Infectious Diseases Consultation Research Articles

Empirical treatment and mortality in bacteremia due to extended spectrum β-lactamase producing Enterobacterales (ESβL-E), a retrospective cross-sectional study in a tertiary referral hospital from Colombia

BackgroundInfections caused by extended spectrum β-lactamase (ESβL) producing bacteria are common and problematic. When they cause bloodstream infections, they are associated with significant morbidity and mortality.MethodsA retrospective cross-sectional observational study was conducted in a single center in Pereira, Colombia. It included people hospitalized with bacteremia due to gram-negative bacilli with the extended-spectrum β-lactamase producing phenotype. A logistic regression analysis was constructed. Clinical characteristics and risk factors for death from sepsis were established.ResultsThe prevalence of bacteremia due to Enterobacterales with extended-spectrum β-lactamase producing phenotype was 17%. 110 patients were analyzed. Most patients were men (62%) with a median age of 58 years, hospital mortality was 38%. Admission to intensive care was 45%. The following risk factors for mortality were established: shock requiring vasoactive support, Pitt score > 3 points, and not having an infectious disease consultation (IDC).Conclusionsbacteremia due to Enterobacterales with extended-spectrum β-lactamase producing phenotype have a high mortality. Early recognition of sepsis, identification of risk factors for antimicrobial resistance, and prompt initiation of appropriate empiric antibiotic treatment are important. An infectious disease consultation may help improve outcomes.

Reduction strategies for inpatient oral third-generation cephalosporins at a cancer center: An interrupted time-series analysis.

Oral third-generation cephalosporins (3GCs) are not recommended for use owing to their low bioavailability and the risk of emergence of resistant microorganisms with overuse. A standardized and effective method for reducing their use is lacking. Here, in a 60-month, single-institution, interrupted time-series analysis, which was retrospectively conducted between April 1, 2017, and March 31, 2022, we evaluated the effectiveness of a four-phase intervention to reduce the use of 3GCs in patients at a cancer center: Phase 1 (pre-intervention), Phase 2 (review of clinical pathways), Phase 3 (establishment of infectious disease consultation service and implementation of antimicrobial stewardship program), and Phase 4 (educational lecture and pop-up displays for oral antimicrobials at the time of ordering). Although no significant changes were observed in Phases 3 and 4, the first intervention resulted in a significant decrease in the trend and level of days of therapy (DOT) for 3GCs. The level for cephalexin DOT and the trend for sulfamethoxazole-trimethoprim DOT increased in Phase 4, and the trend for amoxicillin and amoxicillin-clavulanate DOT increased in Phase 3. Macrolide DOT showed a decreasing trend in Phases 2 and 4 and decreasing and increased levels in Phases 3 and 4, respectively; no change was observed for quinolones. Actual and adjusted purchase costs of 3GCs decreased significantly during all study periods, while those for oral antimicrobials decreased in Phase 2, and actual purchase costs increased in Phases 3 and 4. No significant reduction in resistant organisms, length of hospital stay, or mortality was observed. This is the first study on the effects of oral 3GC reduction strategies in patients with cancer. We conclude that even facilities that substantially use antimicrobials can efficiently reduce the use of 3GCs.

Screening Chest CT Prior to Allogenic Hematopoietic Stem Cell Transplantation

Pulmonary complications constitute a major cause of morbidity and mortality in the post-allogenic hematopoietic stem cell transplant (alloHSCT) period. While Chest X-ray (CXR) is customarily used for screening, we have utilized chest computed tomography (CT). To characterize the prevalence of abnormalities and explore their impact on alloHSCT eligibility and outcomes post-transplant, we conducted a retrospective analysis utilizing real-world data collected at our center for adult patients who were evaluated for alloHSCT from January 2013 through December 2020 and identified 511 eligible patients. The most common primary disease was acute myeloid leukemia in 49% of patients, followed by myelodysplastic syndrome in 23%, lymphoma in 11%, and acute lymphocytic leukemia in 10%. Abnormal screening chest CT was found in 199 patients (39%). The most frequent detected abnormality was pulmonary nodule in 78 patients (35%), followed by consolidation in 42 (19%), ground-glass opacification in 33 (15%), bronchitis and bronchiolitis in 25 (11%), pleural effusions in 14 (6%), and new primary cancer in 7 (2%). CXR detected abnormalities in only about half of the patients (48%) with an abnormal chest CT. Among 199 patients with abnormal chest CT, 98 patients (49%) underwent further assessment and/or intervention before transplant. The most common work up was pulmonary consultation in 32%, infectious diseases consultation in 24%. Lung biopsy was obtained in 20% and antimicrobial therapy was initiated after confirming an infection diagnosis in 20% of patients. Patients with abnormal chest CT demonstrated worse overall survival (P= 0.032), non-relapse mortality (P=0.015), and pulmonary related death (P < 0.001) compared to those who had normal chest CT. Our study suggests that pre-transplant screening chest CT is beneficial in uncovering invasive infections and underlying malignancies and allows appropriate interventions before alloHSCT to prevent potentially serious post-transplant complications without causing a delay in alloHSCT. Nevertheless, abnormal CT findings prior to transplant may be associated with overall worse prognosis.

Predictors of mortality of Staphylococcus aureus bacteremia among patients hospitalized in a Swiss University Hospital and the role of early source control; a retrospective cohort study

S. aureus bacteremia is associated with high mortality. The aim was to identify predictors of mortality among patients with S. aureus bacteremia and evaluate the role of early source control. This retrospective study was conducted at the Lausanne University Hospital, Switzerland. All episodes of S. aureus bacteremia among adult patients from 2015 to 2021 were included. During the study period, 839 episodes of S. aureus bacteremia were included, of which 7.9% were due to methicillin-resistant isolates. Bacteremias were related to bone or joint infections (268; 31.9%), followed by bacteremia of unknown origin (158; 18.8%), proven endocarditis (118; 14.1%) and lower-respiratory tract infections (79; 9.4%). Overall 28-day mortality was 14.5%. Cox multivariate regression model showed that Charlson comorbidity index > 5 (P < 0.001), nosocomial bacteremia (P 0.019), time to blood culture positivity ≤ 13 h (P 0.004), persistent bacteremia for ≥ 48 h (P 0.004), sepsis (P < 0.001), bacteremia of unknown origin (P 0.036) and lower respiratory tract infection (P < 0.001) were associated with 28-day mortality, while infectious diseases consultation within 48 h from infection onset (P < 0.001) was associated with better survival. Source control was warranted in 575 episodes and performed in 345 episodes (60.0%) within 48 h from infection onset. Results from a second multivariate analysis confirmed that early source control (P < 0.001) was associated with better survival. Mortality among patients with S. aureus bacteremia was high and early source control was a key determinant of outcome. Infectious diseases consultation within 48 h played an important role in reducing mortality.

P601 Pneumococcal vaccination in patients with immunomediated inflammatory diseases (IMIDs) using a real-world multidisciplinary project

Abstract Background Vaccination is a crucial element in managing patients with IMIDs, however rates of vaccination remains suboptimal. This study assessed the adherence to pneumococcal vaccination. Methods A prospective cohort study was conducted between January 2020 and December 2021. Vaccine prescription and adherence were assessed during an Infectious Diseases (ID) consultation. Were considered pneumococcal conjugate (PCV13) and polysaccharide (PPS23) vaccines. Results There were 262 patients included (215 with inflammatory bowel disease and 47 with rheumatological diseases), 136 (52%) were male, median age was 41±15 years and 167 (64%) were on immunossuppresive therapy. At baseline, 26 (10%) patients were fully vaccinated against pneumococcal disease and for 236 (90%) vaccination was prescribed as such: PCV13 followed by PPSV23 in 86 (36%) patients, PCV13 in 126 (54%) and PPSV23 in 24 (10%). Adherence to PCV13 occurred in 185 (87%) patients and to PPSV23 in 76 (69%). In patients with both vaccines prescribed (n=86), 57 (66%) had complete adherence and the remaining had at least one of them. In this group (n=86), patients with complete adherence were older than the remaining (45±17 vs. 38±12 years, p=0.03) but no difference was found concerning the baseline disease. After the ID consultation, 175 patients from 236 (74%) became fully vaccinated against pneumococcal disease. Conclusion A multidisciplinary approach and adequate local interventions shall be considered to improve vaccine adherence. ID physicians can play a role in the process of increasing vaccine prescription and adherence.

Antibiotic appropriateness for Gram-negative bloodstream infections: impact of infectious disease consultation

Background We investigated the role of infectious disease consultation (IDC) on therapeutic appropriateness in Gram-negative bloodstream infections (GNBSIs) in a setting with a high proportion of antibiotic resistance. Secondary outcomes were in-hospital mortality and the impact of rapid diagnostic tests (RDTs). Methods Retrospective study on hospitalised patients with GNBSIs. Therapy was deemed appropriate if it had the narrowest spectrum considering infection and patients’ characteristics. Interventional-IDC (I-IDC) group included patients with IDC-advised first appropriate or last non-appropriate therapy. Time to first appropriate therapy and survival were evaluated by Kaplan-Meier curves. Factors associated with therapy appropriateness were assessed by multivariate Cox proportional-hazard models. Results 471 patients were included. High antibiotic resistance rates were detected: quinolones 45.5%, third-generation cephalosporins 37.4%, carbapenems 7.9%. I-IDC was performed in 31.6% of patients (149/471), RDTs in 70.7% (333/471). The 7-day probability of appropriate treatment was 91.9% (95% confidence interval [95%CI]: 86.4–95.8%) vs. 75.8% (95%CI: 70.9–80.4%) with and without I-IDC, respectively (p-value = 0.0495); 85.5% (95%CI: 81.3–89.1%) vs. 69.4% (95%CI: 61.3–77.2%) with and without RDTs, respectively (p-value = 0.0023). Compared to RDTs alone, the combination with I-IDC was associated with a higher proportion of appropriate therapies at day 7: 81.9% (95%CI: 76.4–86.7%) vs. 92.6% (95%CI: 86.3–96.7%). At multivariate analysis, I-IDC and RDTs were associated with time to first appropriate therapy [adjusted hazard-ratio 1.292 (95%CI: 1.014–1.647) and 1.383 (95%CI: 1.080–1.771), respectively], with no impact on mortality. Conclusions In a setting with a high proportion of antibiotic resistance, IDC and RDTs were associated with earlier prescription of appropriate therapy in GNBSIs, without impact on mortality.

P23 The SMASH survey: Subscription Models for Antibiotics in Hospital—preliminary results

Abstract Objectives On 1 July 2022 NHS England launched a novel delinked ‘subscription-type’ payment model for two new antimicrobials, ceftazidime/avibactam and cefiderocol. The SMASH survey (Subscription Models for AntibioticS in Hospitals) aims to capture the views of Infectious Diseases and Microbiology Consultants on key knowledge gaps around the implementation and impact of this model in the NHS. Methods A novel questionnaire was developed and piloted for this survey (https://www.surveymonkey.co.uk/r/SMASHsurvey). The target audience included Consultants in Infectious Diseases and/or Medical Microbiology working at least 1 day per week (2 Programmed activities or equivalent) in an NHS acute hospital in England. The questionnaire was distributed to all eligible Consultants in England using a network of local investigators in 35 key locations around the country. The SMASH survey was sponsored by the London School of Hygiene and Tropical Medicine (REC Reference No 28161/RR/29296) and funded by an independent research grant from Shionogi B.V. Results A total of 111 complete responses were received within the first 21 days of the survey launch. Most responders (55.9%, 62/111) had a CCT in Microbiology or Infectious Diseases and Medical Microbiology (26.1%, 29/111). Only 57.6% (64/111) reported having heard of the new funding model before completing the survey, yet the majority (72.1%, 80/111) agreed that it is a welcome development in the management of drug-resistant infections. Some Consultants reported that cost is a significant consideration when using specific antimicrobials (46.8% Agree or Strongly Agree), while other Consultants were unsure (19.8% Neither Agree or Disagree) or disagreed with this statement (33.4% Disagree or Strongly Disagree). Using a 5-point scoring system and other antimicrobials for carbapenem-resistant infections as comparators, responders indicated that they believed ceftazidime/avibactam and cefiderocol had high insurance (4.28/5 and 4.16/5 respectively) and diversity value (4.11/5 and 4.07/5), moderate enablement (3.37/5 and 3.15/5) and transmission value (3.12/5 and 3.00/5) and low spectrum value (2.13/5 and 2.16/5). Meropenem recorded the highest score for enablement value (3.77/5) and transmission value (3.31/5), while Fosfomycin the highest score for spectrum value (3.06/5). With regards to antimicrobial stewardship, only 20.7% (23/111) of Consultants agreed that the new funding model will lead to reduced use of carbapenems. 46% of responders (51/111) would consider using the two newly introduced antibiotics empirically, when risk factors for antimicrobial resistance are present, while the rest would only use them in microbiologically confirmed carbapenem-resistant infections. The most important resistance risk factors that would justify empirical use were previous infection with carbapenem-resistant bacteria (81.1%), current colonisation with carbapenem-resistant bacteria (73.9%), ward outbreak of carbapenem-resistant bacteria (68.5%), clinical treatment failure of carbapenems (63.1%) and recent admission to high prevalence hospital for carbapenem-resistant bacteria (46.9%). Conclusions The ‘subscription type’ payment model for antimicrobials was introduced in England 5 months ago, yet many infection specialists have not been informed about it. Its effect on stewardship is currently uncertain and introduced antimicrobials are likely to be used empirically. Infection specialists in England agree that new antimicrobials have benefits beyond the treatment of an individual patient, especially in terms of insurance and diversity value.

Perceived barriers and facilitators to the adoption of telemedicine infectious diseases consultations in southeastern Missouri hospitals

Introduction Telemedicine infectious diseases consultations (tele-ID consults) improves access to healthcare for underserved/resource-limited communities. However, factors promoting or hindering implementation of tele-ID consults in low-resource settings are understudied. This study sought to fill this gap by describing perceived barriers and facilitators tele-ID consults at three rural hospitals in southeastern Missouri. Methods Twelve in-depth, semi-structured interviews were conducted with a purposively sampled group of information-rich hospital stakeholders from three rural, southeastern Missouri hospitals with partial or no on-site availability of ID physicians. Our literature-informed interview guide elicited participants’ knowledge and experience with tele-ID consults, perceptions on ID consultation needs, and perceived barriers to and facilitators of tele-ID consults. Interview transcripts were coded using an iterative process of inductive analysis to identify core themes related to barriers and facilitators. Results Perceived barriers to adopting and implementing tele-ID consults included logistical challenges, technology and devices, negative emotional responses, patient-related factors, concerns about reduced quality of care when using telemedicine, lack of acceptance or buy-in from physicians or staff, and legal concerns. Key facilitators included perceived need, perceived benefits to patients and physicians, flexibility and openness to change among staff members and patients, telemedicine champions, prior experiences, and enthusiasm. Discussion Our findings demonstrate that rural hospitals need tele-ID consults and have the capacity to implement tele-ID consults, but operational and technical feasibility challenges remain. Adoption and implementation of tele-ID consults may reduce ID-physician shortage-related service gaps by permitting ID physician's greater geographic reach.

Impact of a Dedicated Pretransplant Infectious Disease Consultation on Respiratory Tract Infections in Kidney Allograft Recipients: A Retrospective Study of 516 Recipients.

Respiratory tract infections (RTIs) are a leading cause of death after kidney transplant. Preventive strategies may be implemented during a dedicated infectious disease consultation (IDC) before transplantation. Impact of IDC on RTIs after transplant has not been determined. We conducted a monocentric retrospective cohort analysis including all kidney transplant recipients from January 2015 to December 2019. We evaluated the impact of IDC on RTIs and identified risk and protective factors associated with RTIs. We included 516 kidney transplant recipients. Among these, 145 had an IDC before transplant. Ninety-five patients presented 123 RTIs, including 75 (61%) with pneumonia. Patient that benefited from IDC presented significantly less RTIs (p = 0.049). RTIs were an independent risk factor of mortality (HR = 3.64 (1.97-6.73)). Independent risk factors for RTIs included HIV (OR = 3.33 (1.43-7.74)) and HCV (OR = 3.76 (1.58-8.96)). IDC was identified as an independent protective factor (OR = 0.48 (0.26-0.88)). IDC prior to transplantation is associated with diminished RTIs and is an independent protective factor. RTIs after kidney transplant are an independent risk factor of death. Implementing systematic IDC may have an important impact on reducing RTIs and related morbidity and mortality.

Post-sign-off events in infectious disease consultation and the incidence of nonadherence to infectious disease recommendations in the post-sign-off period: A retrospective cohort study.

Infectious diseases (ID) consultation has contributed to improving outcomes in hospitalized patients. However, the timing of signing off on ID consultation varies, depending on the consulting ID physician. We studied the descriptive epidemiology of treatment-related adverse events (ADEs) occurring after the ID physician has signed off on consultation and the epidemiology and predictors of nonadherence to ID recommendations in the post-sign-off period. This retrospective cohort study was conducted at a Japanese tertiary-care center. All patients who received ID consultation between January and December 2019 and treatment recommendations for a confirmed or suspected infectious disease were included. The incidence of any treatment-related ADE after signing off, nonadherence to the final ID recommendations, and factors associated with nonadherence to the ID recommendations were identified. In total, 367 patients receiving ID consultation were included. The incidence of post-sign-off events during index hospitalization was 59 (16.1%) of 367, with antimicrobial-associated ADEs accounting for 26 events (44.1%) and HAIs accounting for 13 events (22.0%). After excluding patients who discontinued treatment, nonadherence to ID recommendations was identified in 55 (15.7%) of 351 patients. Newly acquired HAIs during the index hospitalization after signing off on ID consultation was an independent risk factor for nonadherence to ID recommendations (adjusted odds ratio, 3.78; 95% confidence interval, 1.14-12.52). Post-sign-off events were common and led to nonadherence to ID recommendations during the post-sign-off period. Because this nonadherence occurs for various reasons, patients may require continued attention after signing off to ensure their safety.

Outcomes of high-dose oral beta-lactam definitive therapy compared to fluoroquinolone or trimethoprim-sulfamethoxazole oral therapy for bacteremia secondary to a urinary tract infection.

Compare outcomes of patients receiving high-dose oral beta-lactam versus standard oral therapy for Enterobacterales bacteremia from a urinary tract infection (UTI). Retrospective, multicenter, observational cohort. Three Michigan community teaching hospitals. Adult patients admitted between February 1, 2020, and October 1, 2022, with gram-negative bacteremia from a urinary source were evaluated. Patients receiving active empiric intravenous (IV) antibiotics and transitioned to appropriately dosed oral cephalexin, amoxicillin, fluoroquinolone (FQ), or trimethoprim/sulfamethoxazole (TMP/SMX) were included. Patients receiving less than 72 hours of oral therapy, diagnosed with renal abscess, lobar nephronia, or expired during admission were excluded. Standard oral therapy was defined as FQ or TMP/SMX. The primary outcome compared the composite of recurrent bacteremia or mortality within 30 days of therapy between groups. Secondary outcomes compared recurrent UTI, emergency department or hospital readmission, and Clostridioides difficile within 30 days. 194 patients were included (beta-lactam, n = 75 vs standard therapy, n =119). Patients in both groups were treated for a median of 11 days, with 4 days IV and 7 days oral therapy. There was no difference in the primary outcome between groups (beta-lactam 1.3% vs standard therapy 1.7%, OR 1.27 [95% CI 0.11-14.2]). No patients experienced C. difficile in either group (p = 1.0). Infectious disease consultation was independently associated with standard therapy prescribing (OR 4.4 [95% CI 2.24-8.26]). High-dose oral beta-lactams were as safe and effective as oral FQ or TMP/SMX for the treatment of bacteremia from a urinary source. Most patients received 8-10 days of therapy in both groups.

Best practices, implementation and challenges of outpatient parenteral antimicrobial therapy: results of a worldwide survey among healthcare providers.

Outpatient Parenteral Antimicrobial Therapy (OPAT) is considered a patient-friendly and cost-effective practice. Patients in the OPAT service can be at risk for developing adverse events. Due to extensive variations in practice, guidelines have been developed to minimize the risks. In this first worldwide survey on OPAT, we explored the current OPAT services around the world, adherence to recommendations and identified best practices and challenges from different perspectives. An e-survey was conducted and consisted of questions about demographics, characteristics of the OPAT service, role of pharmacy, future developments, and respondents' views on improvements as well as best practices. A total of 126 responses from 28 countries were included. Seventy-eight percent (78%) of the respondents stated that their facility provides antimicrobial therapy in the outpatient setting, whereas 22% did not. Forty-two percent (42%) of the hospitals with OPAT services had a specialized OPAT service, while 14% lacked specialized services and 22% had a partially specialized team in place. In facilities with a specialized OPAT service, the number of mandatory infectious disease (ID) consultations before discharge and clinical monitoring by an ID specialist or OPAT team member, the frequency of monitoring, and the availability of an OPAT registry were higher. A multidisciplinary team's presence was commonly noted as best practices. On the other hand, respondents experienced difficulties with reimbursement and lack of standardization in the screening, follow-up and monitoring of patients. This survey provides a better understanding of the implementation and practices of OPAT services globally and describes best practices and the challenges from different professionals.

Antibiotic prescribing behavior among physicians in Asia: a multinational survey.

To evaluate antibiotic prescribing behavior (APB) among physicians with various specialties in five Asian countries. Survey of antibiotics prescribing behavior in three stages (initial, on-treatment, and de-escalation stages). Participants included internists, infectious diseases (ID) specialists, hematologists, intensivists, and surgeons. Participants' characteristics, patterns of APB, and perceptions of antimicrobial stewardship were collected. A multivariate analysis was conducted to evaluate factors associated with appropriate APB. There were 367 participants. The survey response rate was 82.5% (367/445). For the initial stage, different specialties had different choices for empiric treatment. For the on-treatment stage, if the patient does not respond to empiric treatment, most respondents will step up to broader-spectrum antibiotics (273/367: 74.39%). For the de-escalation stage, the rate of de-escalation was 10%-60% depending on the specialty. Most respondents would de-escalate antibiotics based on guidelines (250/367: 68.12%). De-escalation was mostly reported by ID specialists (66/106: 62.26%). Respondents who reported that they performed laboratory investigations prior to empirical antibiotic prescriptions (aOR = 2.83) were associated with appropriate use, while respondents who reported ID consultation were associated with appropriate antibiotic management for infections not responding to empiric treatment (aOR = 40.87); adherence with national guidelines (aOR = 2.57) was associated with reported successful carbapenem de-escalation. This study highlights the variation in practices and gaps in appropriate APB on three stages of antibiotic prescription among different specialties. Education on appropriate investigation, partnership with ID specialist, and availability and adherence with national guidelines are critical to help guide appropriate APB among different specialties.

Mixed methods evaluation of handshake antimicrobial stewardship on adult inpatient medicine floors.

To evaluate the effects of handshake antimicrobial stewardship on medicine floors at a large tertiary care hospital. Retrospective observational study. 1,278-bed academic hospital. Adults admitted to non-ICU medicine services. A handshake stewardship team consisting of an infectious diseases (ID) physician and pharmacist reviewed charts of patients receiving antimicrobials on medicine floors without a formal ID consult. Recommendations were communicated in-person to providers and acceptance rates were examined with descriptive statistics. Additional data regarding program perception among providers were obtained via surveys. Antibiotic usage trends were extracted from National Healthcare Safety Network Antimicrobial Use option data and evaluated using an interrupted time-series analysis pre- and post-intervention. The overall acceptance rate of interventions was 80%, the majority being recommendations either to discontinue (37%) or de-escalate therapy (28%). Medical residents and hospitalists rated the intervention favorably with 90% reporting recommendations were helpful all or most of the time. There was a statistically significant decrease in vancomycin (78 vs 70 DOT/1,000 d present (DP), p = 0.002) and meropenem (24 vs 17 DOT/1,000 DP, p = 0.007) usage and a statistically significant increase in amoxicillin-clavulanate usage (11 vs 15 DOT/1,000 DP, p < 0.001). Overall antibiotic usage remained unchanged by the intervention, though pre-intervention there was a nonsignificant overall increasing trend while post-intervention there was a nonsignificant decreasing trend in overall usage. There was no change in in-hospital mortality. The addition of handshake stewardship with adult medicine services was favorably viewed by participants and led to shifts in antibiotic usage.

Antibiotic treatment durations for common infectious diseases in Switzerland: comparison between real-life and local and international guideline recommendations

Shortening the duration of antibiotic therapy (DAT) for common infectious diseases may be an effective strategy to tackle antimicrobial resistance. Shorter DAT has been proven safe and effective for community-acquired pneumonia (CAP), cellulitis, and cholangitis. In a retrospective multicentre quality-control study, medical records of 770 patients hospitalized with CAP, cellulitis, and cholangitis at three tertiary care hospitals in Switzerland during 2017-2018 were randomly selected. Appropriateness of antibiotic treatment duration was assessed according to international and local guidelines. Records of 271, 260, and 239 patients with CAP, cellulitis, and cholangitis were included, respectively. Median DAT was seven days (interquartile range [IQR] 6-9), ten days (IQR 8-13), and nine days (IQR 6-13) in CAP, cellulitis, and cholangitis, respectively. DAT longer than recommended by local and international guidelines was observed in 32% and 37% of CAP patients, 23% and 70% of cellulitis patients, and 33% and 37% of cholangitis patients, respectively. Positive blood cultures (odds ratio [OR]=2.42 (95% confidence interval [CI] 1.33-4.34]), infectious diseases consultation (OR=1.79 [95% CI 1.05-2.78]), impaired renal function (OR=0.99 [95% CI 0.98-1.00] per 1 ml/min / 1.73 m2 increase in estimated glomerular filtration rate) and a higher degree of inflammation on admission (OR=1.0 [95% CI 1.001-1.005] per 10 mg/L increase in C-reactive protein) were independently associated with a DAT longer than recommended in international guidelines. DAT exceeded recommendations in a significant proportion of patients with mostly community-acquired infections.

1021. The post-sign-off events of Infectious Diseases (ID) consultation and the incidence of non-adherence to ID consultation during the post-sign-off period: A retrospective cohort study

Abstract Background Infectious Diseases (ID) consultation has contributed to improving the quality of care in inpatient settings. ID physicians traditionally examine patients and provide the final treatment recommendations (i.e., sign-off ID consultation). However, patients may acquire antimicrobial-associated adverse drug events (AAADE) and healthcare-associated infections (HAI) after the sign-off ID consultation. Moreover, it is unclear how these events that occurred during the post-sign-off period were managed. The study aims to scrutinize the post-sign-off events and the current epidemiology of non-adherence to ID recommendations during the post-sign-off period. Methods The retrospective cohort study was performed at a Japanese tertiary care center. Among all ID consultation cases from January to December 2019, those with general ID consultation with treatment recommendations given for the definitive or suspected infectious diseases were included for analysis. The instances of post-sign-off events included AAADE, HAI, and treatment failure of established infections. Non-adherence to ID consultation was defined as the failure of the primary care team to complete ID final recommendations. The incidence of the post-sign-off events and outcomes associated with nonadherence to ID consultations were investigated. Results Among 762 ID consultations that occurred, 367 cases were included for analysis. The incidence of the post-sign-off events was 10.9% (40/367), and AAADEs accounted for 62.5% (25/40) of cases. Non-adherence to ID consultation occurred in 105 (28.6%) cases, and prolonged antimicrobial therapy beyond ID consultation was the most common reason for non-adherence. The primary care team modified antimicrobial therapy in approximately two-thirds of cases (71/105) without ID re-consultation. The length of hospital stay was longer in patients with non-adherence to ID consultation than in those with adherence (36 versus 29 days; p=0.002). Conclusion The post-sign-off events of ID consultation commonly occur, leading to nonadherence to ID consultation during the post-sign-off period. Because nonadherence may be associated with worse clinical outcomes, attention after the sign-off ID consultation is needed to ensure patient safety. Disclosures All Authors: No reported disclosures.

970. The Time for Action is Now: The Impact of Timing with Infectious Diseases Consultation for Staphylococcus aureus Bacteremia

Abstract Background Staphylococcus aureus bacteremia (SAB) is one of the leading causes of bloodstream infections complicated by metastatic diseases leading to extended lengths of stay (LOS). Infectious disease (ID) consultation is associated with greater adherence to standards of care and improved clinical outcomes. There are sparse data evaluating the impact of the timing for ID consult on SAB management. The purpose of this study was to compare the difference in clinical outcomes in patients with SAB who received an early (&amp;lt; 5 days) versus late (≥ 5 days) ID consult. Methods This was an IRB-approved, retrospective, cohort study in hospitalized adult patients with SAB who received an ID consultation between 2015 and 2020. The timing of the ID consult was defined from the order of the index positive blood culture to the placement of the consult. The composite primary endpoint included: identifying the source of SAB, follow-up cultures, obtaining an echo, use of parenteral therapy, and treatment duration. Secondary endpoints included mortality, recurrence, LOS, duration of bacteremia, and readmission rates (30, 60, and 90-day). A machine learning algorithm (MLA) was utilized to determine an alternative to the 5 days threshold for early vs late. Results A total of 321 patients with SAB were included with baseline characteristics (Table 1). The early group was more likely to meet the primary endpoint (62.5% vs. 28.3%, p &amp;lt; 0.001). The median duration of bacteremia and length of stay was shorter in the early group (p &amp;lt; 0.001) (Table 2). MLA determined an alternative threshold of ≤ 3.5 days for early ID consult. Multivariable analyses reported early ID consult in ≥ 5 days (adjusted OR: 6.42, 95% CI [3.20, 12.89]; p &amp;lt; 0.001) and ≤ 3.5 days (adjusted OR: 3.47, 95% CI [2.08, 5.81]; p &amp;lt; 0.001) as independent predictors for achieving the five quality care indicators (Table 3). Comparing the predefined definition of early infectious diseases consultation as &amp;lt; 5 days and late infectious diseases consultation as &amp;gt;= 5 days in univariate analyses to baseline and clinical characteristics. A comparison of an alternative threshold of 3.5 days was also performed in univariate analyses. PWID: persons who inject drugs; ESRD: end-stage renal disease; SD: standard deviation; IQR: interquartile range; MRSA: methicillin-resistant Staphylococcus aureus; ICU: intensive car unit. Comparing the predefined definition of early infectious diseases consultation as &amp;lt; 5 days and late infectious diseases consultation as &amp;gt;= 5 days in univariate analyses to primary and secondary endpoints. A comparison of an alternative threshold of 3.5 days was also performed in univariate analyses. Bivariate analyses were performed with covariates of interest that may be associated with five quality indicators of Staphylococcus aureus bacteremia management (composite primary endpoint). Multivariable analysis was performed to control for covariates statistically significant in the bivariate analyses. Early infectious diseases consultation &amp;lt; 5 days was an independent predictor for meeting the five quality indicators of SAB management. Another multivariable analysis confirmed early ID consultation &amp;lt;= 3.5 days as an independent predictor for meeting the five quality indicators of SAB management. Conclusion Patients with SAB who received an early ID consultation were more likely to achieve the quality care indicators and have a shorter duration of bacteremia and LOS. These data suggest that patients with SAB should have an ID consultation &amp;lt; 5 days from index culture acquisition. Future studies should evaluate if an earlier time frame of 3.5 days for ID consultation improves clinical outcomes. Disclosures All Authors: No reported disclosures.

630. A Single-Center 10-Year Analysis of Immunizations in Heart Transplant Recipients

Abstract Background Vaccine-preventable diseases pose a risk towards heart transplant recipients on lifelong immunosuppression. Immunization rates are low (30-80%) in solid organ transplants. The aim of this study was to examine the vaccination rates in our hospital’s heart transplant recipients with a goal to expose deficiencies and formulate strategies to increase vaccination in this population. Methods This study is a single-center retrospective chart review of patients aged 18 or older who received a heart transplant between January 1, 2012 and March 31, 2022 at our institution in Temple, Texas. We documented vaccination status or seropositivity prior to or after transplant, as recommended by the American Society of Transplantation (AST) for influenza, hepatitis B, hepatitis A, measles, mumps, and rubella (MMR), 23-valent pneumococcal polysaccharide (PPSV23), 13-valent pneumococcal conjugate (PCV13), tetanus, diphtheria, and acellular pertussis (Tdap), varicella, zoster, and COVID-19 immunizations. We evaluated the association with an Infectious Disease (ID) consult. Odds ratios (OR) were calculated with 95% confidence intervals. Results 72 patients received a heart transplant within the 10-year period. Demographics are noted in table 1. Table 2 presents the immunization status as follows: 48.7% for flu vaccine, 55.5% for Hepatitis B, 47.1% for Hepatitis A, 36.1% for MMR, 67.5% for PPSV23, 67.5% for PCV13, 54.1% for Tdap, 83.3% for Varicella and 13.8% for Zoster, and 53.5% for COVID-19. From 2016, an ID consult was required pre-transplant; 45 patients (62.5%) had an ID consult before transplant. ID consult was associated with increased likelihood of receiving the MMR, PCV13, Tdap, and Zoster vaccines (table 3). Table 1Patient demographics Table 2 Immunization status in heart transplant recipients Table 3 Immunization status associated with ID consult Conclusion This study reveals the deficiency of vaccinations in our heart transplant patients, but an ID consult was associated with better immunization rates. To further increase compliance, we propose different interventions including close follow-up with ID, addressing vaccine costs, accessibility limitations, cultural hesitancy, and implementation of protocols. Disclosures All Authors: No reported disclosures.

1122. Early Infectious Diseases Consultation and Procalcitonin-Guided Therapy Limits Unnecessary Antibiotic Use in COVID-19

Abstract Background Antibiotic stewardship has been a central challenge of the COVID-19 pandemic. Empiric antibiotic therapy is offered in 56.6%-74.6% of inpatients with COVID-19, with microbiologically confirmed bacterial pneumonia reported in only 3.5%-16% of cases. Procalcitonin (PCT) as a biomarker for bacterial infection is of interest in improving antibiotic use. PCT-guided antibiotic stewardship initiatives have demonstrated reduction in the use of antibiotics in the COVID-19 pandemic. An Infectious Diseases (ID) consultation was obtained on most patients at our institution throughout the COVID-19 pandemic. We report a significant reduction in antibiotic use among COVID-19 patients in the setting of near-universal ID consultation in COVID-19 patients. Methods We evaluated the records of 1346 patients with COVID-19 from March 2020 – May 2021 at four hospitals with ID consultant availability. We assessed the inclusion of an ID consultant, antibiotic indication, initiation and discontinuation, PCT levels, radiologic images, and changes to therapy decisions. A chi-square test of independence and simple logistic regression were conducted to determine whether an association exists between the PCT level and the decision to discontinue antibiotics. Results Of 1346 patients with a confirmed COVID-19 diagnosis, 64.6% (870/1346) received antibiotics on admission. The most common diagnosis associated with initial antibiotic administration was bacterial pneumonia (692/870, 79.5%). An ID consultation was obtained on 97.8% (677/692) of the patients that received antibiotics for suspected bacterial pneumonia. In 48.1% (326/677) of these patients, antibiotics were discontinued within the first 48 hours of the ID consultation. A statistically significant difference was noted between the PCT level and continuation of antibiotics (Χ2= 67.02, p &amp;lt; .01). The odds of discontinuing antibiotics for the upper (PCT &amp;gt; 0.51) and middle (PCT = 0.26-0.50) groups were 0.22 and 0.37, respectively, when compared to the lower (PCT ≤ 0.25) group. Conclusion Early consultation of an ID specialist and evaluation of PCT levels leads to significant reductions in inappropriate antibiotic use. PCT may be a useful adjunct in assisting with the decision to discontinue antibiotics. Disclosures All Authors: No reported disclosures.

1018. Shifting Antimicrobial Practice to Minimize Length of Stay in Orthopedic Infections: Analysis from an Academic Tertiary Care Center

Abstract Background Increased hospital length of stay (LOS) has been associated with increased rates of readmission, nosocomial infections, and cost during hospitalizations for orthopedic-related infections (HOIs). We hypothesized that Infectious Diseases (ID) consultation is associated with increased LOS for HOIs due to pending culture results delaying final recommendations. We assessed patient and care factors affecting LOS, including duration and timing of ID consultation, and identified process improvements to expedite discharge for HOIs. Methods We performed retrospective chart review of HOI admissions with ID consultation at Vanderbilt University Medical Center from May-August 2021. Differences in HOIs discharged &amp;lt;1 vs. &amp;gt;1 day after ID final recommendations were examined using Fisher’s exact, Chi-squared, and Wilcoxon rank sum testing. Clustering by patient for those with &amp;gt;1 admission was performed. We used multivariable and propensity score weighted negative binomial regression models to estimate adjusted rate ratios (aRR) and 95% confidence intervals (CI) for number of days followed by an ID consultant and LOS. Results HOIs discharged &amp;lt;1 day after ID final recommendations (69/105) had shorter median LOS (3 vs. 8 days, p&amp;lt; 0.001) (Figure 1), more oral-only antibiotic regimens (41% vs. 17%, p=0.003), and more frequent discharge to home (91% vs. 53%, p&amp;lt; 0.001). HOIs discharged &amp;gt;1 day after ID final recommendations were more likely to undergo multiple surgeries (28% vs. 12%, p=0.019) and peripherally inserted central catheter (PICC) placement (69% vs. 43%, p=0.013). For each additional day of ID consultation, there was associated increase in LOS (multivariable aRR 1.12, 95% CI 1.02-1.23; weighted aRR 1.12, 95% CI 0.99-1.26). Figure 1.Length of Stay after ID Final Recommendations Conclusion ID consultation is unlikely to be the primary barrier to hospital discharge but may be a marker for more complicated HOIs and increased LOS. Most patients with prolonged stays were discharged &amp;gt;1 day after ID final recommendations. Implementation of protocols to promote prompt ID consultation, streamline PICC placement, and coordinate outpatient intravenous antibiotics may accelerate transitions of care and discharges. Disclosures Milner B. Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson &amp; Johnson: Stocks/Bonds.