Intravenous Antimicrobial Therapy Research Articles

The risk of serious infection in rheumatoid arthritis patients receiving tocilizumab compared with tumor necrosis factor inhibitors in Korea

ObjectivesTo examine the risk of serious infections (SIs) among patients with rheumatoid arthritis (RA) treated with tocilizumab compared with tumor necrosis factor inhibitor (TNFi) in Korea. MethodsWe conducted a retrospective cohort study using the Korean National Health Insurance data. The study cohort included patients ≥18 years with RA who were initiated with tocilizumab or TNFi between January 2013 and June 2018. The primary outcome was a composite endpoint of SIs, defined as an infection resulting in intravenous antimicrobial therapy or hospitalization. Secondary outcomes were organ-specific SIs. To control for confounders, we used inverse probability of treatment weighting (IPTW) using propensity score. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using a multivariable Cox regression model. ResultsA total of 8794 patients were identified: 1395 and 7399 patients initiated with tocilizumab and TNFi, respectively. The mean follow-up durations were 1.2 years for tocilizumab initiators and 1.0 year for TNFi initiators. After IPTW and adjustment, no increased risk of SIs was observed in tocilizumab versus TNFi (HR, 1.00; 95%CI, 0.90–1.11). In the secondary analysis, tocilizumab was associated with a higher risk of skin and subcutaneous tissue infections (HR, 1.26; 95%CI, 1.02–1.54) and a lower risk of urological and gynecological infections (HR, 0.65; 95%CI, 0.49–0.87) compared to TNFi. ConclusionIn this population-based cohort of RA patients in Korea, tocilizumab was not associated with a higher risk of SI compared to TNFi. However, tocilizumab should be carefully used for patients at high risk for skin-related infections.

Role of infectious diseases pharmacists in outpatient intravenous and complex oral antimicrobial therapy: Society of Infectious Diseases Pharmacists insights

AbstractOutpatient parenteral antimicrobial therapy (OPAT) is a well‐established mechanism to facilitate patient discharge, lower inpatient admission cost, and decrease the risk of health care–acquired infections. Although there are numerous benefits to patients and health care institutions, OPAT is complex and not without risks. Patients may be discharged on long courses of oral antimicrobials, known as complex outpatient antimicrobial therapy (COpAT), which also requires careful monitoring and oversight. This, coupled with the need for antimicrobial stewardship across the continuum of care, positions pharmacists with infectious diseases (ID) training as crucial leaders in the field of OPAT. The development, implementation, and maintenance of these services requires the careful attention of health care personnel in discharge antimicrobial selection, continuity of care at key care transitions, implementation of optimal care bundles, provision of thorough patient education throughout the OPAT process, coordination with a multidisciplinary team including home infusion and nursing, and monitoring of program metrics to determine successes and opportunities for improvement. Ongoing support for optimal delivery of patient care will be required as OPAT practice, and health care delivery at large, continues to evolve. This involves continued advocacy for collaborative practice development, optimizing payment for nondispensatory OPAT services, and integration of effective telehealth programs. This article summarizes the need for practice expansion of ID pharmacist specialists in OPAT/COpAT management across the care continuum and best practices for establishment of these services.

Experiences in outpatient parenteral antimicrobial therapy (OPAT): Barriers and challenges from the front lines.

Outpatient parenteral antimicrobial therapy (OPAT) is now the standard of care for managing patients who no longer need inpatient care but require prolonged intravenous antimicrobial therapy. OPAT increases patient satisfaction, reduces the lengths of hospital stay, lowers emergency department readmission rates, and decreases total healthcare spending. To investigate Virginia Commonwealth University Health System's experience with OPAT and to highlight the obstacles patients and clinicians face when navigating and utilizing this program. We conducted this descriptive study at a large, academic, tertiary-care hospital in Central Virginia. We performed manual reviews of electronic medical records of 602 patient, and we evaluated the records of those receiving OPAT between 2017 and 2020. Reviews included antimicrobial agents, diagnoses requiring OPAT, adverse effects related to antimicrobials, adverse effects related to peripherally inserted central catheters (PICC), readmission rate, discharge destination, and death. We evaluated our program with descriptive statistics. Among 602 patients who received OPAT, most were diagnosed with bacteremia or musculoskeletal infections. Patients were either discharged home or to another healthcare facility, with the former comprising most of the rehospitalizations. Ertapenem and vancomycin were associated with the most adverse drug events among our cohort. Elevated transaminase levels were noted in 23% of patients. The rate of PICC-line adverse events in this study population was 0.05%. Our findings highlight the barriers and challenges that patients and providers face when receiving OPAT, and they can inform efforts to improve patient clinical outcomes.

1134. Substance Use Disorder Patients’ Perspectives of a Multidisciplinary Antimicrobial Infusion Service

BackgroundInjection drug use is associated with infectious diseases such as endocarditis and osteomyelitis requiring prolonged intravenous (IV) antimicrobial therapy. Few programs offer simultaneous inpatient infectious disease and addiction treatment. WVU Medicine implemented a multidisciplinary Infusion Service (IS) to provide IV antimicrobial therapy while treating substance use disorder. From 2017 through 2019, IS cared for over 840 patients. The aim of this study was to evaluate IS by assessing patients’ perspectives of overall experience, interactions with healthcare providers, and preparation for continued recovery from substance use.MethodsAdults ≥ 18 and < 90 years-old with substance use disorder on IS between November 2019 and May 2020 were eligible. Demographic, substance use, and infectious diseases data were obtained by chart review. Confidential surveys with questions about overall experience, interactions with healthcare providers, and preparation for continued recovery were administered during the first week after transfer to IS and again the week of discharge.ResultsForty-two patients completed 39 initial and 12 follow up surveys. All used injection drugs, 85.7% (36/42) used opioids and 66.7% (28/42) used methamphetamine. Endocarditis was most common infection (61.9% (26/42)), with Staphylococcus aureus most often isolated (59.5% (25/42)). IS experience and care for infection were excellent or good in 97.4% (38/39) initial and 100% (12/12) follow up surveys. During IS, patients did not perceive being treated differently due to substance use in 94.9% (37/39) initial and 83.3% (10/12) follow up surveys. Before IS, patients perceived being treated differently in 84.6% (33/39) initial and 100% (12/12) follow up surveys. Patients felt IS would help with continued recovery in 84.6% (33/39) initial and 100% (12/12) follow up surveys.ConclusionAccording to patients’ perspectives, IS is effective in creating a positive overall healthcare experience, reducing stigma associated with substance use, and preparing patients for continued recovery after discharge. This study supports combining inpatient infectious disease and addiction therapy. Infectious diseases providers should be educated about this multidisciplinary approach.Disclosures All Authors: No reported disclosures

599. Dalbavancin Utilization in Rural Healthcare Setting: A Single Center Three Years’ Experience

BackgroundDalbavancin is a second generation lipoglycopeptide, approved by the Food and Drug Administration (FDA) for treatment of acute bacterial skin and skin structure infections (ABSSSI). The weekly dosing of Dalbavancin has encouraged its off-label use to treat other severe infections, especially in patients deemed to be poor candidates for intravenous antimicrobial therapy through a long-term intravenous catheter.MethodsSingle center retrospective chart review of 33 patients who were planned to receive Dalbavancin between March 2015 and March 2019 at a rural medical center in New Hampshire.We reviewed demographics, indications, microbiological, intravenous drug use status and compliance data.ResultsDalbavancin therapy was planned for 25/33 patients (75.75%) specifically due to safety concerns around use of a peripherally inserted central catheter (PICC) in Persons Who Inject Drugs (PWID). All 25 patients (75.75%) were actively injecting at the time of the infection with 16/33 patients (48.48%) receiving or newly enrolled in medication assisted treatment. The planned duration of therapy was not completed in 15/33 patients (45.45%) and all were PWID. 11/33 patients (33.3%) were lost to follow up. Additionally, 6 patients experienced insurance coverage issues or difficulty having peripheral access placed. The average driving distance between home and infusion suite was 47 miles.Methicillin Resistant Staphylococcus aureus (19/33) and Methicillin Susceptible Staphylococcus aureus (8/33) were the most commonly treated organisms and the average pathogen-directed therapy duration prior to starting Dalbavancin was 15 days.ConclusionDespite recent data suggesting that Dalbavancin therapy for PWID has good compliance rates in urban settings, our experience suggests that the same principle might not be true in rural settings as the non-compliance and loss to follow up rates were very high.Disclosures All Authors: No reported disclosures

Is Early Oral Antimicrobial Switch Useful for Less Critically Ill Adults with Community-Onset Bacteraemia in Emergency Departments?

To compare prognoses and adverse events between bacteraemic patients in the emergency department (ED) who received an early antimicrobial IV-to-PO switch and those treated with late or no IV-to-PO switch, an 8-year multicentre cohort consisting of adults with community-onset bacteraemia was conducted. The clinical characteristics and outcomes were compared in matched cohorts by the closest propensity score calculated based on the independent determinants of 30-day mortality identified by the multivariate regression model. Of the 6664 hospitalised patients who received no or late IV-to-PO switch, 2410 were appropriately matched with 482 patients treated with early IV-to-PO switch and discharged from the ED. There were no significant differences between the two matched groups in their baseline characteristics, including the patient demographics, severity and types of comorbidities, severity and sources of bacteraemia, and the 15- and 30-day mortality rates. Notably, in addition to the shorter lengths of intravenous antimicrobial administration and hospital stay, less phlebitis and lower antimicrobial costs were observed in patients who received an early IV-to-PO switch. Similarity was observed in the clinical failure rates between the two groups. Furthermore, the inappropriate administration of empirical antibiotics and inadequate source control were identified as the only independent determinants of the post-switch 30-day crude mortality in patients who received an early IV-to-PO switch. In conclusion, for less critically ill adults with community-onset bacteraemia who received appropriate empirical antimicrobial therapy and adequate source control, an early IV-to-PO switch might be safe and cost-effective after a short course of intravenous antimicrobial therapy.

Safety of Nurse- and Self-Administered Paediatric Outpatient Parenteral Antimicrobial Therapy.

This study aimed to compare and contrast the safety and efficacy of nurse- and self-administered paediatric outpatient parenteral antimicrobial therapy (OPAT) models of care and to identify clinical factors associated with documented adverse events (AEs). A total of 100 OPAT episodes among children aged between 1 month and 18 years who were discharged from hospital and who received continuous 24 h intravenous antimicrobial therapy at home via an elastomeric infusion device were included. All documented AEs from the case notes were reviewed by a paediatrician and classified as either major or minor. Multivariable logistic regression was used to determine associations between clinical factors and any AE. A total of 86 patients received 100 treatment OPAT episodes (49 self-administered, 51 nurse administered). The most commonly prescribed antimicrobial via continuous infusion was ceftazidime (25 episodes). Overall, an AE was recorded for 27 (27%) OPAT episodes. Major AEs was recorded for 15 episodes and minor AEs were reported in 14 episodes. The odds of an AE was increased in episodes with self-administration (adjusted odds ratio (aOR) 6.25, 95% confidence interval (CI) 1.44–27.15) and where the duration of vascular access was >14 days (aOR 1.08, 95%CI 1.01–1.15). Our findings suggest minor AEs may be more frequently reported when intravenous antimicrobials are self-administered via 24 h continuous infusions.

Association of Infectious Disease Physician Approval of Peripherally Inserted Central Catheter With Appropriateness and Complications

Peripherally inserted central catheters (PICCs) are frequently used to deliver intravenous antimicrobial therapy. However, inappropriate PICC use may lead to patient harm. To evaluate whether infectious disease physician approval prior to PICC placement for intravenous antimicrobials is associated with more appropriate device use and fewer complications. This cohort study of 21 653 PICCs placed for a primary indication of intravenous antimicrobial therapy between January 1, 2015, and July 26, 2019, was conducted in 42 hospitals participating in a quality collaborative across Michigan among hospitalized medical patients. Appropriateness of PICCs was defined according to the Michigan Appropriateness Guide for Intravenous Catheters as a composite measure of (1) single-lumen catheter use, (2) avoiding use of PICCs for 5 days or less, and (3) avoiding use of PICCs for patients with chronic kidney disease (defined as an estimated glomerular filtration rate <45 mL/min/1.73 m2). Complications related to PICCs included catheter occlusion, deep vein thrombosis, and central line-associated bloodstream infection. The association between infectious disease physician approval, device appropriateness, and catheter complications was assessed using multivariable models, adjusted for patient comorbidities and hospital clustering. Results were expressed as odds ratios with 95% CIs. A total of 21 653 PICCs were placed for intravenous antimicrobials (11 960 PICCs were placed in men [55.2%]; median age, 64.5 years [interquartile range, 53.4-75.4 years]); 10 238 PICCs (47.3%) were approved by an infectious disease physician prior to placement. Compared with PICCs with no documented approval, PICCs with approval by an infectious disease physician were more likely to be appropriately used (72.7% [7446 of 10 238] appropriate with approval vs 45.4% [5180 of 11 415] appropriate without approval; odds ratio, 3.53; 95% CI, 3.29-3.79; P < .001). Furthermore, approval was associated with lower odds of a PICC-related complication (6.5% [665 of 10 238] with approval vs 11.3% [1292 of 11 415] without approval; odds ratio, 0.55; 95% CI, 0.50-0.61). This cohort study suggests that, when PICCs were placed for intravenous antimicrobial therapy, infectious disease physician approval of PICC insertion was associated with more appropriate device use and fewer complications. Policies aimed at ensuring infectious disease physician approval prior to PICC placement for antimicrobials may improve patient safety.

Characterising heterogeneity and the role of attitudes in patient preferences: A case study in preferences for outpatient parenteral intravenous antimicrobial therapy (OPAT) services

Choice modelling techniques have established themselves as a key analysis tool in health economics and have been used to understand patient and practitioner preferences across a wide variety of settings. A key interest in recent years has been the incorporation of ever more flexible levels of heterogeneity in preferences across individual decision makers, and in particular a growing interest in the potential role that attitudes and perceptions might play in healthcare choices. At the same time however, many applications simply apply these new tools without then investigating the resulting richness in the results. This paper not only presents a novel application of hybrid choice modelling in health, by looking at preferences for outpatient parenteral intravenous antimicrobial therapy (OPAT), but also carefully explores the findings in terms of sources of heterogeneity, disentangling the role of attitudes from other heterogeneity. We find that a large share of the heterogeneity can be attributed to two key underlying attitudinal constructs, related to the general attitude towards hospitals and whether responsibility for healthcare should lie with the patient or the practitioner. Especially the latter accounts for more than 60% of the overall heterogeneity in preferences for the type of treatment. These results may help design services that are suitable and appealing for a wide variety of patients as well as providing some insights into how nudging of attitudes and perceptions could help drive patients towards safer and more cost-effective treatment options.

Time to antimicrobial therapy in septic shock patients treated with an early goal-directed resuscitation protocol: A post-hoc analysis of the ARISE trial.

Intravenous antimicrobial therapy within 1 h of the diagnosis of septic shock is recommended in international sepsis guidelines. We aimed to evaluate the association between antimicrobial timing and mortality in patients presenting to the ED with septic shock. Post-hoc analysis of 1587 adult participants enrolled in the Australasian Resuscitation in Sepsis Evaluation (ARISE) multicentre trial of early goal-directed therapy for whom the time of initial antimicrobial therapy was recorded. We compared participants who had initiation of antimicrobials within the first hour (early) or later (delayed) of ED presentation. A propensity score model using inverse probability of treatment weighting was constructed to account for confounding baseline covariates. The primary outcome was 90-day mortality. The median (interquartile range) time to initiating antimicrobials was 69 (39-112) min with 712 (44.9%) participants receiving the first dose within the first hour of ED presentation. Compared with delayed therapy, early administration was associated with increased baseline illness severity score and greater intensity of resuscitation pre-randomisation (fluid volumes, vasopressors, invasive ventilation). All-cause 90-day mortality was also higher; 22.6% versus 15.5%; unadjusted odds ratio (OR) 1.58 (95% confidence interval [CI] 1.16-2.15), P = 0.004. After inverse probability of treatment weighting, the mortality difference was non-significant; OR 1.30 (95% CI 0.95-1.76), P = 0.1. Live discharge rates from ICU (OR 0.81, 95% CI 0.72-0.91; P = 0.80) and hospital (OR 0.93, 95% CI 0.82-1.06; P = 0.29) were also not different between groups. In this post-hoc analysis of the ARISE trial, early antimicrobial therapy was associated with increased illness severity, but 90-day adjusted mortality was not reduced.

Safety and Clinical Outcomes of Hospital in the Home.

The aim of the study was to evaluate clinical outcomes and adverse events (AEs) experienced by patients treated within the Hospital in the Home (HITH) service of a major metropolitan hospital in South Australia. A retrospective case note audit of 100 HITH episodes among adults who received continuous intravenous antimicrobial therapy via an elastomeric or electronic infusion device was undertaken. Age- and sex-adjusted binomial logistic regression analyses were undertaken to identify factors associated with major and minor AEs. Of the 100 patients included, 71 were male and the mean (SD) patient age was 62.8 (17.19) years. Elastomeric infusion devices were used for 98 patients. The mean (SD) HITH treatment duration was 20.1 (11.9) days. Overall, 130 AEs were documented for 72 patients (72%), of whom 12 patients experienced a major AE and 68 patients experienced a minor AE. There were 45 occasions among 23 patients where an infusion administered through an elastomeric device did not run to completion. Fifteen patients were readmitted to hospital. Minor AEs were more likely among people with more vascular line days (adjusted odds ratio [aOR] = 1.05; 95% confidence interval (CI) = 1.01-1.10 per day increase) and females (aOR = 4.43; 95% CI = 1.14-17.17). An increased number of vascular line days was associated with an increased likelihood of an incomplete infusion (aOR = 1.05; 95% CI = 1.01-1.09). Hospital readmission was more likely with increasing age (aOR = 1.06; 95% CI = 1.01-1.11 per year increase). Adverse events need to be monitored carefully when HITH treatment is provided for extended periods.

Impact of Mandatory Infectious Diseases Consultation and Real-time Antimicrobial Stewardship Pharmacist Intervention on Staphylococcus aureus Bacteremia Bundle Adherence.

BackgroundThe purpose of this study was to evaluate the impact of infectious diseases consultation (IDC) and a real-time antimicrobial stewardship (AMS) review on the management of Staphylococcus aureus bacteremia (SAB).MethodsThis retrospective study included adult inpatients with SAB from January 2016 to December 2018 at 7 hospitals. Outcomes were compared between 3 time periods: before mandatory IDC and AMS review (period 1), after mandatory IDC and before AMS review (period 2), and after mandatory IDC and AMS review (period 3). The primary outcome was bundle adherence, defined as appropriate intravenous antimicrobial therapy, appropriate duration of therapy, appropriate surveillance cultures, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary end points included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality.ResultsA total of 579 patients met inclusion criteria for analysis. Complete bundle adherence was 65% in period 1 (n = 241/371), 54% in period 2 (n = 47/87), and 76% in period 3 (n = 92/121). Relative to period 3, bundle adherence was significantly lower in period 1 (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.37–0.93; P = .02) and period 2 (OR, 0.37; 95% CI, 0.20–0.67; P = .0009). No difference in bundle adherence was noted between periods 1 and 2. Significant differences were seen in obtaining echocardiography (91% vs 83% vs 100%; P < .001), source control (34% vs 45% vs 45%; P = .04), and hospital LOS (10.5 vs 8.9 vs 12.0 days; P = .01). No differences were noted for readmission or mortality.ConclusionsThe addition of AMS pharmacist review to mandatory IDC was associated with significantly improved quality care bundle adherence.

Management of Staphylococcus aureus bacteraemia (SAB) in the oncology patient: Further evidence supports prompt removal of central venous catheters and shorter duration of intravenous antimicrobial therapy

SummaryBackgroundStaphylococcus aureus bacteraemia (SAB) is associated with relatively high risk of complications and high levels of mortality. Internationally, SAB management guidelines lack consensus and especially so regarding oncology patients. This is likely a reflection of insufficient randomised control trials (RCT) and the diversity of SAB patient populations. However, there are 2011 guidelines recommending a minimum of 14 days of appropriate IV antibiotic therapy for SAB.ObjectiveWe wished to determine whether our practice of shortened duration of intravenous antimicrobial therapy in favour of oral administration proved as effective as recommended guidelines in a mixed oncology patient cohort.MethodsRetrospective review of patient records that included any SAB episode among oncology patients from January 2002 to December 2015. Medical chart reviews were undertaken to determine patient demographics, clinical management & antimicrobial therapy, duration of stay, presence of a central venous catheter (CVC) and outcome.ResultsOur CVC removal rate was just 73% in SAB where CVC was the identified source of infection, with an attributable mortality rate (<4%) far lower than would be expected. Antimicrobial therapy durations were considerably lower (10 days) than current recommendations of 14 days IV therapy. The recurrence rate of 15% was also significantly lower than has been reported previously.ConclusionsOur observations contribute new insights concerning the management of SAB in oncology patients. Our findings suggest that therapeutic approaches should perhaps remain individualised and reflective of patient characteristics taking into consideration the complex nature of oncology patients.

Guideline adherence for the management of emergency department patients with febrile neutropenia and no infection source: Is there room for improvement?

Febrile neutropenia is an oncologic emergency associated with significant morbidity and mortality. The objective of our study was to assess guideline adherence and clinical outcomes associated with the management of high- and low-risk febrile neutropenia patients presenting to the emergency department. A retrospective observational cohort study was conducted at a 60,000-visit emergency department at an academically-affiliated tertiary referral hospital. Patients were identified as low- or high-risk using the guideline-recommended Multinational Association for Supportive Care in Cancer score. The primary outcome was the proportion of cases in which the management was concordant with applicable febrile neutropenia guidelines. Guideline adherence was defined as hospital admission and intravenous antimicrobial therapy for high-risk patients and discharge home with oral antimicrobial therapy for low-risk patients. Secondary outcomes included appropriate vancomycin administration, hospital length of stay, rates of acute kidney injury, in-hospital Clostridium difficile infection rates, and 30-day mortality. Of the 237 patients included, 94 (39.7%) were low-risk patients and 143 (60.3%) were high-risk patients. Guideline adherence occurred in 96.8% of high-risk patients and 0.4% of low-risk patients. Mean hospital length of stay of the low-risk group was 5 ± 5.0 days compared to 7.2 ± 7.3 days in the high-risk group. Vancomycin was often inappropriately given in 69.5% of high-risk patients. Clostridium difficile occurred in 15 (10.3%) adherent and 4 (4.4%) non-adherent patients. By 30 days, 4 (4.3%) low-risk and 15 (10.7%) high-risk patients died. Adherence to the febrile neutropenia guidelines was low resulting in unnecessary hospital admissions of low-risk patients and frequent over-prescription of empirical vancomycin.

Shortening antibiotic duration in the treatment of acute cholangitis: rationale and study protocol for an open-label randomized controlled trial

BackgroundAntimicrobial therapy with appropriate biliary drainage is considered the standard of care for acute cholangitis, but the optimal duration of antimicrobial therapy remains unknown. Seven to 10 days of antimicrobial therapy are common for the treatment of acute cholangitis, but a recent retrospective cohort study suggested a shorter duration might be effective. A shorter duration of antimicrobial therapy can be beneficial in decreasing the length of hospital stay, improving patients’ quality of life, decreasing adverse effects, and even contributing to a decrease in the occurrence of antimicrobial resistance.Methods/designWe will conduct a multi-centre, open-label, randomized, non-inferiority trial to compare short-course therapy (SCT) with conventional long-course therapy (LCT) in treating patients with acute cholangitis. SCT consists of 5-day intravenous antimicrobial therapy if the patients had clinical improvement, while at least 7 days of intravenous antibiotics will be provided to the LCT group. The primary outcome is clinical cure at 30 days after onset. Patients will be randomly assigned in an open-label fashion. A total sample size of 150 was estimated to provide a power of 80% with a one-sided α level of 2.5% and a non-inferiority margin of 10%.DiscussionThis trial is expected to reveal whether SCT is non-inferior to conventional LCT or not, and may provide evidence that one can shorten the treatment duration for acute cholangitis for the benefit of patients.Trial registrationUniversity Hospital Medical Information Network, UMIN000028382. Registered on 30 August 2017.

1041. Staphylococcus aureus Bacteremia Bundle Adherence Pre- and Post-Implementation of Mandatory Infectious Diseases Consultation and Antimicrobial Stewardship Pharmacist Intervention

BackgroundInfectious diseases consult (IDC) and antimicrobial stewardship (AMS) intervention independently demonstrate improved management of Staphylococcus aureus bacteremia (SAB). However, data supporting utilizing both strategies is limited. The objective of the current study is to assess evidence-based bundle adherence for SAB in the presence and absence of mandatory IDC and AMS pharmacist review in a multi-site health system.MethodsThis retrospective study included adult inpatients with SAB from January 2016 to December 2018 at seven hospitals. Outcomes were compared between three groups: pre-mandatory IDC and AMS review (group 1), post-mandatory IDC and pre-AMS review (group 2), and post-mandatory IDC and AMS review (group 3). The primary outcome was bundle adherence defined as: appropriate intravenous antimicrobial therapy, appropriate duration of therapy, 24–48-hour surveillance cultures until documented clearance, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary endpoints included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality.ResultsA total of 579 patients met the final inclusion criteria for analysis. Complete bundle adherence was achieved in 65% of patients for group 1 (n = 371), 54% for group 2 (n = 87), and 76% for group 3 (n = 121). Adherence to bundle elements was significantly higher in group 3 when compared with group 1 (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37–0.93), and group 2 (OR 0.37, 95% CI 0.20 – 0.67). No difference in bundle adherence was noted between groups 1 and 2. When comparing groups 1, 2 and 3, significant differences were seen in obtaining echocardiography (91% vs. 83% vs. 100%; P = 0.0378), and hospital LOS (10.5 vs. 8.85 vs. 12.0 days; P = 0.0149), respectively. Increased hospital LOS in group 3 may be due to nonsignificant higher rates of complicated bacteremia compared with groups 2 and 1 (32% vs. 44% vs. 43%, P = 0.09), respectively. No differences were noted for readmission or mortality.ConclusionThe addition of AMS pharmacist review to mandatory IDC significantly improved quality care bundle adherence.Disclosures All authors: No reported disclosures.

Multifocal abdominal abscessation in a three-month-old puppy due to Escherichia coli

A 12-week-old, crossbreed, male entire dog was evaluated for a three-week history of lethargy, nausea, anorexia, haemorrhagic diarrhoea and free abdominal fluid. Abdominal ultrasound revealed multiple cavitated hepatic masses, abdominal...

245 Febrile Neutropenia Treatment in the Emergency Department: Overtreatment and Unnecessary Hospital Admissions are Common

Febrile neutropenia (FN) is an oncologic emergency associated with a risk of major complications and mortality. The objective of this study is to assess adherence to the Infectious Diseases Society of America (IDSA) guidelines for the use of antimicrobial agents in neutropenic patients with cancer as well as the outcomes associated with treatment administered to febrile neutropenic patients in the emergency department. This was a single center, observational cohort study conducted at a 60,000 visit Midwestern tertiary referral ED in febrile neutropenic patients between January 2009 to July 2018. Patients included were > 18 years of age, had an ANC < 500/mm3, and were febrile (>38°C). Patients were excluded if they had no concomitant cancer diagnosis or had a suspected source of infection. The primary outcome of this study was proportion adherence to the current febrile neutropenia guidelines. Secondary outcomes included 30-day mortality, hospital length of stay, appropriate vancomycin administration, culture results, rates of acute kidney injury (AKI), and C. difficile infections. Low-risk patients were defined as those with a MASCC score of > 21, while high-risk patients were defined as those with a MASCC score of <21 or >21 and a clinical indicator for admission. Adherence to the guidelines was defined as hospital admission with intravenous (IV) broad-spectrum antimicrobial therapy for high-risk patients and discharge to home with oral antimicrobial therapy for low-risk patients. Vancomycin appropriateness was determined using the IDSA febrile neutropenia guideline recommendations. Acute kidney injury was determined using the current Kidney Disease Improving Global Outcomes (KDIGO) guidelines. Relative risks of each demographic and clinical characteristic were assessed predicting adherence. A total of 237 patients were included in this study, 94 low-risk patients and 143 high-risk patients. Nonadherence to the guidelines occurred in 91 (96.8%) low-risk patients and 1 (0.4%) high-risk patients. The mean hospital length of stay for patients in the low-risk group was 5 ± 5.0 days compared to 7.2 ± 7.3 days in the high-risk group. Eighty-nine (94.7%) low-risk patients received broad-spectrum antimicrobial therapy. The 30-day mortality rate was 2.9% in low-risk patients and 16% in high-risk patients. Vancomycin was administered to 38.4% of patients (59 (41.3%) high-risk and 32 (35.2%) low-risk patients) In the high-risk patients, vancomycin administration was inappropriate in 42 (71.2%) of the cases. C. difficile occurred in 10 (10.6%) low-risk patients and 4 (2.8%) high-risk patients. Adherence to the febrile neutropenia guidelines was low, particularly in the low-risk population resulting unnecessary hospital admissions and receipt of inappropriate broad-spectrum antimicrobials. Future studies should focus on evaluating the impact of information technology and educational opportunities to improve guideline adherence for the management of febrile neutropenic patients presenting to the ED.

2741 Emphysematous Gastritis: A Real Indication for Emergent Surgical Intervention?

INTRODUCTION: Emphysematous gastritis (EG) is a rare, life-threatening form of gastritis caused by gas-forming microorganisms which has a high mortality rate of 62%. Microorganisms associated with EG include Streptococcus, Escherichia coli, Enterobacter, Clostridium, Pseudomonas aeruginosa, Staphylococcus aureus, Candida, and Mucor. Only 40 cases of EG have been reported in English-language literature, and there are no guidelines available for the management of EG. We would like to highlight the importance of early diagnosis and optimum management of EG. CASE DESCRIPTION/METHODS: A 96-year-old male with a history of aortic valve replacement on aspirin and warfarin presented with epigastric discomfort, coffee ground emesis, and melena. He was hemodynamically stable on presentation. He had epigastric tenderness on examination. Blood work showed leukocytosis, thrombocytopenia, elevated blood urea nitrogen with normal creatinine level. Blood cultures were unremarkable. He underwent computed tomography (CT) of the abdomen, which showed gastric wall thickening along with gas. Esophagogastroduodenoscopy (EGD) showed findings consistent with gastric wall necrosis. He was managed conservatively with nasogastric tube (NG) gastric decompression, intravenous (IV) Pantoprazole, broad-spectrum IV antibiotics, and IV fluids. The patient did very well with conservative management and was discharged home in stable condition. DISCUSSION: The predisposing factors for EG are alcohol abuse, abdominal surgery, diabetes, immunosuppression, and phytobezoars. It is diagnosed based on the clinical presentation of an acute abdomen associated with systemic toxicity along with imaging findings. CT is the diagnostic imaging modality, which shows gas bubbles in the stomach wall. Management includes intravenous fluids and anti-microbial therapy covering gram-negative bacteria, anaerobes, and fungi. Emergent surgical intervention is indicated in the presence of gastric perforation and clinical deterioration despite medical management. Our patient did not have any known risk factors and was successfully managed conservatively after he was diagnosed with EG. Through this case, we want to highlight that EG can be successfully managed conservatively in selected patients without the need for surgery.

Clinical effectiveness of oral antimicrobial therapy for acute pyelonephritis caused by extended-spectrum β-lactamase-producing Enterobacteriales.

Infections caused by extended-spectrum β-lactamase-producing Enterobacteriales (ESBL-PE) are commonly treated with intravenous antibiotics. This study investigated whether oral antimicrobial therapy (OAT) is as effective as intravenous antimicrobial therapy (IVT) for acute pyelonephritis (APN) caused by ESBL-PE. A retrospective cohort of patients with APN caused by ESBL-PE was studied at a tertiary-care hospital from January 2014 through December 2016. The OAT group comprised patients treated with an appropriate oral antimicrobial agent following 7days or less of IVT. The primary endpoint was treatment failure defined as clinical and/or microbiological failure. The secondary endpoint was length of hospital stay and recurrences of APN within 2months and within 1year. Propensity score matching and multivariable Cox proportional hazard modeling were used to minimize bias. Among 238 eligible cases, Escherichia coli (83.6%) was the most common pathogen. Sixty patients received OAT after a median of four days of appropriate IVT, and 178 patients completed treatment with IVT. Fluoroquinolones (58.3%) were the most commonly prescribed OAT, followed by trimethoprim-sulfamethoxazole and amoxicillin-clavulanate. OAT was not associated with treatment failure (adjusted OR 0.66; 95% CI 0.18-2.44) and hospitalization length was shorter in the OAT group (6.2days versus 10.7days; P < 0.01). APN recurrence caused by ESBL-PE infection within 2months was not associated with OAT (adjusted HR 0.56; 95% CI 0.16-2.00). OAT reduced hospital stay without adverse effects on treatment outcome. OAT could be safely applied as a carbapenem-saving option in treatment of APN.