step protocol from June 2015 to November 2017 at our community hospital. Patients with documented IgE-mediated hypersensitivity (HSR), rash or unknown reactions were eligible. Those with anaphylaxis or Type II-IV HSR were excluded. Treating clinicians selected the antibiotic for testing guided by the protocol: 323/336 patients (96%) were challenged with C. Based on results, allergies were updated in patients’ charts, noting that tolerance of cephalosporins does not preclude penicillin allergy. Charts were reviewed to determine adverse events and antibiotic narrowing, the latter adjudicated by ID specialists not directly involved in the patient’s care. A cost analysis used the acquisition cost of administered antibiotics before and after testing.Results336 patients (53 Medical, 283 Surgical) underwent the allergy test dose protocol: 267 with reported P allergy, 47 C allergy, 22 P+C allergy. None had a major adverse reaction. 7 patients (2%) experienced minor reactions: rash (4), throat irritation (1), urticaria (1), wheezing (1). Before testing, 321/336 were prescribed inappropriate or broad antibiotics. After challenge dose testing, the antibiotic spectrum was narrowed in 308/321 (96%). The total Pharmacy cost savings was $38,281.00 with the optimized antibiotic regimen, translating to $630 saved per patient. In Surgical patients there was a 50% cost savings.ConclusionDespite the frequency with which β-lactam allergies are reported, few patients had an allergy that interfered with optimal treatment when tested. This standardized protocol can be safely performed in a community hospital setting and lead to improved antibiotic choice and pharmacy cost savings.ReferenceIammateo M et al, J Allergy Clin Immunol Pract, November 2014; 2, 768–74.Disclosures All authors: No reported disclosures.

1824. Care Transformation in Infectious Diseases: Using a Novel Approach for Tracking Antimicrobial Stewardship Metrics

BackgroundA key component of antimicrobial stewardship (AS) programs is the use of adequate metrics to monitor antimicrobial utilization. Limitations have been described in the literature for traditional metrics such as Defined Daily Doses (DDD) and Days of Therapy (DOT), including practitioner’s unfamiliarity with the terminology in relation to their meaning. This abstract describes an innovative approach developed by our organization that resulted in improved utilization of high-cost antimicrobials and increased the engagement of practitioners based on real-time (RT) analytics using a novel metric: Defined Daily Goal (DDG).MethodsA RT medication utilization dashboard (DB) for daptomycin (DAP) was created in October 2017 by clinical analysts and pharmacists. The DB provides a list of patients with active orders for DAP and compares the sum of active orders to the sum of available orders to meet the DDG. At Florida Hospital Orlando (FHO), the DAP goal based on national benchmark data were 6.8 days of therapy (DOT)/1,000 patient days (PDs) or a total of 240 orders/month. The average PDs/month was calculated to be 35, 380, thus the DAP DDG for FHO was determined to be 8 orders/day to meet a goal of 6.8 DOT/month. This goal of 8 DAP orders/day was built into the DB for daily AS team review. This calculation allowed for a conversion of our monthly DOT goal to a DDG equivalent.ResultsFrom October to December 2017, the DB identified an average of 230.7 orders/month at FHO, which was below the goal of 240 orders/month. Visualizing the daily goals for the number of allotted orders for DAP using a DDG format, this allowed the AS team to effectively meet the DOT/1,000 PDs goal. Focusing on the DDG combined with standard AS activities, resulted in a significant reduction of DAP utilization. When discussing utilization goals with ID specialists and general practitioners, the use of the DDG concept proved to be intuitive and facilitated understanding around specific metrics.ConclusionImplementation of a medication utilization RT DB, combined with the introduction of the DDG concept, allowed for an actionable measure to trend daily and facilitated the goals of our AS program. Based on this valuable information provided by the DB, this intiative has now been expanded to include other high-cost agents across all campuses.Disclosures All authors: No reported disclosures.

Vancomycin Prescribing Habits – Are We Still Afraid of Mississippi Mud?

Abstract Background Debates over the safety and efficacy of vancomycin have plagued clinical practice for more than half a century. A recent paradigm shift has occurred as the science of PK-PD has encouraged the use of optimized regimens which achieve targeted exposures. However, change is slow and we suspect prescribing habits may not be in line with this consensus approach. Herein, using data from electronic decision support software (EDSS), we describe clinicians’ vancomycin prescribing habits. Methods Data obtained over a 20-month period from an EDSS included: 1) clinician demographics; 2) patient demographics; 3) clinician-selected antimicrobials; and 4) EDSS suggested PK-PD optimized antimicrobial regimens. A vancomycin regimen was considered to be PK-PD optimized if the EDSS provided percent probability of PK-PD target attainment (PTA) was ≥90%. Results Data for 87 clinicians and 104 vancomycin-treated cases were available. Of all clinicians, 62% were clinical pharmacists, 38% were physicians, with close to half of being ID specialists. Of all the clinicians, 55% had ≥10 years of clinical experience. Of the 104 cases, the median (min, max) patient age, weight and creatinine clearance were 43.5 (23, &amp;gt;90) years, 81.6 (47.6, 170.6) kg, and 100.2 (7.3, 188.1) mL/min/1.73 m2, respectively. For 61.5% of selected vancomycin regimens, PTA were ≥90%. The distribution of PTA for the remaining 38.5% of cases is shown in Figure 1. Among these 38.5%, an alternative optimized regimen was presented 97.5% of the time. Further evaluation of clinician demographics among cases with a PK-PD optimized regimen demonstrated that 61% had ≥ 10 years clinical experience while only 44% of those who did not chose a PK-PD-optimized regimen had the same experience. While the majority of clinicians in both the optimized and non-optimized groups were clinical pharmacists, ID physicians represented 55% of all physicians who chose a non-optimized vancomycin regimen. Conclusion Data obtained from an EDSS demonstrated that clinicians who chose a non-optimized vancomycin regimen had less experience than those who chose an optimized regimen. Data suggest that education for optimizing vancomycin dosing using PK-PD is needed as part of antimicrobial stewardship training initiatives. Disclosures S. M. Bhavnani, ICPD Technologies: Shareholder, stock options. C. M. Rubino, ICPD Technologies: Shareholder, stock options. P. G. Ambrose, ICPD Technologies: Shareholder, stock options.

Infectious Disease Consultation Is Associated with Decreased Mortality with Enterococcal Bloodstream Infections

Background Enterococcal bloodstream infections (EBSI) have been attributed with significant morbidity and mortality. The objective of this study was to determine whether IDC is associated with improved mortality in patients hospitalized with EBSI.MethodsThis is a cross-sectional study of patients admitted to the University of Alabama Health System between January 1, 2015 and June 30, 2016 who had EBSI. Patients who died within 2 days of hospitalization were excluded. Categorical variables were analyzed with chi-square or Fisher’s exact test and continuous variables were analyzed with a t-test or Wilcoxon rank-sums test when appropriate. A P-value < 0.05 was considered significant. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CI) for factors associated with 30-day in-hospital mortality.ResultsA total of 213 patients met the case definition. One hundred and thirty-four (63%) received IDC. Baseline patient demographics and comorbidities were similar in both groups. Patients with IDC were more likely to have repeated blood cultures (99% vs. 72%, P < 0.001), echocardiogram performed (77% vs. 46%, P < 0.001), and interventions for source control (19% vs 6%, P = 0.01). Patients without IDC were more likely to have inappropriate antibiotic treatment or no antibiotics (20% vs. 0%, P < 0.001) as well as inappropriate duration of therapy (54% vs. 10%, P < 0.001). There were no differences in the rates of recurrent bacteremia or readmission within 60 days. Patients who did not receive IDC had higher 30-day in-hospital mortality (27% vs. 13%, P = 0.02). Having an echocardiogram (OR 2.75, 95% CI 1.36–5.55), surgical intervention (OR 3.11, 95% CI 1.07–9.05) and an IV catheter (OR 3.90, 95% CI 1.39–10.88) were associated with increased likelihood of IDC while inappropriate duration of antibiotics was associated with an 87% decreased likelihood of IDC (OR 0.13, 95% CI 0.06–0.29). The strongest association observed with 30-day mortality was inappropriate duration of antibiotics (OR 4.93, 95% CI 1.93–12.61).ConclusionIDC was associated with reduced 30-day in-hospital mortality in patients with EBSI. Although further investigation is warranted, the results of this study suggest that early involvement of ID specialists in EBSI may lead to better outcomes.Disclosures All authors: No reported disclosures.

240Effectiveness of a Pharmacist Driven Antibiotic Stewardship Program at Two Critical Access Hospitals Using a Remote Infectious Diseases Pharmacist

• New Ulm Medical Center (NUMC) and River Falls Area Hospital (RFAH), both part of Allina Health, are critical access hospitals (CAHs) with 62 and 25 licensed beds, respectively. • Antimicrobial stewardship programs (ASPs) improve patient care by reducing inappropriate antimicrobial use, antimicrobial resistance, and hospital-acquired infections. • Guidelines recommend an ASP be led by an ID physician and ID-trained pharmacist; however, these resources are often difficult to obtain. • The purpose of this study was to evaluate the effectiveness of a pharmacist-driven ASP in two CAHs using a remote ID pharmacist and ID pharmacy resident within the same healthcare system as the ID specialists overseeing the ASP.

Medical Center Support for Transplant Infectious Diseases Programs.

Introduction: Transplant Infectious Diseases (TxID) as a subspecialty has gained popularity in the past decade. However, the number and characteristics of formal TxID programs are unknown, and TxID program and personnel support varies. We sought to provide insight into these issues through a survey of members of the ID Community of Practice (COP). Methods: An electronic survey was sent to ID specialists registered with the AST ID COP. Each transplant center received one survey to limit duplication. Survey questions related to transplant center demographics, TxID program structure, and sources of financial support for the TxID program. Results: Of 116 questionnaires, 51 (44.0%) were returned (41 adult, 7 pediatric centers, 3 incomplete). Of the 41 evaluable surveys from adult programs, 36 (87.8%) had a dedicated TxID program. The median number of solid organ transplants (SOT) annually was 250 (range 0 - 565), hematopoietic stem cell transplants (HCT) 55 (range 0-450), and total transplants 260 (range 50 to 780). In programs that provided staffing details, there was a range of 1 to 12 TxID specialists (median 3.0, mean 3.8). Ratio of TxID staff per SOT per year was calculated (mean 60, range 15-254), but no association was seen between ratio and institutional salary support. There was a greater likelihood of salary support for TxID in larger SOT programs (>250 SOT/year) as compared with small or medium sized programs (13/15 large programs vs. 1/6 small programs), provided as direct funds (47.6%) or full-time equivalents (FTE) (52.4%). Non-salary support was more common in larger programs and included office space (37.2%), administrative (27.9%), and research support (16.3%). The majority of support came from the medical center or the ID division. Five programs offered a TxID fellowship program. Conclusions: Larger transplant programs were more likely to offer institutional support for TxID Programs, via FTEs as well as non-salary support. Analysis of these patterns may offer prospects for obtaining assistance to programs lacking support, with the goal of improving outcomes after SOT and HCT transplantation.

Antimicrobial Shortages Threaten Patient Care Quality

BOSTON – Some antimicrobial agents are in such short supply that a majority of infectious disease specialists surveyed reported having to switch to a more toxic or expensive alternative, adversely affecting patient care, reported investigators at the annual meeting of the Infectious Diseases Society of America. Among 634 members of the IDSA’s Emerging Infections Network, 78% said they had to modify their antimicrobial choice because of a shortage of the preferred agent within the past 2 years, and 52% reported that the shortage had adversely affected patient care or outcomes, said Dr. Philip M. Polgreen of the University of Iowa in Iowa City. Fully 70% of the ID specialists learned of the shortage from the pharmacy only after they had prescribed the drug, and only 24% said they found out about the shortage from an official source such as the Food and Drug Administration’s Drug Shortages website. “Some of the adverse effects that were reported were exposing a patient to a more toxic drug, exposing them to a much more expensive drug, exposing them to a drug with a much broader spectrum than was needed, and in some cases the physician reported that a patient had to stay longer in the hospital or had a failure of therapy,” Dr. Polgreen said at a briefing. In a subgroup of 250 respondents, 28% said that patients incurred long-term morbidity from inadequate treatment. The drugs that are reported to be in short supply tend to be those recommended for less common infections. The study was not designed to examine reasons for shortages. The drugs reported most frequently to be unavailable or in short supply include the intravenous formulation of trimethoprim/sulfamethoxazole (Bactrim), amikacin (Amikin), aztreonam (Azactam), foscarnet (Foscavir), and penicillin G. Other agents in short supply include oseltamivir (Tamiflu) oral suspension, and acyclovir (Zovirax) tablets, as well as injectable biologic agents and vaccines, including intravenous immune globulin, live zoster vaccine, yellow fever vaccine, and inactivated influenza vaccine. The investigators sent a web-based survey with nine questions to all 1,350 members of the IDSA-EIN, a sentinel network of physicians. They received a total of 634 responses (47% response rate). Dr. Polgreen acknowledged that members who had encountered a drug shortage were more likely to respond. He said that physicians need more effective ways of learning about impending or current shortages and acceptable alternatives to first-line agents. Such efforts are particularly important in light of the fact that there are very few antimicrobial agents in the drug development pipeline, he said. In a separate presentation, Dr. Helen Boucher, of Tufts Medical Center, Boston, and her colleagues reported that drug companies aren’t exactly scrambling to solve the problem of antimicrobial resistance to existing agents. The researchers identified nine drugs in clinical development for parenteral use against gram-negative bacilli. Of these agents, only two have novel mechanism of action, and none is being studied for efficacy against community-acquired bacterial pneumonia, or hospitalor ventilator-associated pneumonia. The number of new antibiotics approved for marketing in the United States annually continues to decline, and major pharmaceutical companies are slackening the pace of antimicrobial agent development, Dr Boucher said. “We all know that with antibiotics, attrition happens, so that even in the later stages of development, we can’t count on getting all or even a majority of these compounds to market,” she said. Dr. Polgreen’s study was supported by the Centers for Disease Control and Prevention. He reported no conflict of interest. Dr. Boucher disclosed serving on an adjudication committee for Merck and as a consultant to Merck, Wyeth/ Pfizer, Durata, and PolyMedix. CfA

Aggressive Attack on C. difficile Results in Significant Decrease in Hospital Infection Rate - The INTEGRIS Baptist Medical Center Experience

Purpose: In recent years there has been a dramatic increase in frequency of Clostridium difficile infection (CDI), with CDC estimates of 500,000 cases in the U.S. annually, with approximately 15,000 deaths. INTEGRIS Baptist Medical Center, a tertiary care facility in Oklahoma City admitting approximately 26,000 patients per year, experienced a similar increase in CDI. Methods: A “war on C. diff” committee was formed, consisting of GE's, ID specialists, an internist and the nursing head of infection control. We initiated a multi-faceted attack on CDI, including improved prevention, early detection and aggressive treatment measures. National SHEA infection control guidelines were reviewed and fully implemented. In addition to standard isolation procedures, we elicited suggestions from physicians and nurses to best ensure compliance, such as: trash can near door to avoid traversing room after de-gowning; uncluttered sink area; appropriate size gloves; easily accessible stethoscopes. We held multiple discussions with physician groups and nursing leaders about our goals. Periodic “snapshots” of physician and nursing staff compliance with isolation procedures was undertaken. We initiated a campaign to limit proton pump inhibitor use outside of critical care units. We encouraged nursing staff to send stool for CDT if CDI was suspected, without waiting for physician order, so as to cut the “lead time” between earliest symptom of CDI and initiation of isolation and treatment. We initiated a C. diff prevention trial on the general medical service. Consenting patients who required in-hospital antibiotics were randomized, in 2:1 fashion, to receive concurrent probiotics vs. placebo. Daily reports on CDT positive specimens are reviewed for patient characteristics and hospital location. Review of CDT positive cases revealed a disproportionately high rate of CDI in our transplant population. Consequently, we plan to initiate a C. diff prevention trial assessing both efficacy and safety of probiotics in the transplant population. Stools were tested for CDT using enzyme immunoassay; methodology remained the same throughout the study intervals. Results: In the 12 months prior to our interventions, the incidence of CDT positive hospitalized patients was 11.3 per 1000 admissions (national average reported as 13 per 1000). After a 3 month implementation period, the ensuing 12 month CDT positive incidence fell to 6.9 per 1000 patients, a decrease in CDI incidence of 40%. The rate of CDT (+) patients also decreased on the Transplant unit from 6.8% during months 1-6 post implantation, to 3.6% in months 7-12. Conclusion: A “war on C. diff” can have a significant positive impact on a hospital's rate of CDI.

Curbside Consults by ID Specialists Do Add Up

Curbside Consults by ID Specialists Do Add Up