Mandatory Infectious Diseases Consultation Research Articles

Impact of infectious diseases consultation for hospitalized patients with Clostridioides difficile infection.

Clostridioides difficile infection (CDI) is associated with substantial morbidity and mortality. This study described outcomes associated with mandatory infectious diseases (ID) consultation in hospitalized patients with CDI. ID consultation was associated with increased appropriate concomitant antibiotic use, however longer courses of concomitant antibiotics were administered.

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 < 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

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.

The interplay of infectious diseases consultation and antimicrobial stewardship in candidemia outcomes: A retrospective cohort study from 2016 to 2019.

To evaluate the need for mandatory infectious diseases consultation (IDC) for candidemia in the setting of antimicrobial stewardship guidance. Retrospective cohort study from January 2016 to December 2019. Academic quaternary-care referral center. All episodes of candidemia in adults (n = 92), excluding concurrent bacterial infection or death or hospice care within 48 hours. Primary outcome was all-cause 30-day mortality. Secondary outcomes included guideline-adherence and treatment choice. Guideline-adherence was assessed with the EQUAL Candida score. Of 186 episodes of candidemia, 92 episodes in 88 patients were included. Central venous catheters (CVCs) were present in 66 episodes (71.7%) and were the most common infection source (N = 38, 41.3%). The most frequently isolated species was Candida glabrata (40 of 94, 42.6%). IDC was performed in 84 (91.3%) of 92 candidemia episodes. Mortality rates were 20.8% (16 of 77) in the IDC group versus 25% (2 of 8) in the no-IDC group (P = .67). Other comparisons were numerically different but not significant: repeat blood culture (98.8% vs 87.5%; P = .17), echocardiography (70.2% vs 50%; P = .26), CVC removal (91.7% vs 83.3%; P = .45), and initial echinocandin treatment (67.9% vs 50%; P = .44). IDC resulted in more ophthalmology examinations (67.9% vs 12.5%; P = .0035). All patients received antifungal therapy. Antimicrobial stewardship recommendations were performed in 19 episodes (20.7%). The median EQUAL Candida score with CVC was higher with IDC (16 vs 11; P = .001) but not in episodes without CVC (12 vs 11.5; P = .81). In the setting of an active antimicrobial stewardship program and high consultation rates, mandatory IDC may not be warranted for candidemia.

Impact of Infectious Disease Consultation on S. aureus Bacteremia Mortality

Objective: This study evaluated the impact of a hospital policy requiring infectious disease (ID) consultation and follow-up from an antimicrobial stewardship (AMS) pharmacist-driven team on S. aureus Bacteremia (SAB) patient mortality and improved clinical outcomes. Methods: This retrospective study included adult inpatients with SAB from 1 August 2016 to 30 May 2018 (pre-policy) and June 1 2018 to 29 February 2020 (post-policy). The primary outcome variable was in-hospital mortality, and secondary outcomes were 30-day readmission rate, acute kidney injury (AKI) at discharge, stay length, and adherence to evidence-based treatment. Results: The final sample included 435 patients for analysis. Management by non-ID physicians was associated with an 8.1 increased likelihood of mortality while hospitalized (CI 95%, 3.701–17.569). Overall mortality was reduced from 11% (n = 25) pre-policy to 6% (n = 13) after policy implementation (p = 0.07). Patients with antibiotics managed by non-ID physicians were 3 times more likely to be readmitted within 30 days. Those with a history of being immunocompromised (64% vs. 36%), or cardiovascular disease (56% vs. 44%), and patients whose providers followed guidelines (23% vs. 7%) were more likely to be discharged with AKI. Policy implementation reduced non-consultant cases from 11% to 0%. Conclusion: A policy of mandatory ID consultation with pharmacist-driven AMS review to ensure compliance can improve patient mortality, 30-day readmission rates, and clinical outcomes.

988. Is There Value of Infectious Diseases Consultation in Candidemia? A Single Center Retrospective Review From 2016-2019

BackgroundCandidemia is the second most common cause of healthcare-associated bloodstream infections in the US with mortality of approximately 25%. Studies demonstrate lower candidemia mortality with infectious diseases consultation (IDC). We evaluated effects of IDC on mortality and guideline-adherence at our institution to determine if mandatory IDC was warranted.MethodsWe retrospectively reviewed adults hospitalized with candidemia (≥ 1 blood culture positive for Candida) between 1/1/2016-12/31/2019. Exclusion criteria included age < 19 years, polymicrobial blood culture, or death or hospice within 48 hours. Primary outcome was all-cause 30-day mortality. Secondary outcomes included guideline-adherence and treatment choice. Guideline-adherence was assessed with a modified EQUAL Candida score (Table 1). Descriptive statistics were performed.Table 1. Original vs Modified EQUAL Candida Score Abbreviations. CVC: central venous catheter, BCx: blood cultureResultsOf 187 patients reviewed, 92 episodes of candidemia with 94 species of Candida were included. Patient characteristics are shown in Table 2. Central venous catheters (CVCs) were present in 66 (71.7%) patients and were the most common infection source (N=38 [41.3%]) followed by intra-abdominal (N=23 [25%]). The most isolated species were Candida glabrata (40/94 [42.6%]) and C. albicans/dublienensis (35/94 [37.2%]). 30-day mortality was 21.7%. IDC was performed in 84 (91.3%) cases. Outcomes are in Table 3. Mortality was not different between IDC vs no IDC (18 [21.4%] vs 2 [25%]); other comparisons were numerically different but not significant: repeat blood culture (98.8% vs 87.5%), echocardiography (70.2% vs 50%), CVC removal (91.7% vs 83.3%), and initial treatment echinocandin (67.9% vs 50%). All patients received antifungal therapy. IDC resulted in more ophthalmology consultations (77.4% vs 12.5%, p< 0.01). Mean modified EQUAL Candida score was higher with IDC (17.4 vs 13.9, p< 0.01).Table 2. Patient Characteristics Abbreviations. TPN: total parenteral nutrition, ICU: intensive care unit, AIDS: acquired immunodeficiency syndromeTable 3. Outcomes Abbreviations. NS: non-significant, CVC: central venous catheterConclusionIDC was common in candidemic patients and not associated with significant differences in outcomes. Current antimicrobial stewardship and consultation practices at our center do not warrant mandated IDC for candidemia.Disclosures Trevor C. Van Schooneveld, MD, FACP, BioFire (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Insmed (Individual(s) Involved: Self): Scientific Research Study Investigator; Merck (Individual(s) Involved: Self): Scientific Research Study Investigator; Rebiotix (Individual(s) Involved: Self): Scientific Research Study Investigator

Variation Among Infectious Diseases Pharmacists for the Treatment of Staphylococcus aureus Bacteremia

Introduction: Staphylococcus aureus bacteremia (SAB) remains complex, in that optimal treatment for patients, including complicated or persistent infection, remains unclear. Two recent surveys have demonstrated practice variations in SAB among infectious diseases (ID) physicians. Objectives: The purpose of this survey was to examine practice variations in SAB among ID pharmacists. Methods: A thirty-five-question survey was electronically distributed to the American College of Clinical Pharmacy (ACCP) Infectious Diseases Practice and Research Network (IDPRN) in Fall 2019 to determine differences in SAB management. Data were analyzed utilizing Pearson’s Chi-Square or Fisher’s Exact Test. Results: A total of 106 ID pharmacists responded. Only 28% of pharmacists practiced at hospitals with mandatory ID consultation for SAB. A majority (75%) had rapid diagnostic technology (RDT) for identifying SABSI, but 32% of those facilities with RDT did not notify pharmacy with results. Anti-staphylococcal penicillins were preferred for MSSA blood stream infections (BSI) in patients with central nervous system infection and endocarditis, whereas cefazolin was favored for other MSSA BSI. For persistent MRSA BSI, 34% selected daptomycin alone while 38% elected to combine daptomycin and ceftaroline. Pharmacists at hospitals less than 500 beds were more likely to use daptomycin, while those at larger hospitals were more likely to use daptomycin and ceftaroline for persistent MRSA BSI (P < .05). Conclusions: A survey of ID pharmacists showed variation in the management of SABs, as well as the definition and treatment of persistent SAB. Mandatory ID consultation and RDT use to improve SAB management have not been optimized.

Standardized Treatment and Assessment Pathway Improves Mortality in Adults With Methicillin-resistant Staphylococcus aureus Bacteremia: STAPH Study.

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) management remains challenging for clinicians. Numerous in vitro studies report synergy when vancomycin (VAN) and daptomycin (DAP) are combined with beta-lactams (BLs), which has led to clinical implementation of these combinations. While shorter durations of bacteremia have often been reported, there has been no significant impact on mortality.MethodsThe Detroit Medical Center (DMC) developed and implemented a clinical pathway algorithm for MRSA BSI treatment in 2016 that included the early use of BL combination therapy with standard of care (VAN or DAP) and a mandatory Infectious Diseases consultation. This was a retrospective, quasi-experimental study at the DMC between 2013 and 2020. Multivariable logistic regression was used to assess the independent association between pathway implementation and 30-day mortality while adjusting for confounding variables.ResultsOverall, 813 adult patients treated for MRSA BSI were evaluated. Compared with prepathway (PRE) patients (n = 379), those treated postpathway (POST; n = 434) had a significant reduction in 30-day and 90-day mortality: 9.7% in POST vs 15.6% in PRE (P = .011) and 12.2% in POST vs 19.0% in PRE (P = .007), respectively.The incidence of acute kidney injury (AKI) was higher in the PRE compared with the POST group: 9.6% vs 7.2% (P = .282), respectively. After adjusting for confounding variables including Infectious Diseases consult, POST was independently associated with a reduction in 30-day mortality (adjusted odds ratio [aOR], 0.608; 95% CI, 0.375–0.986).ConclusionsImplementation of an MRSA BSI treatment pathway with early use of BL reduced mortality with no increased rate of AKI. Further prospective evaluation of this pathway approach is warranted.

82. Post-Prescription Review with Threat of Infectious Disease Consultation and Sustained Reduction in Meropenem Use Over Four Years

BackgroundFollowing a meropenem shortage, we implemented a post-prescription review with feedback (PPRF) in November 2015 with mandatory infectious disease (ID) consultation for all meropenem and imipenem courses > 72 hours. Providers were made aware of the policy via an electronic alert at the time of ordering.MethodsA retrospective study was conducted at the University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC) to evaluate the impact of the policy on antimicrobial consumption and clinical outcomes pre- and post-intervention during a 6-year period. Antimicrobial use was tracked using days of therapy (DOT) per 1,000 patient-days, and data were analyzed by an interrupted time series.ResultsThere were 4,066 and 2,552 patients in the pre- and post-intervention periods, respectively. Meropenem and imipenem use remained steady until the intervention, when a marked reduction in DOT/1,000 patient-days occurred at both hospitals (UWMC: percentage change -72.1%, (95% CI -76.6, -66.9), P < 0.001; HMC: percentage change -43.6%, (95% CI -59.9, -20.7), P = 0.001). Notably, although the intervention did not address antibiotic use until 72 hours after initiation, there was a significant decline in meropenem and imipenem initiation (“first starts”) in the post-intervention period, with a 64.9% reduction (95% CI 58.7, 70.2; P < 0.001) at UWMC and 44.7% reduction (95% CI 28.1, 57.4; P < 0.001) at HMC.Meropenem and Imipenem DOT (January 2013 – November 2019) ConclusionMandatory ID consultation and PPRF for meropenem and imipenem beyond 72 hours resulted in a significant and sustained reduction in the use of these antibiotics and notably impacted their up-front usage.Disclosures All Authors: No reported disclosures

291. Impact of Surveillance and Offered Infectious Diseases Consults for Staphylococcus aureus Bacteremia on Quality of Care Indicators

Background Staphylococcus aureus bacteremia (SAB) remains the leading cause of bloodstream infections and is associated with 20–40% mortality. Past studies demonstrated that Infectious Diseases (ID) consultation is associated with better adherence to quality of care indicators (QCIs), including follow-up blood cultures, echocardiography, early source control, and appropriate choice and duration of antibiotics. A 2014 quality improvement project at Medstar Washington Hospital Center (MWHC) by Narsana et al. showed significantly better adherence to SAB QCIs among patients with ID consults and a non-significant trend towards lower mortality. In 2015, MWHC instituted a policy advocating ID consultation for all SAB patients, and active surveillance was performed by the ID Section to offer prompt consults prospectively. Our study aimed to assess the impact of this policy and the proactively offered ID consults on adherence to SAB QCIs and mortality rates amongst patients with SAB with and without ID consults.MethodsWe retrospectively reviewed 557 patients diagnosed with SAB between July 1st, 2015 - June 30th, 2018. Data included follow-up blood cultures, echocardiography, presence of a focal source of infection, use of appropriate antibiotics, measurement of vancomycin levels, duration of therapy, death during hospitalization, and presence of an ID consultation. Chi-Square and Fisher exact tests, and t-test and Wilcoxon rank sum test were used to analyze categorical and continuous variables, respectively.ResultsA total of 513 patients were included in the analysis, 88% (n=453) of whom had ID consultations. Patients with ID consultations were more likely to have a focal source of infection (84% vs. 50%, p < 0.0001), echocardiography (97% vs. 56%, p < 0.0001), use of a beta-lactam antibiotic for methicillin-susceptible S. aureus (90% vs 65%, p < 0.0001), and a longer duration of therapy (33 vs 9 days, p< 0.0001). Mortality was lower among patients with ID consults (16% vs. 23%, p=0.1495), but the difference was not statistically significant.Table 1 ConclusionOur study demonstrates that ID consultation is associated with better adherence to SAB QCIs, with a trend towards lower mortality. Hospital systems should support mandatory ID consultation for patients with Staphylococcus aureus bacteremia.Disclosures All Authors: No reported disclosures

Reduction of 30-day death rates from Staphylococcus aureus bacteremia by mandatory infectious diseases consultation: Comparative study interventions with and without an infectious disease specialist

ObjectivesMost Japanese hospitals need to keep to higher Staphylococcus aureus bacteremia (SAB) quality-of-care indicators (QCIs) and create strategies that can maximize the effect of these QCIs with only a small number of infectious disease specialists. This study aimed to evaluate the clinical outcomes of patients with SAB before and after the enhancement of the mandatory infectious disease consultations (IDCs). MethodsThis retrospective study was conducted at a tertiary care hospital in Japan. The primary outcome was the 30-day mortality between each period. A generalized structural equation model was employed to examine the effect of the mandatory IDC enhancement on 30-day mortality among patients with SAB. ResultsA total of 114 patients with SAB were analyzed. The 30-day all-cause mortality differed significantly between the two periods (17.3% vs. 4.8%, P = 0.02). Age, three-QCI point ≥ 1, and Pitt bacteremia score ≥ 3 were the significant risk factors for 30-day mortality. The intervention was also significantly associated with improved adherence to QCIs. ConclusionMandatory IDCs for SAB improved 30-day mortality and adherence to QCIs after the intervention. In Japan, improving the quality of management in patients with SAB should be an important target.

Postprescription Review With Threat of Infectious Disease Consultation and Sustained Reduction in Meropenem Use Over Four Years.

Following a meropenem shortage, we implemented a postprescription review with feedback (PPRF) in November 2015 with mandatory infectious disease (ID) consultation for all meropenem and imipenem courses > 72 hours. Providers were made aware of the policy via an electronic alert at the time of ordering. A retrospective study was conducted at the University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC) to evaluate the impact of the policy on antimicrobial consumption and clinical outcomes pre- and postintervention during a 6-year period. Antimicrobial use was tracked using days of therapy (DOT) per 1000 patient-days, and data were analyzed by an interrupted time series. There were 4066 and 2552 patients in the pre- and postintervention periods, respectively. Meropenem and imipenem use remained steady until the intervention, when a marked reduction in DOT/1000 patient-days occurred at both hospitals (UWMC: percentage change -72.1% (95% confidence interval [CI] -76.6, -66.9), P < .001; HMC: percentage change -43.6% (95% CI -59.9, -20.7), P = .001). Notably, although the intervention did not address antibiotic use until 72 hours after initiation, there was a significant decline in meropenem and imipenem initiation ("first starts") in the postintervention period, with a 64.9% reduction (95% CI 58.7, 70.2; P < .001) at UWMC and 44.7% reduction (95% CI 28.1, 57.4; P < .001) at HMC. PPRF and mandatory ID consultation for meropenem and imipenem use beyond 72 hours resulted in a significant and sustained reduction in the use of these antibiotics and notably impacted their up-front usage.

Description of a pharmacist-driven safety algorithm in Staphylococcus aureus bacteremia: Compliance, interventions, and good saves.

To evaluate the impact of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) safety bundle supported by leadership and to compare compliance before and after implementation. Retrospective cohort study with descriptive and before-and-after analyses. Tertiary-care academic medical center. All patients with documented SAB, regardless of the source of infection, were included. Patients transitioned to palliative care were excluded from before-and-after analysis. A pharmacist-driven safety bundle including documented clearance of bacteremia, echocardiography, removal of central venous catheters, and targeted intravenous therapy of at least 2 weeks duration was implemented in November 2015 and was supported by leadership with stepwise escalation for nonresponse. A descriptive analysis of all patients with SAB during the study period included pharmacy interventions, acceptance rates, and escalation rates. A pre-post implementation analysis of 100 sequential patients compared bundle compliance and descriptive parameters. Overall, 391 interventions were made in the 20-month period following implementation, including 20 "good saves" avoiding potentially major adverse events. No statistically significant differences in complete bundle compliance were detected between the periods (74% vs 84%; P = .08). However, we detected a significant increase in echocardiography after the bundle was implemented (83% vs 94%; P = .02) and fewer patients received suboptimal definitive therapy after the bundle was implemented (10% vs 3%; P = .045). This pharmacist-driven SAB safety bundle with leadership support showed improvement in process measures, which may have prevented major adverse events, even with available infectious diseases (ID) consultation. It provides a critical safety net for institutions without mandatory ID consultation or with limited antimicrobial stewardship resources.

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.

888. Impact of Mandatory Infectious Diseases Consult on All-cause In-patient Mortality and 30-Day Readmission in Patients with Severe Sepsis

BackgroundSevere sepsis is associated with high mortality and readmission rates. Infectious diseases (ID) consultations (IDC) improve clinical outcomes in patients with severe infections. In March 2016, a mandatory ID consultation (MIDC) policy for this patient population was implemented. This study’s goal was to determine the impact of MIDC on clinical outcomes.MethodsIn efforts to reduce mortality and complications from sepsis at our institution, multidisciplinary intervention led to a policy for MIDC for patients with sepsis. This intervention was monitored daily by the clinical initiatives team to ensure compliance. We conducted a retrospective chart review of patients with severe sepsis from all sources in Pre-MIDC group from January 2015 to February 2016 and Post-MIDC group from March 2016 to December 2017. The primary endpoint of the study was to evaluate the impact of MIDC on all-cause inpatient mortality (ACIM) and 30-day readmission in patients with severe sepsis. Secondary endpoint focused on the impact of MIDC on time to IDC and patient seen by ID physician. Subgroup analysis evaluated the impact of early vs. late IDC on ACIM.ResultsThere was a total of 511 patients in Pre-MIDC and 635 patients in Post-MIDC groups. No differences were seen in the demographics between the groups. Overall a difference was not seen in ACIM between the two groups (9.2% vs. 8%, P = 0.52); however, Post-MIDC group had lower rates of 30-day readmission due to sepsis/infection (12.1% vs. 4.9%, P = 0.01) and shorter length of stay (8.5 vs. 6.7 days, P = 0.001). We did observe an association with early IDC from admission to a decrease in ACIM compared with late IDC (7.8% vs. 9.4%, P = 0.03). Times to IDC from admission (33.5 hours vs. 16.75 hours, P = 0.001) and patient seen by ID physician from time of IDC order (23 hours vs. 8.75 hours, P = 0.0001) was faster in Post-MIDC group. A decline was observed in sepsis mortality by 16% since MIDC implementation compared with Pre-MIDC.ConclusionImplementation of MIDC led to faster time to IDC and patients seen by ID physicians which was directly associated with a decrease in ACIM. MIDC did not show a difference in overall ACIM; however, it decreased 30-day readmission due to sepsis/infection and shorter LOS. We also observed a consistent decline in overall sepsis mortality through this intervention.Disclosures All Authors: No reported Disclosures.

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.

Infectious diseases consultation improves key performance metrics in the management of Staphylococcus aureus bacteremia: A multicentre cohort study.

Staphylococcus aureus bacteremia (SAB) is associated with significant morbidity and mortality. We sought to identify factors associated with infectious diseases consultation (IDC) and understand how IDC associates with SAB patient management and outcomes. A multicentre retrospective study was performed between 2012 and 2014 in a large Canadian Health Zone in order to determine factors associated with IDC and performance of key quality of care determinants in SAB management and clinical outcomes. Factors subject to quality of care determinants were established a priori and studied for associations with IDC and 30-day all-cause mortality using multivariable analysis. Of 961 SAB episodes experienced by 892 adult patients, 605 episodes received an IDC. Patients receiving IDC were more likely to have prosthetic valves and joints and to have community-acquired and known sources of SAB, but increasing age decreased IDC occurrence. IDC was the strongest independent predictor for quality of care performance metrics, including repeat blood cultures and echocardiography. Mortality at 30 days was 20% in the cohort, and protective factors included IDC, achievement of source control, targeted therapy within 48 hours, and follow-up blood cultures but not the performance of echocardiography. There were significant gaps between the treatments and investigations that patients actually received for SAB and what is considered the optimal management of their condition. IDC is associated with improved attainment of targeted SAB quality of care determinants and reduced mortality rates. Based on our findings, we propose a policy of mandatory IDC for all cases of SAB to improve patient management and outcomes.

Mandatory infectious diseases consultation leads to improved process measure adherence in the management of Staphylococcus aureus bacteremia: A multicentre, quasi-control study

Background: Staphylococcus aureus bacteremia (SAB) results in high morbidity and mortality. Infectious diseases (ID) consultation for SAB has been associated with improved process measures and outcomes in SAB. Recent guidelines have been implemented to include ID consultation in the management of positive SAB culture. We sought to determine whether a policy of mandatory ID consultation for SAB would improve management and mortality. Methods: We conducted a retrospective quasi-experimental study of patients with SAB at three academic hospitals comparing adherence to process measures, and mortality as a secondary measure, before and after implementation of a hospital policy of mandatory ID consultation for all cases of SAB. Results: ID consultation was performed in 239/411 (58%) patients in the pre-intervention period and 196/205 (96%) patients in the post-intervention period (p &lt; 0.0001). Compared with pre-intervention, mandatory consultation was associated with better adherence to quality process measures including echocardiography (319/411 (78%) versus 186/205 (91%) p &lt; 0.0001), subsequent blood culture within 2–4 days (174/411 (42%) versus 143/205 (70%) p &lt; 0.0001) and avoidance of vancomycin as definitive antibiotic therapy for methicillin-susceptible S. aureus (MSSA) (54/347 (16%) versus 13/177 (7%) p = 0.0082). In-hospital mortality rate was 94/411 (23%) in the pre-intervention group and 33/205 (16%) in the post-intervention group. The unadjusted sub-distribution hazard ratio (sHR) for in-hospital mortality in the postintervention period was 0.67 (95% CI 0.45 to 0.99, p = 0.0447). After adjusting for significant prognostic factors, post-intervention in-hospital mortality had an sHR of 0.79 (95% CI 0.52 to 1.20, p = 0.2686). Conclusions: A policy of mandatory ID consultation for patients with SAB was easily implemented leading to consultation in nearly all SAB patients and improved adherence to standard of care process measures. In-hospital mortality did not improve significantly after adjusting for patient characteristics. Our study provides the framework to support this easily implemented institutional policy in academic hospitals.

1220. Impact of Mandatory Infectious Diseases Consultation on the Use of Core Measures and Mortality in Staphylococcus aureus Bacteremia (SAB) at an Academic Medical Center

BackgroundMultiple studies have shown that Infectious Diseases (ID) consultation significantly improves adherence to guidelines for patients with SAB and decreases mortality. Data from a prior retrospective study done at Hahnemann University Hospital showed that ID consultation improved the use of guideline-based core measures for SAB management. Based on these data, a mandatory ID consultation was established at our institution in November 2016.MethodsA retrospective, observational study was conducted to evaluate patient characteristics, adherence to core measures for SAB, and in-hospital mortality. All patients with at least one documented blood culture positive for S. aureus were stratified into two groups: pre-mandatory consult (January 1, 2014–November 1, 2016) and post mandatory consult (November 2, 2016–February 1, 2018).ResultsThree hundred seventy-three discrete episodes of SAB were included in the final analysis, 238 episodes before mandatory consult, and 135 episodes after the mandatory consult policy was enacted. Mandatory consultation significantly improved the use of the following core measures for SAB: surveillance blood cultures (87.7% pre vs. 99.2% post, P < 0.001), echocardiography (81.9% vs. 96.9%, P < 0.001), early targeted antimicrobial therapy with nafcillin or cefazolin in MSSA (71.7% vs. 88.6%, P < 0.001), and appropriateness of final antibiotic choice (80.2% vs. 95.2%, P < 0.001). In addition, in-hospital mortality (15.4% vs. 6.2%, P = 0.011), and infection-related mortality (14.3% vs. 5.6%, P = 0.011) were found to be statistically significantly lower in the post mandatory consultation patients.ConclusionImplementation of a mandatory ID consultation for patients with SAB at our institution was associated with increased adherence to guideline-based core measures for management of SAB, and decreased in-hospital and infection-related mortality. Our results suggest that mandatory ID consultation for SAB should be considered at all institutions.Disclosures All authors: No reported disclosures.

1868. Successful Use of Telemedicine vs. On-site Infectious Diseases Consultation After Implementation of a System-Wide Antimicrobial Stewardship-Led Staphylococcus aureus Bacteremia Care Bundle

BackgroundTelemedicine (TM) programs have been effectively implemented to deliver specialty care through virtual platforms to overcome geographic and resource constraints. Yet, few data exist to describe outcomes associated with TM-based management of patients with infectious diseases (ID). The purpose of this study was to compare adherence and other outcomes associated with TM and on-site (SOC) ID consultation (IDC) implementation strategies of an antimicrobial stewardship (ASP)-led S. aureus bacteremia (SAB) bundle.MethodsWe launched an SAB bundle at 10 acute care hospitals in the metro Charlotte, NC area in September 2016 for adult patients admitted with SAB and conducted a retrospective cohort study using data collected through 2017. Bundle components included (1) mandatory IDC, (2) appropriate antibiotics within 24 hours of S. aureus speciation, (3) repeat blood cultures at least every 72 hours until clearance, (4) obtainment of an echocardiogram, and (5) appropriate duration of intravenous antibiotic therapy based on SAB severity. ASP facilitated bundle initiation and assisted with compliance for all patients. The primary outcome was bundle adherence. Secondary outcomes included time to culture clearance and persistent SAB (i.e., positive blood cultures for >7 days). We used Wilcoxon rank-sum and chi-squared tests to compare outcomes.ResultsWe evaluated 872 patients with SAB during the study interval. After excluding 126 patients (prematurely discharged or died/transitioned to comfort care within 48 hours of S. aureus speciation), we analyzed 583 SOC and 163 TM group patients. There were no differences observed in overall SAB bundle adherence (SOC 86% vs. TM 88%, P = 0.52), or its individual components. No differences were found in time to culture clearance (median days: SOC = 2.9 vs. TM = 2.8, P = 0.96) and persistent SAB (SOC 11% vs. TM 11%, P = 0.77).ConclusionOur findings provide preliminary evidence to support TM-based strategies for IDC and ASP-led care bundles in resource-limited settings. Future analyses will compare mortality and hospital readmission outcomes. Disclosures All authors: No reported disclosures.