Infectious Diseases Consultation Research Articles

Bridging the gap: opportunities for transitions of care pharmacist review of outpatient parenteral antimicrobial therapy prescriptions prior to hospital discharge.

Pharmacist-led initiatives providing optimization of medications during transitions of care (TOC) have shown to have a positive impact on prescribing practices and patient outcomes. This study aims to evaluate the role and impact of TOC pharmacist review of outpatient parenteral antimicrobial therapy (OPAT) prescriptions prior to hospital discharge. In a retrospective chart review, patients with OPAT prescriptions between November 1, 2022 and January 31, 2023 were evaluated using prescription-specific and intervention-specific data points. Prescription-specific data points included intravenous antimicrobials prescribed, indication, prescribing team, and time from OPAT prescription to TOC pharmacist review. Intervention-specific data points included antimicrobial optimization (dose/frequency, duration, and other), prescription clarification, and laboratory monitoring. Of the 137 OPAT prescriptions evaluated, 67 required intervention by TOC pharmacists (48.9%). The General Infectious Disease Consult team placed 71.5% of OPAT prescriptions and required interventions less frequently (42.9%) compared to the other teams. Antimicrobial optimization interventions accounted for 54.2% of interventions, which were primarily related to medication dose and frequency. The TOC pharmacists can play a key role in the evaluation of OPAT prescriptions at hospital discharge. This intervention demonstrated how TOC pharmacists can effectively collaborate with the OPAT team, which builds on prior evidence of the role and value of pharmacists in the transitional care setting.

Fixing a Hole: a retrospective cohort study evaluating HAV, HBV, tetanus screening, and vaccination during hospitalization in persons who use substances.

Rates of serious injection-related infections in persons who use drugs have increased. Resulting admissions are an opportunity for screening and vaccination of preventable infections such as hepatitis A virus (HAV), hepatitis B virus (HBV), and tetanus. We conducted a retrospective review of adults with documented substance use admitted for bacterial infection between July 2015 and March 2020. We evaluated HAV, HBV, and tetanus vaccination status at admission, along with screening for HAV and HBV infection and immunity. We identified the proportion of patients at risk for infection who received HAV, HBV, and tetanus vaccines during admission and patient-level factors associated with vaccination. We identified 280 patients who met our inclusion criteria. Of the 198 (70.7%) patients at risk for HAV, infectious disease providers recommended vaccination for 21 (10.6%) and 15 (7.6%) received HAV vaccine. Of the 174 (62.1%) patients at risk for HBV, infectious disease providers recommended vaccination for 32 (18.3%) and 25 (14.4%) received HBV vaccine. A large proportion of patients (31.4%, 88) had no documentation of prior tetanus vaccination, and infectious disease providers recommended tetanus vaccination for three (1.1%) and five patients (1.8%) received a tetanus booster. Infectious disease consult vaccine recommendations were statistically significantly associated with HAV or HBV vaccination prior to discharge. Over 70% of our population is at risk for one or more of these preventable infections. Efforts are needed to maximize inpatient screening and vaccination for HAV, HBV, and tetanus in patients with barriers to care.

Appropriateness of Empiric Initiation of Meropenem in the Intensive Care Unit as Determined by Internal Medicine Residents.

To evaluate the appropriateness of empiric initiation of meropenem in the intensive care unit (ICU) and to determine theagreement between internal medicine (IM) residents and infectious diseases (ID) physicians/pharmacists on appropriateness. Retrospective observational study. ICU in a tertiary care community teaching hospital. Adult patients admitted to the ICU and started empirically on meropenem between April 1 and October 31, 2021. Meropenem usage was categorized as appropriate or inappropriate according to criteria developed from previously published indications and modified by ID physicians/pharmacists to reflect local practices. Two investigators (an IM resident and either an ID physician or pharmacist) assessed the appropriateness, with a second ID physician resolving any disagreements. Inter-rater reliability was measured using the kappa statistic. Ninety-seven participants were enrolled, with a mean age of68 (SD, 17.0) years. Pneumonia was the most common infection (30.9%). Among the participants, 92.8% received an ID consultation, with 55.6% of these occurring before meropenem initiation. IM residents deemed 56.7% of meropenem administrations appropriate, whereas an ID physician/pharmacist deemed only 48.5% appropriate, agreeing on 79.4% of cases (kappa statistic 0.59, P <.001). After a third reviewer's assessment was included, agreement between theresident and at least one of the tworeviewers reached 90.7% (kappa 0.81, P <.001). Approximately half of empiric meropenem started in the ICU was deemed inappropriate using institution-specific criteria. There was good agreement between IM residents and ID physicians/pharmacists on meropenem appropriateness. IM residents could contribute to antimicrobial stewardship efforts, like prospective audit and feedback, using standardized criteria for appropriateness.

Enigmatic CNS Lupus Vasculitis: A Heuristic Approach

Systemic lupus erythematosus is an autoimmune disease affecting all organs of the body. It has a higher incidence in women and can affect the central nervous system (CNS) in 10% to 20% of cases. Any structure in the CNS can be involved, resulting in a varied and often complex symptomatology. CNS lupus vasculitis is an even rarer manifestation characterized by small vessel inflammation that can result in vessel thrombosis and necrosis. We present the case of a 31-year-old woman with a history of systemic lupus erythematosus and Sjögren’s syndrome who was treated at our institution for an acute exacerbation of lupus complicated by CNS lupus vasculitis. This case was particularly challenging due to concurrent bacteremia and a travel history that broadened the differential diagnosis widely, thus requiring our input as infectious disease consultants. CNS lupus vasculitis is a diagnosis of exclusion that requires a high level of clinical suspicion to arrive at a prompt diagnosis paired with aggressive management to guarantee good outcomes. In this report, we share our stepwise approach to this challenging case in a didactic manner to benefit trainees and independent infectious diseases providers who may encounter similar clinical scenarios in their practice.

Impact of a hospital sepsis management protocol on the selection of empirical antibiotics in infectious disease consultations

It is well-established that Infectious Diseases consultation (IDC) enhances the prognosis of bloodstream infections. However, it is unclear if adoption of an institutional sepsis protocol would lead to any further improvement in a setting where IDC and infectious diseases approval (IDA) - available throughout 7 days/24 hours -are mandatory for administering broad spectrum antibiotics. We aimed to evaluate the influence of the institutional sepsis protocol developed by Department of Infectious Diseases and Clinical Microbiology on the selection of appropriate empirical antibiotics by IDC through focusing on patients who had bloodstream infections caused by Extended-spectrum β-lactamase (ESBL) producing Escherichia coli and Klebsiella pneumoniae, which poses a therapeutic challenge. One hundred and fifty-three adult patients (58 patients in the pre-protocol period and 95 patients in the post-protocol period), who received empirical antibiotic treatment for ESBL-producing E. coli and K. pneumoniae, in whom at least one systemic antibiotic was started either on the day blood cultures were drawn or not later than 24 hours were included in the study, retrospectively. The primary outcome was whether the empirical treatment regimen included a carbapenem that was accepted as the appropriate treatment based on the results of the MERINO trial. Secondary outcomes included empirical treatment based on pre-defined risk factors suggesting multidrug resistance (MDR), 30-day inpatient mortality, and appropriate antibacterial treatment according to antimicrobial susceptibility test (AST) results. The median age (Interquartile range) was 61 (48-70.5) years and 76 (49.7%) out of 153 patients were male. The patients in the post-protocol period were older compared to the pre-protocol period (54 years vs 64 years, p = 0.045). The Charlson Comorbidity Index was higher during the post-protocol period compared to the pre-protocol period (4 vs 5, p=0.038). At least one risk factor for MDR bacteria infection was present in 147 (96.1%) of the 153 patients. While the rate of risk factors for MDR bacteria infections did not differ significantly between the pre-protocol and post-protocol periods, the post-protocol period showed a significantly higher level of appropriate antibiotic treatment according to the presence of MDR risk factors compared to the pre-protocol period (44.8% vs 64.2%, p=0.019). There was a significant increase in the use of carbapenems in the post-protocol period compared to the pre-protocol period (34.5% vs. 56.8%, p=0.007). When the subgroup of patients who were likely to have infection caused by ESBL-producing bacteria is taken into consideration, the carbapenem use was more frequent in the post-protocol period (37.8% vs 68.9%, p=0.002). The rate of appropriate empirical treatment according to AST was not statistically different between pre-protocol and post-protocol period. The 30-day mortality rates were similar in both periods (24.1% vs 31.5, p=0.33). However, the rate of susceptibility to piperacillin-tazobactam was statistically higher in the pre-protocol period (82.6% vs 46.2%, p=0.016) when 39.7% of the patients received piperacillin-tazobactam as the empirical treatment. This study highlights the significance of using a structured protocol to attain appropriate empirical treatment for patients suspected of sepsis, even in a setting where IDC is readily available.

Non-infectious diseases in infectious disease consultation: A descriptive study in a tertiary care teaching hospital

In this retrospective study, we aimed to investigate the frequency, trend, and nature of non-infectious diseases (non-IDs) as the final diagnosis for patients during an infectious disease (ID) consultation in an acute care hospital in Japan. This study included adult inpatients who underwent ID consultations between October 2016 and March 2018. The demographic data, clinical manifestations, and final non-ID diagnoses of cases were explored. Among the 502 patients who underwent ID consultations, 45 (9.0%) were diagnosed with non-IDs. The most common diagnoses were tumors (22.2%, n = 10), connective tissue and collagen vascular diseases (13.3%, n = 6), other inflammatory diseases (8.9%, n = 4), and drug-induced fever (8.9%, n = 4). Multiple logistic regression analysis showed that the presence of consultations for diagnosis (odds ratio [OR], 22.0; 95% confidence interval [CI], 10.1–48.2; p&lt;0.01), consultations from the internal medicine department (OR, 2.5; 95% CI, 1.2–5.2; p = 0.02), and non-bacteremia cases (OR, 5.2; 95% CI, 1.4–19.3; p = 0.01) were independently associated with diagnosed non-IDs. Non-IDs after ID consultations were mainly tumor-related, inflammatory diseases, and drug fever. The presence of consultations for diagnosis, consultations from the internal medicine department and non-bacteremia cases were related to non-IDs among ID consultations. Further research is needed to explore the frequency and pattern of non-IDs to improve the quality of ID consultations in daily practice.

HIV Type-1 Genotyping in the Context of the COVID-19 Pandemic: A Critical Tool for Identifying Antiretroviral Drug Resistance and Optimizing Treatment Strategies

Abstract Introduction/Objective The COVID-19 pandemic strained the healthcare system and the WHO recently reported increased rates of antibiotic resistance. Meanwhile, antiretroviral resistance can also lead to treatment failure and disease progression, especially in HIV patients. Here, we investigated the rates of HIV drug resistance (HIVDR) in our HIV population between pre and post-COVID-19 eras. Methods/Case Report The post-COVID-19 era began on 03/11/2020. Patients positive for HIV-1 between 01/2019- 08/2021 were included (total: 94 patients, 46 pre-COVID-19; 48 post-COVID-19). Patients’ charts were reviewed for demographics, laboratory results (including HIV-1 sequencing/genotyping (e.g., Genosure)), clinical presentation and management. Student t-test and Fisher exact test were calculated. Results (if a Case Study enter NA) Most patients were male (70%) and had a mean age of 49 years. 70% of patients had sufficient viral loads in samples reflexed to HIV genotyping. Post-COVID-19 patients harbored lower viral loads (1.8x105 vs. 3.4x105 copies/mL, p=0.05), CD4 counts (174 vs. 196 cells/mcL, p=0.7), CD8 counts (555 vs. 800 cells/mcL, p=0.04), and higher CD4/CD8 ratio (0.312 vs. 0.266, p=0.57). Overall, 20% of patients had HIVDR. Following COVID-19 pandemic, there was a 9% increase in HIVDR, predominantly seen in non-nucleotide reverse transcriptase inhibitors (NNRTI), although insignificant. Specifically, high resistance was documented for drugs Efavirenz (16%), Nevirapine (16%), and Rilpivirine (13%). We observed an increased prevalence of G190A, K101, K103, and E138 mutations conferring resistance to NNRTIs. Changes to therapy were observed in 47.8% (42/88) of total cases, with an increase of 12.5% in patients from post-COVID-19 era. Additionally, changes to therapy were observed more in patients with infectious diseases consultation (16% increase). Conclusion Increasing HIVDR was seen in our patient population post-COVID-19. Continued surveillance is critical to managing HIVDR and improving patient outcomes. The clinical utility of sequencing tests can outweigh the cost if results are appropriately acted upon which may involve the participation of other clinical teams and the antimicrobial stewardship committee.

810. Predictors of 30-Day Mortality Among Critically Ill Patients with Candidemia Identified by T2Candida Panel

Abstract Background Candidemia is associated with mortality rates exceeding 40%. However, prior studies indicate mortality may be reduced when antifungal therapy is initiated within 12 hours. The T2Candida Panel is a diagnostic assay that detects Candida species directly from a whole blood specimen within 3-5 hours (T2 Biosystems, Lexington, MA). The objective of this study is to identify predictors of 30-day mortality in patients with candidemia identified by T2Candida Panel. Methods This is a retrospective, multicenter study of critically ill patients with candidemia identified by T2Candida Panel from January 2016 - December 2022. Critically ill patients were defined as those who developed candidemia during an intensive care unit (ICU) stay or within 72 hours of ICU admission or discharge. T2Candida sites were chosen across the United States based on T2Candida utilization. Exclusion criteria were patients &amp;lt; 18 years of age, those with prophylactic indications for antifungal therapy, prisoners and pregnant patients. Multivariate logistic regression was conducted to identify factors associated with 30-day mortality measured from the T2Candida draw time. Results There were 171 ICU patients from seven institutions with candidemia identified by T2Candida panel. The mean (standard deviation [SD]) age was 59.7 (14.8) years and 52.1% were male. Mean (SD) APACHE II and Charlson Comorbidity Index scores were 20.6 (7.1) and 4.9 (2.8), respectively. Empiric antifungal therapy was administered to 36.8% of patients and the majority received infectious diseases (ID) consult (92.4%). Echinocandins were the most common agents used for empiric (72.7%) and definitive therapy (62.6%). Overall, 30-day mortality occurred in 36.0% and was not associated with antifungal de-escalation. Administration of empiric therapy (aOR 0.457, 95% CI 0.199-1.054) and ID consult (aOR 0.225, 95% CI 0.056-0.913) were associated with reduced odds of 30-day mortality. Conclusion Empiric antifungal administration and ID consult were independently associated with reduced odds of 30-day mortality in patients with candidemia identified by T2Candida Panel. Future studies are needed to evaluate the impact of the T2Candida panel on antifungal stewardship. Disclosures Ryan K. Shields, PharmD, MS, Allergan: Advisor/Consultant|Cidara: Advisor/Consultant|Entasis: Advisor/Consultant|GSK: Advisor/Consultant|Melinta: Advisor/Consultant|Melinta: Grant/Research Support|Menarini: Advisor/Consultant|Merck: Advisor/Consultant|Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Roche: Grant/Research Support|Shionogi: Advisor/Consultant|Shionogi: Grant/Research Support|Utility: Advisor/Consultant|Venatorx: Advisor/Consultant|Venatorx: Grant/Research Support Michael J. Rybak, PharmD, PhD, MPH, Abbvie, Merck, Paratek, Shionogi, Entasis, La Jolla, T2 Biosystems: Advisor/Consultant

820. Clinical Outcomes in Patients with Candidemia with and without Infectious Diseases Consult

Abstract Background Candidemia is associated with high mortality rates in the United States. In 2016, the Infectious Diseases Society of America (IDSA) provided recommendations for the management of candidemia in hospitalized patients. However, there may be further benefit with the addition of an Infectious Diseases consultation (IDC) in patients with candidemia, as seen in patients with Staphylococcus aureus bacteremia. Methods We conducted a retrospective cohort study to assess the impact of IDC on adult hospitalized patients with ≥ 1 blood culture positive for Candida species admitted from January 1, 2016 to December 31, 2021. Patients who were deceased or discharged prior to culture positivity, deceased within 24 hours of culture collection, or transitioned to comfort care within 48 hours from the time of positive blood cultures were excluded. The primary outcome was in-hospital and 30-day mortality. Secondary outcomes included duration of candidemia, time to active antifungal therapy, source control, and adherence to IDSA candidemia guideline recommendations. Results A total of 195 patients met study inclusion criteria, of which 74.9% had an IDC. In-hospital and 30-day mortality were numerically higher in the non-IDC group, but were not statistically significant (24.7% vs. 34.7%, p=0.17; 18.5% vs 30.6% p=0.07). Duration of candidemia was similar between groups, but trended longer in the non-IDC group (3.25 vs. 3.90 days, p=0.28). Median time to source control, when achieved, was four days in both groups with a higher rate of obtaining source control seen in the IDC group (56.2% vs. 49%, p=0.38). Overall compliance to IDSA guidelines was higher in IDC group versus non-IDC group (47.26% vs. 42.86%, p=0.59). Conclusion In our study, IDC was associated with lower in-hospital and 30-day mortality rates in hospitalized patients with candidemia, although not statistically significant. IDC may also be associated with shorter duration of candidemia, higher rate of achieving source control, and higher rates of adherence to the IDSA candidemia guideline recommendations, including using echinocandins as empiric therapy, repeating blood cultures, and conducting eye examinations. A larger study is warranted to solidify the findings of this study. Disclosures All Authors: No reported disclosures

1235. A Retrospective Review of Antimicrobial Stewardship Audit and Feedback: Assessing Acceptance of Stewardship Recommendations During the COVID-19 Pandemic

Abstract Background Antimicrobial stewardship is an underutilized strategy to mitigate the impact of antimicrobial resistance. It is well documented that many Antimicrobial Stewardship Programs (ASPs) were tasked with assisting healthcare teams in navigating the COVID-19 pandemic, leaving less time/fewer resources for day-to-day ASP activities. The aim of this study was to evaluate the acceptance of stewardship recommendations during a season when the ASP had less time to perform regular educational activities and handshake stewardship. Methods A retrospective study of patients receiving antimicrobial therapy at Saint Francis Hospital during 12/30/2020-10/01/2022, for which audit and feedback by the ASP was conducted. A well-established ASP existed prior to the pandemic. Independent variables included the reason for intervention, type of infection by organ system, and type of intervention. Interventions included recommendations to stop antibiotics, de-escalation, duration of therapy, ID consultation, or change the route of administration. The primary outcome was the audit and feedback acceptance rate, and the secondary outcome was whether the intervention resulted in infectious disease consultation. Results 297 patients underwent audit and feedback. Interventions most accepted by providers included changing the route of administration (100%) and consulting ID formally (92%). Adjusting the duration of therapy was the least accepted intervention at 78%. Regardless of intervention, 33% of providers requested a formal ID consult. The number of interventions varied sporadically, coinciding with periods of decreased availability by the ASP team and during peak waves of the COVID-19 pandemic. Conclusion Our ASP team, despite decreased resources while battling an ongoing pandemic, were still able to perform audit and feedback to providers with a good acceptance rate of recommendations, consistent with current literature. Having not only an existing but robust ASP prior to the pandemic, allowed continued success with ASP intervention acceptance rates, despite less dedicated time for typical ASP activities during the pandemic. Fostering good relationships between providers and ASP teams, as well as continued support and funding from hospital leadership, are vital to ongoing success. Disclosures All Authors: No reported disclosures

697. Characteristics of Hospitalized Patients Colonized with Clostridioides difficile at an Academic Medical Center

Abstract Background Clinical spectrum of C. difficile can range from colonization to fulminant colitis. Patients with toxin antigen negative, C. difficile nucleic acid amplification (NAAT)-positive diarrhea are frequently only colonized and do not suffer consequences of C. difficile associated disease (CDAD) but receive treatment for CDAD due to the perceived low risk of oral vancomycin vs. the risk of developing CDAD. Methods We performed a retrospective cohort study of hospitalized adult patients with positive C. difficile NAAT and negative toxin antigen results at University of Iowa Health Care between 9/1/2021 and 9/30/2022. Chart review was conducted to obtain patient age, immunocompromised state, involvement of infectious disease (ID) consultant, prior C. difficile test status and treatment course. Results Of the 295 NAAT-positive C. difficile results, 210 (71%) were toxin antigen negative. Patient characteristics and frequency of common risk factors are shown in Table 1. C. difficile colonization was detected ≥4 days after admission in 111 (53%), with internal medicine and stem cell transplant (SCT)/hematologic malignancies (HM) services having the most patients with colonization (31% and 18%, respectively). Antibiotic use in the prior 30 days was reported in 154 (73%). Of 134 (64%) patients on systemic antibiotics at time of C. difficile testing, antibiotics were discontinued in 29 (22%). Only 43 patients (20%) did not receive any treatment for C. difficile. Median treatment duration was 10 days with 133 (80%) being treated for 10-14 days (Table 2). ID consult was obtained in 48 (23%) and recommended no treatment initially in 11 (23%), 4 of whom were started on treatment in subsequent days. Oral twice a day vancomycin for prophylaxis was given to 28 (13%) patients, 19 (68%) of whom were immunocompromised (16 SCT/HM and 3 solid organ transplant). Conclusion Patients with C. difficile colonization have similar risk factors as patients with CDAD. Understanding treatment patterns for C. difficile colonization can guide educational activities. Most colonized patients received C. difficile treatment and/or prophylaxis, likely due to ongoing systemic antibiotic use and immunosuppression. Benefit of treatment and prophylaxis in colonized patients remains an unresolved issue. Disclosures Kelly M. Percival, PharmD, Gilead Sciences Inc: Advisor/Consultant

2617. Antiviral usage for herpes simplex virus (HSV) detected in bronchoalveolar lavage fluid (BALF) by polymerase chain reaction (PCR) in hematologic malignancy (HM) and solid organ malignancy (SOM) patients with pulmonary infiltrates; impact of infectious disease consultation (IDC) on antiviral stewardship

Abstract Background HSV reactivation (HSVr) is frequent in HM and SOM patients while oropharyngeal/ mucocutaneous infections (OP-MCI) and especially HSV pneumonitis (HSVP) are uncommon. BALF-HSV-PCR can identify shedding or disease, however, may result in inappropriate high dose antiviral usage in non-HSVP situations. We report a cohort of patients with positive BALF-HSV-PCR, its impact on antiviral usage and role of IDC on antiviral use. Methods Retrospective chart review of BALF-HSV-PCR positive patients who had IDC between 1/1/2018 and 8/31/2022. Exclusion criteria: No chest imaging (CT scan or chest X-ray imaging within ±7 days of positive test) and no malignancy. Data collection: demographics, laboratory and clinical findings, and antiviral medication dosing before and after each positive BALF-HSV-PCR preceding the IDC. Clinical diagnosis and treatment of HSVP versus non-HSVP was based on IDC. Kruskal-Wallis tests was used for continuous variables and Fisher’s exact test for categorical variables, and p-values reported were 2-sided at significance level of 0.05.Table 3.Impact of BALF HSV PCR and IDC on Antiviral use. PPX=prophylaxis, Y=yes, N=No; ACV=acyclovir Results One-hundred-nine patients met inclusion criteria. Nineteen (17.4%) had HSVP, 90 (82.6%) non-HSVP. In non-HSVP; 83 (92%) had oropharyngeal shedding (HM &amp;gt;SOM), 6 (6%) OP-MCI and 1 (1%) immunotherapy related pneumonitis (IrP). Tables 1-3 provide details on demographics and baseline characteristics, antiviral use, and statistical analysis. HSV shedding/ disease (HSVP and OP-MCI) was more common in HM patients. All HSVP patients received high dose antiviral agents. Of ninety patients determined as non-HSVP, 42% were overtreated with antivirals with a positive test that preceded IDC. Positive PCR led to change in antiviral dose (p &amp;lt; 0.05) with highly significant impact on the dose of acyclovir used (prophylaxis vs. OP-MCI vs. HSPV doses) (p&amp;lt; 0.0001). IDC led to modification of HSVP dosing to either prophylaxis or complete discontinuation in 84.2% of patients (p=0.008). Conclusion BALF-HSV-PCR positive test without HSVP led to overtreatment in both HM and SOM patients that is preventable by IDC, underscoring its value in antiviral stewardship. Diagnostic stewardship can further limit inappropriate use of antivirals. Disclosures Randy Taplitz, MD, Karius: Advisor/Consultant|Merck: Advisor/Consultant|SNIPR biome: Advisor/Consultant Sanjeet S. Dadwal, MD, FACP, FIDSA, Allovir: Advisor/Consultant|Allovir: Grant/Research Support|Ansun Biopharma: Grant/Research Support|Aseptiscope, Inc: Stocks/Bonds|Astellas: Honoraria|Karius: Grant/Research Support|Matinas Biopharma: Stocks/Bonds|Merck: Advisor/Consultant|Merck: Grant/Research Support|Pfizer/Amplyx: Grant/Research Support|Takeda: Advisor/Consultant|Takeda: Honoraria|Viracor: Honoraria

673. Sniffing Out Adherence: Evaluation of a Clostridioides difficile guideline at a Tertiary Academic Medical Center

Abstract Background Tufts Medical Center’s (TMC) Antimicrobial Stewardship Team (AMT) in collaboration with gastroenterology (GI) developed an institutional treatment algorithm to guide appropriate inpatient management of Clostridioides difficile infection (CDI). The CD treatment algorithm was revised in April 2022 to reflect updated national clinical practice guidelines and disseminated to TMC providers. Our study aimed to assess provider compliance to TMC’s CD treatment algorithm. Methods A retrospective study of adult patients hospitalized from April 15, 2022 to October 31, 2022 and tested for CD was conducted. We collected patient demographics, white blood cell count, serum creatinine (SC), length of stay, CD treatment, Infectious Diseases (ID) &amp; GI consult, occurence of severe CDI (defined as white blood cell &amp;gt; 15 K/uL or SC &amp;gt; 1.5 mg/dL), occurrence of recurrent CDI, and immunocompromised status (defined by having had organ or bone marrow transplant, receiving immunomodulatory therapy or chronic steroids). A 2-step Clostridioides difficile (CD) testing algorithm was used. For CD toxin A/B &amp; glutamate dehydrogenase antigen (GDH) indeterminate results, reflex to nucleic amplification test (NAAT) was performed only with AMT approval. Results A total of 111 inpatients had CD toxin/GDH stool testing; 70 (63%) positive and 41 (37%) indeterminate. Of patients who had an indeterminate CD toxin/GDH, none had subsequent CD NAAT testing, and none receive CDI treatment. Of the others, 81 (73%), 23 (21%), and 7 (6%) were diagnosed with non-severe, severe, and fulminant CDI, respectively. The overall adherence to the institutional CD treatment algorithm was 58% (figure 1). More patients were appropriately treated with oral vancomycin (11, 65%) compared to those who were appropriately treated with fidaxomicin (9, 24%). Guidance adherence was (3) 38% among patients who had one or more recurrent episodes of CD, and none received suggested ID or GI consultation for additional CDI treatment consideration. Conclusion Adherence to institutional CD treatment algorithm was low. This study highlights opportunities to improve prescription of first line CDI therapy, especially among patients who are at higher risk for recurrence. Disclosures Maureen Campion, PharmD, BCIDP, Shinoigi: Speaker

2836. Prostate Abscess due to Staphylococcus aureus: a Retrospective Case Series

Abstract Background Most cases of prostate abscess are due to gram-negative enteric bacteria, but there are increasing reports of Staphylococcus aureus as a causative pathogen. Due to being an uncommon diagnosis, there are no current guidelines for the evaluation and treatment of S. aureus prostate abscesses. We examined the epidemiology and management of prostatic abscess due to S. aureus at an academic, urban tertiary center. Methods In this retrospective analysis, we identified patients with diagnosis of prostate abscess and concomitant culture with S. aureus who were aged 18 years or older and hospitalized at Temple University Hospital between 2016 and 2022. Cases were identified if they had both (1) a diagnosis code consistent with prostate abscess; and (2) positive blood, urine, or abscess cultures with S. aureus. Each case was reviewed to verify clinical or imaging criteria for diagnosis. Data regarding risk factors, interventions, and outcomes were compiled in REDCap, a de-identified electronic database for data management. Results We identified 18 patients who met inclusion criteria, with median [IQR] age of 50 years [40-70]. Computed tomography was used in all cases for identifying an abscess. The most common risk factors were intravenous drug use (IVDU) 55.6% [10/18] and diabetes 50% [9/18]. Culture positivity was 100% [6/6] for abscess fluid, 61.1% [11/18] for urine, and 56.3% [9/16] for blood. Of these, methicillin resistance was detected in 72.2% [13/18] of cases. Computed tomography was used in all cases for identifying an abscess. 61.1% [11/18] of patients underwent procedural interventions for treatment. Infectious Diseases consultation resulted in a change in management in 92.8% [13/14] of cases, with a median length of antibiotic administration of 42 days. 66.7% [6/9] of the bacteremic patients had additional infectious complications such as endocarditis or osteomyelitis. Conclusion Prostate abscess due to S. aureus should be considered in patients presenting with lower urinary tract symptoms and a history of injection drug use or diabetes. Evaluation should include imaging and cultures, particularly from blood. Treatment involves prolonged antibiotics and urology consultation for consideration of procedural intervention. Disclosures All Authors: No reported disclosures

177. Infectious Diseases Consultation Associated with Decreased Mortality in Gram-Negative Bacteremia

Abstract Background Bloodstream infections (BSIs) are major causes of morbidity and mortality for which prior analyses and validated scoring tools have attempted to stratify risk. This study investigated institutional and epidemiologic predictors of mortality with Gram-negative BSIs to better identify targeted antimicrobial stewardship efforts to improve outcomes. Methods All patients with aerobic, monomicrobial, Gram-negative BSIs admitted and discharged from our academic medical institution between July 2022 and March 2023 were included. Data collected included patient demographics, microbiological data, clinical management, length of stay, ID consultation, and clinical outcomes (in-hospital or hospice mortality). Univariate and multivariable logistic regression models were performed to identify variables that were primary drivers for inpatient mortality. Results Overall, 259 patients (83.7% Caucasian, 49% male, mean age 53.7 yrs) were identified. The most common organisms were E. coli (37.8%), K. pneumoniae (11.2%), P. aeruginosa (10.0%), S. marcescens (8.5%), and E. cloacae (6.2%). The majority (65.3%) were community acquired infections with 41.7% in the ICU, and 46.7% received an infectious diseases consult. The overall mortality was 14.7% with the highest mortality due to P. aeruginosa (34.6%) followed by S. marcescens (27.3%), K. pneumoniae (13.8%), E. cloacae (12.5%), and E. coli (8.2%). Overall mortality was significantly associated with several parameters in a univariate analysis (Table 1). In multivariable regression analysis hospital-acquired infection (0=0.002), cancer (p=0.012), qPitt &amp;gt; 2 (p&amp;lt; 0.001), SBP&amp;lt; 100 or vasopressor use at 72-96 hrs after positive blood culture (p=0.017) was associated with increased risk of mortality. The only parameter to reduce mortality within the multivariable regression analysis, by more than two-fold, was ID consultation (p=0.022). Parameters Associated with Mortality in Univariate Analysis Conclusion The only factor found to significantly reduce mortality was formal ID consultation. ID consultation should be considered part of routine care for all patients with Gram-negative bacteremia. Disclosures Katie B. Olney, PharmD, BCIDP, The Society of Infectious Diseases Pharmacists (SIDP): Grant/Research Support

2230. Consumption of Quinolones, Macrolides, and Beta-Lactam Antibiotics at a Tertiary Care Veterans Affairs Medical Center (VAMC) during COVID-19 Pre-pandemic and Pandemic periods: A 4-year Analysis and Implications for Antimicrobial Stewardship

Abstract Background During the coronavirus disease 2019 (COVID-19) pandemic, antimicrobial use increased tremendously. Evidence suggests that the pandemic has resulted in an increased rate of AMR due to inadvertent antibiotic use. This likely reflects difficulties in distinguishing COVID-19 from community-acquired pneumonia when patients first arrive at a hospital. Strengthening antimicrobial stewardship (AMS) efforts by formulating policies for the use of antibiotics is crucial to prevent emergence of AMR. Methods A retrospective analysis to assess changes in antibiotic use during the pandemic and pre-pandemic patterns was done. Results : In the inpatient setting, there was an overall decrease in antibiotic use (all units that follow are in DOT/1000 BDOC) from an average of 380 to 300, vancomycin from 90 to 62, cefazolin from 30 to 17, Linezolid from 5 to 2, Zosyn from 57 to 30 from pre-pandemic period (Jan 2019) to pandemic period (Dec 2022). Antimicrobials that showed an increase during the pandemic included ceftriaxone from 70 to 82, Cefepime from 5 to 8, Levofloxacin from 2 to 5, and fluconazole from 4 to 10 compared to pre-pandemic use. In the outpatient settings (units are in fills/1000 unique patients), levofloxacin use doubled from 3 to 6, cefuroxime use increased from 0.5 to 2 and Azithromycin use dropped from 80 to &amp;lt; 20, with concomitant increase in doxycycline use from 45 to 60. Outpatient antibiotic prescriptions were high for levofloxacin, doxycycline and cefuroxime and increases corresponded to peaks in cases of COVID-19. Conclusion Our analysis demonstrates that COVID-19 had shifted the antibiotic consumption curve towards treatment of pneumonia and invasive fungal infections (in seriously ill patients) which has key implications for AMS. Implementation of stringent AMS and mandatory Infectious disease consultation for all COVID 19 infections helped keep our antibiotic consumption well below the national average and curtail AMR. Disclosures All Authors: No reported disclosures

Impact of a New Diagnostic Stewardship Team on Utilization and Interpretation of a Microbial Cell-Free DNA Detection Test

Abstract Background After commercial metagenomic next-generation sequencing of plasma microbial cell-free DNA (NGS-mcfDNA) became available at Children’s Healthcare of Atlanta (CHOA) in 2018 with an institutional requirement for Infectious Disease (ID) consultation and approval, we observed an initial period of test utilization without consistent ID involvement. Subsequently we assembled a Diagnostic Stewardship Team (DST) composed of a clinical microbiologist and 3 ID clinicians with expertise in diagnosis and management of infections in immunocompromised children and antimicrobial stewardship, to improve test utilization by clinicians and to optimally impact patient care. Methods We performed a retrospective medical record review as an IRB-deemed Quality Improvement project. NGS-mcfDNA results and their clinical impacts prior to the formation of the DST were assessed, using previously published standardized criteria as an initial framework (Hogan 2021)1. We shared our findings with Bone Marrow Transplant (BMT), Pediatric Intensive Care Unit (PICU), and ID clinicians, providing education on the potential benefits and limitations of NGS-mcfDNA testing. Stakeholder acceptability and engagement with the DST was prioritized, with emphasis on highlighting the benefits to clinicians of expertise in patient selection for testing and with interpretation of results which can be discordant with conventional microbiological tests. DST approval became required for all NGS-mcfDNA tests, with approval decision and discussion documented in the medical record, followed by documentation of test results, interpretation, and communications with treating and consulting clinicians. After one year of DST engagement, which began on June 1, 2021, we repeated our analysis of NGS-mcfDNA utilization and clinical impacts to evaluate the results of DST involvement. We classified time periods into pre-DST, February 28, 2018 - April 12, 2021, and post-DST, June 1, 2021 – May 31, 2022. Results The majority of NGS-mcfDNA tests sent in both the pre- and post-DST periods resulted in no or indeterminate clinical impact (65% pre-DST vs. 73% post-DST), while post-DST the percentage of positive clinical impacts increased (18% pre-DST vs. 25% post-DST), and the percentage of negative clinical impacts decreased (16% pre-DST vs. 2% post-DST), likely due to DST engagement. The number of tests per year increased by three-fold, while fewer patients had multiple NGS-mcfDNA tests sent. Awareness of the requirement for DST consultation and test approval lead to more selective NGS-mcfDNA test requests on the part of BMT clinicians, and the majority of positive clinical impacts from NGS-mcfDNA testing in BMT patients resulted from collaboration between BMT and ID in de-escalation of antimicrobials. An increased awareness of the potential benefits of NGS-mcfDNA testing for pre-treated and diagnostically challenging patients led to an increase in NGS-mcfDNA test requests from ID clinicians. Conclusion Implementation of a DST resulted in universal ID engagement with clinicians requesting NGS-mcfDNA tests and ID involvement in test interpretation. Discussion with experienced diagnostic stewards at the time of NGS-mcfDNA test consideration, with attention to the rationale for test request and consideration of potential test limitations prior to return of results, in addition to rigorous interpretation of results, can increase the positive clinical impacts and decrease the negative clinical impacts of NGS-mcfDNA tests. Reference 1. Hogan CA, Yang S, Garner OB, Green DA, Gomez CA, Dien Bard J, Pinsky BA, Banaei N. Clinical Impact of Metagenomic Next-Generation Sequencing of Plasma Cell-Free DNA for the Diagnosis of Infectious Diseases: A Multicenter Retrospective Cohort Study. Clin Infect Dis. 2021 Jan 27;72(2):239-245. doi: 10.1093/cid/ciaa035. PMID: 31942944. Characteristics of NGS-mcfDNA tests sent from CHOA NGS-mcfDNA tests in BMT patients post-DST (n=19 tests)

Routine Infectious Disease Consultation Prior to an Allogeneic Hematopoietic Cell Transplant.

A transplant infectious disease (TID) assessment is essential to select recipients for an allogeneic hematopoietic cell transplant (HCT) and tailor prophylactic and empirical treatment recommendations. We performed a retrospective single-center study to describe our model of care based on a routine TID consultation prior to an allogeneic HCT between 2018 and 2022 in 292 adult (≥18-year-old) consecutive patients. We describe the performance of a TID consultation, arbitrarily defined as major (HCT postponement, procedure, cytomegalovirus [CMV] recipient serology reinterpretation) and minor interventions. Overall, 765 interventions were observed in 257 of 292 (88%) patients: 88 of 765 (11.5%) major and 677 of 765 (88.5%) minor interventions. Among major interventions, HCT was postponed in 8 of 292 (2.7%) patients and a procedure was requested in 18 of 292 (6.2%) patients. The CMV recipient serostatus was changed from indeterminate/low-titer positive to negative in 60 of 292 (20.5%) patients. Among 677 minor interventions, there were 68 (8.8%) additional consultations with other services requested, 260 (33.7%) additional diagnostic tests requested, 102 (13.2%) additional treatments recommended, 60 (7.8%) non-CMV serology reinterpretations performed, 115 (14.9%) deviations from routine anti-infective prophylaxis, and 72 (9.3%) deviations from routine empirical antibiotic treatment recommendations in case of neutropenic fever. We are proposing a structured, clearly defined, and comprehensive pretransplant checklist for an effective assessment of infectious disease risks and complications prior to an allogeneic HCT. Further studies or experiences like ours could help to define a global strategy or new models of care to be implemented in HCT centers in the future.

Hepatitis C and obstetrical morbidity in a substance use disorder clinic: a role for telemedicine?

Hepatitis C infection often co-occurs with substance use disorders in pregnancy. Accessing hepatitis C treatment is challenging because of loss to follow-up in the postpartum period, attributable to social and financial barriers to care. Telemedicine has been explored as a means of increasing routine postpartum care, but the potential impact on retention in and completion of care for postpartum hepatitis C has not been assessed. This study aimed to evaluate the impact of hepatitis C on obstetrical morbidity in a substance use disorder-specific prenatal clinic, and the effect of Infectious Disease telemedicine consultation on subsequent treatment delivery. We performed a retrospective cohort study of all patients in our substance use disorder prenatal clinic from June 2018 to February 2023. Telemedicine consults for hepatitis C diagnoses began in March 2020 and included electronic chart review by Infectious Disease when patients were unable to be seen. Our primary outcome was composite obstetrical morbidity (preterm birth, preeclampsia, fetal growth restriction, fetal anomaly, abruption, postpartum hemorrhage, or chorioamnionitis) compared between patients with and without active hepatitis C. We additionally evaluated rates of completed referral and initiation of hepatitis C treatment before and after implementation of telemedicine consult. A total of 224 patients were included. Of the 222 patients who underwent screening, 71 (32%) were positive for active hepatitis C. Compared with patients without hepatitis C, a higher proportion of patients with hepatitis C were White (80% vs 58%; P=.02), had a history of amphetamine use (61% vs 32%; P<.01), injection drug use (72% vs 38%; P<.01), or overdose (56% vs 29%; P<.01), and were on methadone (37% vs 18%; P<.01). There was no difference in the primary outcome of composite obstetrical morbidity. The rate of hepatitis C diagnosis was not statistically significantly different between the pre- and posttelemedicine cohorts (N=29 [41%], N=42 [27%]), and demographics of hepatitis C virus-positive patients were similar, with most being unemployed, single, and publicly insured. A lower proportion of patients in the posttelemedicine group reported heroin use compared with the pretelemedicine cohort (62% vs 90%; P=.013). After implementation of telemedicine, patients were more likely to attend the visit (19% vs 44%; P=.03), and positive patients were much more likely to receive treatment (14% vs 57%; P<.01); 100% of visits in the posttelemedicine group occurred via telemedicine. There were 7 patients who were prescribed treatment by their obstetrician after chart review by Infectious Disease. Patients with and without hepatitis C had similar maternal and neonatal outcomes, with multiple indicators of social and financial vulnerability. Telemedicine Infectious Disease consult was associated with increased follow-up and hepatitis C treatment, and obstetricians were able to directly prescribe. Because patients with substance use disorders and hepatitis C may have increased barriers to care, telemedicine may represent an opportunity for intervention.

Abstract 15982: Management and Follow-Up of Inpatients With Cardiac Implantable Electronic Devices and Bacteremia With and Without Electrophysiology Consultation

Introduction: Transvenous cardiac implantable electronic device (CIED) infection is a significant cause of morbidity and mortality. Expert consensus recommends a multidisciplinary approach to bacteremia in the context of CIED incorporating both infectious disease (ID) and electrophysiology (EP) consultation to balance the risks of infection with those of CIED removal. Hypothesis: Not all patients with CIEDs and bacteremia are evaluated with EP consultation, and this difference is associated with variability in management. Methods: Using the EMR, we retrospectively identified inpatients with a CIED and a positive blood culture across three hospitals: one academic, one specialty and one community. True infection versus contaminant was determined by an EP or ID attending at the time of presentation or adjudicated retrospectively by an EP who performs extractions. We examined the rates of EP consultation based on hospital site, CIED removal and appropriate follow-up in those without CIED removal. Fisher’s exact test was used to compare the rates of follow up. Results: We identified 88 inpatients with a CIED and positive blood culture between January 2020 - February 2023. True bacteremia was adjudicated in 48 patients (55%). Of these patients, 24 were seen by EP (50%), 22 were seen by EP and ID (46%), and 14 were seen by neither (29%). Patients admitted to an academic hospital were more likely to be seen by EP (22/38, 57%) than those admitted to a specialty or community hospital (2/10, 20%). CIED removal was performed in 15 of 24 patients seen by EP (63%). Patients seen by EP were significantly more likely to have documented plans, repeat blood cultures after antibiotic completion, and appropriate follow up than those not seen by EP (24/24 100% vs. 3/24, 8%, p&lt;0.001). Conclusion: Even at a high-volume extraction center, EP consultation for patients with true bacteremia in the context of CIED only occurred 50% of the time. Patients admitted to an academic hospital were more likely to be seen by EP than at a community or subspecialty hospital. EP consultation is important for all bacteremic patients with CIEDs, not only to recommend extraction if appropriate, but also to ensure timely follow-up and management of treatment failure, consistent with expert consensus.