Outpatient Intravenous Antibiotic Research Articles

P6: Mechanical Circulatory Support for Acute Severe Aortic Regurgitation and Cardiogenic Shock

Background: We describe a case of cardiogenic and septic shock complicated by acute severe aortic regurgitation (AR) temporized by left-atrial-venoarterial (LA-VA) ECMO. Patient Presentation & Results: A 42-year-old female with end stage renal disease, type 2 diabetes, and osteomyelitis of the right foot on outpatient intravenous antibiotics presented with fevers. On initial evaluation, transthoracic echocardiogram (TTE) demonstrated normal left ventricular (LV) function with no valvular abnormalities and methicillin resistant staphylococcus aureus was identified in blood cultures. Despite several days of antibiotic treatment, the patient decompensated requiring intubation and vasopressors. Vitals were notable for a blood pressure of 80/10 mmHg. A repeat TTE demonstrated severe AR with leaflet perforation consistent with endocarditis. The patient suffered cardiac arrest and after return of spontaneous circulation, she was taken to the catheterization laboratory for mechanical circulatory support. Via the right femoral vein, initial transeptal puncture revealed a LA pressure of 35mmHg with V waves to 45mmHg. A 21Fr transeptal drainage cannula was placed in the LA with a 17Fr return cannula in the left common femoral artery for extracorporeal support with a Tandem Heart (Livanova) system. Right heart catheterization on 5Lpm of support along with epinephrine, levophed, dopamine and vasopressin were as follows: RA 13mmHg, PA 50/22 mmHg (mean 35mmHg, PA sat 53.5%) and CO/CI of 4.49/2.27 L/min/m2. Overnight the transeptal cannula was dislodged and an oxygenator was rapidly spliced converting the system to VA ECMO. On this configuration she underwent bedside guillotine amputation of the right foot and was then taken back to the catheterization laboratory where a second drainage cannula was placed into the LA, this time from the left femoral vein. A Y-connector was used to allow simultaneous inflow from both the displaced right atrial cannula (which was partially pulled into the IVC) and the new LA cannula into the pump (Picture 1). The patient underwent successful surgical aortic valve replacement (SAVR) with a 23mm Edwards Inspirus bioprosthesis. She was successfully weaned off circulatory support and ultimately discharged. Conclusion: Severe AR has been known to be a major contraindication for VA ECMO. In addition to hemodynamic instability and rapidly rising LA pressures with subsequent pulmonary edema, a noncompetent aortic valve makes MCS a unique challenge in cases of acute severe AR. In our case, normal LV function and unloading of the LA allowed for appropriate native LV output despite increased afterload from femoral artery return in the setting of severe AR. LA-VA ECMO created a window of hemodynamic stability to allow for amputation of an infected foot and successful SAVR.

1753. Impact of a Pharmacist-Driven Home Hospital Antimicrobial Stewardship Program Pilot within a Large Community Health System

Abstract Background Home Hospital (HH) is a unique and rapidly expanding care model that allows patients to receive medical therapy and monitoring through telehealth communication and nursing visits, and there are currently no published studies evaluating antimicrobial stewardship interventions in the HH setting. The goal of this study is to evaluate the impact of a pharmacist-driven antimicrobial stewardship pilot for the HH program. Methods This was a pre-post quasi-experimental study of adult patients enrolled in HH program between January through March in 2021 (control cohort) and in 2022 (intervention cohort), who received antibiotics (oral/intravenous) during their HH admission. Patients on long-term prophylactic antimicrobials, antifungals, external antimicrobials, or mycobacterial treatment were excluded. The antimicrobial stewardship pharmacist performed prospective audit and feedback and provided recommendations to clinicians through the electronic medical record. The primary endpoint was antibiotic use (days of therapy per 1000 patient-days). Secondary endpoints included broad-spectrum antibiotic usage; appropriateness of antibiotic indication, dosing, and duration; compliance with the institution’s outpatient antibiotic reference guide or outpatient intravenous antibiotic therapy (OPAT) monitoring; treatment failure; antibiotic-associated adverse effects; and cost of antibiotic therapy. Results The study included 73 and 127 patients in the control and intervention group, respectively (Figure 1). On average, the pharmacist reviewed 8 eligible patients/day. Interventions were generally well received by HH providers (Figure 2). There was no significant difference in the primary outcome. More inappropriate antibiotic indication was identified in the intervention group (46 [36%] vs. 15 [19%], p=0.01), associated with post-surgical infection prophylaxis after orthopedic procedures (Figure 3). Other secondary outcomes did not vary significantly between the groups. Figure 1:Study inclusion flowchartFigure 2:Intervention breakdownFigure 3:Infection types Conclusion The pilot allows for better understanding of outpatient and HH antibiotic prescribing practices to provide targeted interventions, and suggests the need for additional antimicrobial stewardship involvement to optimize antibiotic therapy in this novel care setting. Disclosures Elizabeth B. Hirsch, PharmD, FCCP, FIDSA, Melinta: Advisor/Consultant|MeMed: Advisor/Consultant|Merck: Advisor/Consultant|Merck: Grant/Research Support.

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

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

The management of tubo-ovarian abscess - A retrospective analysis of a centre offering outpatient intravenous antibiotic therapy

Background Tubo-ovarian abscess (TOA) carries long-term sequale in women of reproductive age. Consensus of the optimal treatment of tubo-ovarian abscess remains lacking. The aims of this study are to identify risk factors predicting the need for early drainage and compare clinical outcomes of current management practices of TOA. Methods From 2015 to 2019, a retrospective cohort study of 92 women admitted to a tertiary centre for gynaecological surgery was performed. Patients with diagnosed TOA were classified into two groups: treatment with antibiotics only, and those receiving additional drainage. Primary outcomes included length of hospital stay (LoS), length of antibiotic treatment (LoA) and need for re-intervention. Results In this study, 52 women (56.5%) were successfully treated with first line intravenous antibiotics; 40 (43.5%) received surgical drainage. Significant predictors for successful medical treatment only include age < 35 (OR: 0.89, 95% CI: 0.82-0.97) and abscess size < 6cm (OR: 0.17, 95% CI: 0.04-0.64), using multivariate analysis. Pyrexia ≥ 38°C predicted a need for drainage (OR: 3.82, 95% CI: 1.01-8.12). Patients who received additional drainage had significantly longer LoA, LoS and higher rates of re-intervention. Within this group, drainage within 72 hours of admission resulted in a trend towards shorter LoA and LoS than drainage after 72 hours, albeit not statistically significant. Conclusions Parameters include age > 35 years, pyrexia ≥ 38°C and a TOA size > 6cm may independently predict the need for drainage of TOA. Early identification of these patients is imperative for timely surgical intervention to avoid prolonged hospitalisation, antibiotic usage, and patient morbidity. More work is required to identify whether early drainage may reduce length of hospital stay and antibiotic treatment, including identifying certain patient groups who most likely to benefit from outpatient antibiotic intravenous therapy.

Risk Factors Associated With Nephrotoxicity During Outpatient Intravenous Vancomycin Administration.

Background: Many studies have described an association between intravenous vancomycin and nephrotoxicity; however, the majority have evaluated incidence and risk factors among hospitalized patients. Outpatient administration of intravenous antibiotics is a growing practice and presents its own set of unique challenges. Objective: The aim of this study was to identify risk factors for vancomycin-associated nephrotoxicity in the outpatient setting. Methods: A case-control study of patients who received intravenous vancomycin through an Outpatient Parenteral Antimicrobial Therapy (OPAT) program was conducted. Patients were identified who developed an acute kidney injury (AKI) during treatment. The primary outcome was the incidence of AKI during treatment. Results: A total of 37 out of 130 patients (28.5%) met the criteria for AKI. AKI was more likely to occur in patients with a longer duration of therapy, higher maximum trough concentration, co-administration of a fluoroquinolone or metronidazole, and those who received another potentially nephrotoxic medication. Co-administration of a fluoroquinolone (OR = 5.96, P = 0.009, [CI: 1.59, 24.38]), any nephrotoxic medication (OR = 11.17, P < 0.001, [CI 3.14, 51.23]), and a higher maximum vancomycin trough (OR = 1.29, P < 0.001, [CI 1.17, 1.44]) were all indicative of a higher odds of an AKI. Conclusion: In this cohort, vancomycin-associated nephrotoxicity was common during outpatient intravenous antibiotic therapy. Co-administration of a fluoroquinolone, any nephrotoxic medication, and a higher maximum vancomycin trough were associated with AKI development. Further study is needed to determine how this impacts long-term clinical outcomes and what measures can be taken to reduce nephrotoxicity risk.

Surgical treatment of acute appendicitis in pandemic: COVID -19 collateral damage

Background: COVID-19 pandemic has generated changes regarding the management of patients with all kind of pathologies. Here we show the experience concerning the surgical treatment of acute appendicitis (AA) in a teaching hospital in the city of Buenos Aires during the lockdown, and its comparison with the same period of 2019 in order to assess the differences between the timing for consultation, intraoperative findings and the treatment outcome. Material and methods: A prospective database was retrospectively analyzed. We compared patients undergoing surgical treatment for AA in March-July of 2019 v. March-July 2020, taking into account the preoperative period and comparing the outcome regarding the surgical intervention and the impact in the postoperative period between the two groups. Results: 127 patients were included, 46 treated during the pandemic. Patients undergoing surgical treatment during the pandemic had a higher incidence of peritonitis (61.7% vs. 76.1%; p = 0.09) and higher requirement of abdominal drainage (9.9% vs. 23.9%; p = 0.03). There was an increase in the incidence of complications (10.9 vs. 4.9%; p: 0.21), reoperations (8.7 vs. 1.23%, p: 0.03), readmissions (6.5 vs. 0%, p: 0.02) and need for out-patient intravenous antibiotics (6.5 vs. 0%; p: 0.02). The average hospital length was of 1.89 (SD 2.04) and 3.24 (SD 7.31) for the groups operated before and during pandemic, respectively. Conclusions: During the COVID-19 pandemic, the number of patients undergoing surgical intervention because of AA decreased compared to the previous year, with increased complications in the postoperative period, higher compromise of the appendix, and longer hospital stay.

The influence of a ban on outpatient intravenous antibiotic therapy among the secondary and tertiary hospitals in China

BackgroundAntimicrobial resistance (AMR) is a serious global public health challenge. Physicians’ over-prescription of antibiotics is a major contributor, and intravenous (IV) antibiotic use has been a particular concern in China. To address the rapid fallout of antibiotic overuse, the Chinese government has piloted a ban of IV antibiotics in the outpatient department (OD) with the exemption of paediatrics, emergency department (ED), and inpatient ward of secondary and tertiary hospitals in several provinces.MethodsTo assess the potential impact of the policy, we conducted a mixed-methods study including 1) interviews about the ban of IV antibiotic use with 68 stakeholders, covering patients, health workers, and policy-makers, from two cities and 2) a hospital case study which collected routine hospital data and survey data with 207 doctors.ResultsOur analyses revealed that the ban of IV antibiotics in the OD led to a reduction in the total and IV antibiotic prescriptions and improved the rational antibiotic prescribing practice in the OD. Nevertheless, the policy has diverted patient flow from OD to ED, inpatient ward, and primary care for IV antibiotic prescriptions. We also found that irrational antibiotic use in paediatrics was neglected. Radical policy implementation, doctors circumvented the regulations, and lack of doctor-patient communication during patient encounters were barriers to the implementation of the ban.ConclusionsFuture efforts may include 1) to de-escalate both oral and IV antibiotic therapy in paediatric and reduce oral antibiotic therapy among adults in outpatient clinics, 2) to reduce unnecessary referrals by OD doctors to ED, primary care, or inpatient services and better coordinate for patients who clinically need IV antibiotics, 3) to incorporate demand-side tailored measures, such as public education campaigns, and 4) to improve doctor-patient communication. Future research is needed to understand how primary care and other community clinics implement the ban.

Evaluation of a Safe Neutrophil Count for Cessation of IV Antibiotics and Early Hospital Discharge in Stable, Afebrile Patients Recovering after Acute Myeloid Leukaemia (AML) Therapy or an Autograft

Background Currently there are no guidelines on a safe neutrophil count for intravenous antibiotic (IVAB) cessation and hospital discharge in haematology patients recovering after myelosuppressive chemotherapy complicated by febrile neutropenia (FN). Aims We assessed the safety in stable afebrile patients after recent FN of (i) appropriately stopping IVAB and (ii) early hospital discharge respectively within 24 hrs of absolute neutrophil count (ANC) recovery to ≥0.2x10^9/L. Appropriate cessation required a minimum of 3 days of IVAB and no focus of unresolved infection. Safety was defined as the absence of (i) fever recurrence after IVAB cessation and (ii) readmission in the 10-days post discharge for non-line related bacterial sepsis. Barriers to early discharge were also evaluated. Methods A retrospective, single centre audit on adult haematology patients admitted with AML (n=73 courses of induction or consolidation; 27 patients) or for an autograft (n=68 admissions;65 patients) between 2017-2019 and 2016-2017 respectively. Exclusion criteria included patients with secondary AML, reduced intensity AML chemotherapy (low dose cytarabine or azacitidine) and outpatient IVAB use post-discharge. Patients who continued on oral antibiotics as inpatients or on discharge were included in the analysis. Data were analysed with Mann Whitney U test, Chi square test and Fisher's exact test where appropriate. Results Both cohorts had a median age of 59 years. Autograft conditioning consisted mostly of high dose melphalan alone (57%) or with busulfan (7%) and BEAM (19%). All of the AML regimens contained either intermediate or high-dose cytarabine and/or an anthracycline. Most admissions (n=128; 91%) were complicated by FN, 32% (n=41) with positive blood cultures. Nearly half (n=61; 48%) of FN episodes ceased IVAB appropriately with 22/61 (36%) transitioned to oral antibiotics; another 19 (15%) episodes ceased IVAB prior to ANC ≥0.2. None of these 80 episodes had recurrent fever requiring IVAB resumption. IVAB were continued in the remaining 48 (37%) episodes, due to (a) unresolved fever (n=21) (b) recent bacteraemia or unresolved infective focus (n=17) or (c) empirically at physician discretion (n=10), for a median (range) duration of 3 (1-10), 3 (1-15) and 2 (1-5) days respectively. Thirty-seven (29%) of all FN episodes were discharged on oral antibiotics. Discharge within 24h from ANC≥0.2 occurred in 47% overall; more frequently in AML (60%) vs autograft (32%; p=0.001) patients, predominantly due to less unresolved gastrointestinal toxicity (5% vs 59% respectively). Other barriers to early discharge with an incidence of &amp;gt;5% included IVAB use, persistent fever, analgesia for mainly mucositis and transfusion requirement. Unplanned readmission rates were low (6% autograft, 3% AML) with none due to confirmed non-line related bacteraemia; these did not differ according to discharge ANC (≤0.5 or &amp;gt;0.5; p=0.217). Conclusion In afebrile, clinically stable AML and autograft patients without medico-social barriers to early discharge, IVAB can be ceased and hospital discharges safely done within 24h from recovery ANC≥0.2. Disclosures No relevant conflicts of interest to declare.

First Pediatric Outpatient Parenteral Antibiotic Therapy Clinic in Indonesia

Background: Infection remains a major pediatric health problem in Indonesia and usually leads to longer hospitalization due to the need for extended intravenous antibiotic administration. In developed countries, pediatric outpatient parenteral antibiotic therapy (P-OPAT) is well-established and proven to be safe and effective at reducing the length of hospital stay; however, data on low- and middle-income countries such as Indonesia remain limited. This P-OPAT service is new and the first service in Indonesia.Methods: The medical records of patients attending Indonesia's first P-OPAT clinic between April 2015 and March 2017 were retrospectively investigated.Results: During the 24-month period, 32 patients received treatment at the P-OPAT clinic, saving a total of 258 bed days. The majority of patients (n = 16; 50%) were diagnosed with urinary tract infection, followed by cellulitis (n = 4; 12.5%) and osteomyelitis (n = 4; 12.5%). Ceftriaxone was the most commonly used antibiotic (n = 16; 50%). All patients used a peripheral intravenous catheter and were sent home with this device. Twelve patients (37.5%) needed to change IV access more than once. None of the patients used elastomeric infusor device. The median duration of OPAT was 5 days (range 1–27 days). All patients were successfully treated with no recurrence after 30 days. One patient (3.1%) experienced drug-related complication and another one (3.1%) was readmitted due to an underlying medical condition. All the patients complied with P-OPAT schedules.Conclusions: P-OPAT service offers a safe and effective option for the delivery of outpatient intravenous antibiotics in selected patients even in resource-poor settings.

Cost analysis of inpatient versus outpatient intravenous antibiotic treatment for periprosthetic joint infections : A simulation

HintergrundDie parenterale Antibiotikagabe im Rahmen der Therapie von periprothetischen Infektionen erfordert in der Regel eine stationäre Behandlung und geht mit hohen Kosten einher.FragestellungEs wurden tatsächliche stationäre Behandlungskosten („inpatient parenteral antibiotic therapy“ [IPAT]) mit simulierten Kosten einer ambulanten Behandlung („outpatient parenteral antibiotic therapy“ [OPAT]) von Patienten mit periprothetischen Gelenkinfektionen verglichen. Die Auswertung erfolgte aus Perspektive der Kostenträger (gesetzliche Krankenversicherung [GKV]) und Leistungserbringer (Krankenhäuser).Material und MethodenDie Analyse und Simulation erfolgten auf Grundlage einer ICD-10 (Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme, 10. Revision) für das Behandlungsjahr 2015 mit der Diagnose T84.ErgebnisseDie simulierte Reduktion von 159 Bettentagen bei den in die Studie eingeschlossenen 12 Patienten erbrachte aus Sicht der Kostenträger eine Reduktion der Gesamtkosten um >18.000 €. Aus Perspektive der Leistungserbringer verbesserte sich der Reinerlös um >22.000 €. Die Gesamtkosten der OPAT für den Kostenträger beliefen sich auf >57.000 €. Für den Leistungserbringer zeigte sich in der Differenz von Poliklinikerlös und -kosten der OPAT ein Verlust von >1500 €.DiskussionDie OPAT ist für Leistungserbringer insgesamt finanziell vorteilhaft. Weitere Vorteile durch Opportunitätskosten erscheinen interessant. Für den Kostenträger ist die OPAT insbesondere durch die ambulanten Medikamentenkosten mit einem finanziellen Mehraufwand verbunden. Der niedergelassene Sektor sollte durch die anzunehmende Mehrbelastung ebenso wie der anzunehmende Patientenkomfort bedacht werden.

Analysis of outpatient and home parenteral intravenous antibiotic therapy (OHPAT) cases at the Newcastle upon Tyne Hospitals NHS Foundation Trust from April 2017 to June 2019

Introduction and Methods Newcastle’s OHPAT service has been operating since 2011, providing intravenous antimicrobials on outpatient basis for deep seated infections (DSI) and skin and soft tissue infections (SSTI); either provided at the OHPAT service in hospital (H-OPAT), delivered to the patient’s home (C-OPAT) or self-administered by an instructed patient (S-OPAT). The service aims to reduce admissions and inpatient bed days. Data from a prospective database was analysed to determine bed days saved, admissions avoided, location and success rate of treatment and adverse outcomes. Results 292 patients (174 male, 118 female) median age 54 (range 17– 97) April 2017-June 2019. 148 patients with SSTI and 143 DSI. 140 patients previously treated as inpatients. 141 admissions avoided; 3540 bed days saved; 267 patients treated with H-OPAT; 21 C-OPAT; 4 S-OPAT. High cure rate of 100% in SSTI and 97% in DSI (3 re-admissions, 1 self-discharge). Low complication rate with no death, MSSA/other bacteraemia or CDT-associated diarrhoea. Low complication rate of 0.7%: rash in 1 patient (on ceftriaxone) and line blockage in 1 patient. Conclusion The aim of the OHPAT service is equality of effectiveness and safety compared to inpatient care. This has been achieved in the ongoing low rate of complications and adverse outcomes. The service treated a wide range of DSI which contribute a larger proportion of bed days for much fewer cases than SSTI. Significant numbers of hospital stays were avoided or shortened. OHPAT has been able provide complex regimes with home delivered and self-administered dosing.

Daily outpatient intravenous antibiotic therapy for the management of paediatric periorbital cellulitis, a retrospective case series.

To evaluate whether outpatient treatment of periorbital cellulitis with daily administration of intravenous antibiotics and physician evaluation is an effective and safe alternative to admission. A retrospective chart review study of paediatric patients treated on an outpatient basis for periorbital cellulitis at a tertiary children's hospital between 2013 and 2015 was performed. Children were assessed day by a paediatrician to monitor for resolution of symptoms or complications. The Montreal Children's hospital, a tertiary care centre. Children diagnosed with an uncomplicated periorbital cellulitis secondary to an acute sinusitis or upper respiratory tract infection. The number of days of intravenous antibiotics, complications or need for subsequent admission. Complications were defined as formation of an abscess or phlegmon confirmed on computerised tomography scan, worsening or recurrent persistent cellulitis, failure to improve on intravenous antibiotics, and intracranial complications. Sixty-six children with a diagnosis of uncomplicated periorbital cellulitis secondary to sinusitis who received intravenous antibiotics via medical day hospital and who fit the inclusion criteria were identified. The mean duration of intravenous antibiotic therapy was 4.1days. All children received ceftriaxone, with one patient also receiving cefuroxime. Two of 66 patients developed complications; one patient required admission for failure to improve/subperiosteal phlegmon and later underwent functional endoscopic sinus surgery, and one patient developed an eyelid abscess that did not require admission. No patients developed severe neurological or visual deficits. Outpatient intravenous therapy with daily reassessment by a physician may be a safe alternative to admission in select cases of periorbital cellulitis without systemic signs of illness.

Patient preferences for treatment of acute bacterial skin and skin structure infections in the emergency department

BackgroundLimited research has assessed patient preferences for treatment disposition and antibiotic therapy of acute bacterial skin and skin structure infection (ABSSSI) in the emergency department (ED). Understanding patient preference for the treatment of ABSSSI may influence treatment selection and improve satisfaction.MethodsA survey was conducted across 6 US hospital EDs. Patients with ABSSSI completed a baseline survey assessing preferences for antibiotic therapy (intravenous versus oral) and treatment location. A follow-up survey was conducted within 30–40 days after ED discharge to reassess preferences and determine satisfaction with care.ResultsA total of 94 patients completed both baseline and follow-up surveys. Sixty (63.8%) participants had a history of ABSSSI, and 69 (73.4%) were admitted to the hospital. Treatment at home was the most common preference reported on baseline and follow-up surveys. Patients with higher education were 82.2% less likely to prefer treatment in the hospital. Single dose intravenous therapy was the most commonly preferred antibiotic regimen on baseline and follow-up surveys (39.8 and 19.1%, respectively). Median satisfaction scores for care in the ED, hospital, home, and with overall antibiotic therapy were all 8 out of a maximum of 10.ConclusionsIn these patients, the most common preference was for outpatient care and single dose intravenous antibiotics. Patient characteristics including higher education, younger age, and current employment were associated with these preferences. Opportunities exist for improving ABSSSI care and satisfaction rates by engaging patients and offering multiple treatment choices.

EMPYEMA NECESSITATIS AS A COMPLICATION OF DIABETIC FOOT INFECTION

SESSION TITLE: Chest Infections 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: We report a case of empyema necessitatis associated with diabetic foot infection secondary to Staphylococcus simulans, a commensal organism uncommonly associated with invasive infection. CASE PRESENTATION: A 58-year-old Caucasian man with a history of tobacco abuse and uncontrolled type 2 diabetes mellitus with associated neuropathy presented to a hospital emergency department three weeks after stepping on a tack. He developed a local infection, including cellulitis and myositis, which worsened until he decided to seek medical care. During this time, he had also noticed the development of a right-sided anterior chest wall mass. Exam and initial labs were significant for signs of sepsis and a fluctuant soft tissue mass at the right costochondral junction. Broad-spectrum IV antibiotics were started. Chest radiographs demonstrated a large right-sided pleural effusion, and an echocardiogram was negative for vegetations. Thoracentesis fluid studies indicated an exudative effusion with the presence of Gram-positive cocci eventually identified as a methicillin-resistant strain of Staphylococcus simulans. CT imaging of the chest demonstrated extension of the empyema through the mediastinum to the anterior right chest wall (Figure 1). A pleural drain was placed and intrapleural thrombolytics were administered. There was significant improvement on chest radiographs, and the patient was discharged from the hospital. Follow-up imaging after six weeks of outpatient broad-spectrum intravenous antibiotics showed resolution of the empyema, including the mediastinal and chest wall components (Figure 2). DISCUSSION: Empyema necessitatis, a complication of pleural empyema in which the infection invades the chest wall to create a soft tissue infection and/or abscess, is an uncommon complication of pleural infection.1 The most common causes are Mycobacterium tuberculosis and Actinomyces spp.1 In this case, the only identified organism was Staphylococcus simulans, a coagulase-negative commensal organism found in normal skin flora that is occasionally recognized as the likely culprit of skin and soft tissue infections and can be associated with significant antibiotic resistance.2 The most likely etiology of this empyema was hematogenous spread from his diabetic foot infection. Despite extension through the mediastinum to the distant anterior chest wall, local management of the empyema with chest tube drainage and intrapleural thrombolytics, as well as broad-spectrum IV antibiotics, successfully resolved this infection. CONCLUSIONS: Management of empyema necessitatis involves drainage and antimicrobial drugs and can be effective at resolving infection even at sites of distant invasion. Culture data is extremely important to guiding therapy and suspicion for Mycobacterium tuberculosis infection should remain high, especially in patients with risk factors. Reference #1: Freeman AF, Ben-Ami T, Shulman ST. Streptococcus pneumoniae empyema necessitatis. Pediatr Infect Dis J. 2004; 23(2): 177-9. Reference #2: Shields BE, Tschetter AJ, Wanat KA. Staphylococcus simulans: An emerging cutaneous pathogen. JAAD Case Rep. 2016; 2(6): 428-9. DISCLOSURES: no disclosure on file for Gregory Bobulsky; No relevant relationships by Joe Chiles, source=Web Response No relevant relationships by James Lamb, source=Web Response No relevant relationships by Ellen Liu, source=Web Response

An Assessment of an Outpatient Antimicrobial Therapy Program in a Rural Medical Center : A Retrospective Chart Review.

Current literature supports outpatient parenteral antimicrobial therapy (OPAT). This article presents results from a research study that evaluated an OPAT program that treated community-acquired pneumonia. If patients had the opportunity to receive outpatient intravenous antibiotics for community-acquired pneumonia, would this prevent future hospitalization? Was there a decrease in hospital admissions? An informal cost-benefit analysis comparing OPAT with inpatient hospital admissions for the same disease was also reviewed to provide evidence whether there was a change. What was the overall health care cost savings? The medical charts of 50 patients with confirmed pneumonia who had received OPAT in a 3-month period were reviewed. A retrospective medical record review was performed. All patients were evaluated by the in-house OPAT team. The resulting analysis provided evidence that an estimated savings of approximately $2100 per day would be achieved by decreasing hospital readmissions for patient who had been treated with OPAT. The conclusion of this study provides evidence that the implement of an OPAT program was, and is, essential for patient care and evidence-based best practice adherence.

Evaluating an admission avoidance pathway for children in the emergency department: outpatient intravenous antibiotics for moderate/severe cellulitis

ObjectiveChildren with moderate/severe cellulitis requiring intravenous antibiotics are usually admitted to hospital. Admission avoidance is attractive but there are few data in children. We implemented a new pathway for children...

Emergency Department Utilization During Self-Administered Outpatient Parenteral Antimicrobial Therapy

BackgroundSelf-administered outpatient parenteral antimicrobial therapy (S-OPAT) has been established as a clinically safe and effective alternative to inpatient or outpatient extended-course intravenous antibiotics while reducing healthcare resource utilization. However, previous research has not confirmed that transferring patients from the hospital to home for treatment does not cause a compensatory increase in emergency department (ED) visits. We sought to validate S-OPAT clinical safety and healthcare costs associated with S-OPAT by confirming that S-OPAT does not increase ED utilization during treatment.MethodsWe conducted a before-after study of ED utilization among S-OPAT patients. We compared ED visits, hospital admissions resulting from ED visits, hospital admissions due to OPAT-related causes, and hospital charges associated with all ED visits 60 days before and after initiation of S-OPAT. A 60-day time frame was selected to effectively encompass the maximum treatment duration (8 weeks) for S-OPAT. Paired t-tests were used to compare the change in ED utilization before and after initiation of S-OPAT.ResultsAmong our cohort of 944 S-OPAT patients, 430 patients visited the ED 60 days before or after starting treatment. Of the patients with ED visits, 69 were admitted to the hospital for OPAT-related causes and 228 incurred hospital charges from their visit. Initiation of S-OPAT was associated with a statistically significant reduction in total ED visits, all-cause hospital admission, OPAT-related hospital admission, and hospital charges (see Table 1).ConclusionOur review of ED utilization among S-OPAT patients demonstrates a reduction in multiple parameters of ED utilization with the initiation of S-OPAT treatment. Our findings confirm that S-OPAT does not yield an increase, but rather a decrease, in ED visits with the transfer of patients from hospital to home.Table 160 days before S-OPAT60 days after starting S-OPATPaired t-test p- valueED visits (encounters per patient) N = 4303.4 ± 2.92.9 ± 2.6<0.001Hospital admissions (inpatient-days per patient) N = 43014.8 ± 16.56.2 ± 13.2<0.001Hospital admissions: S-OPAT-related (inpatient-days per patient) N = 699.6 ± 9.54.0 ± 6.8<0.001Hospital charges (dollars per patient) N = 228$81,034 ± 59,552$36,105 ± 59,972<0.001Disclosures All authors: No reported disclosures.

Disease severity and treatment does not affect satisfaction in diverticulitis

BackgroundPatient satisfaction is widely reported and impacts satisfaction despite a limited understanding of the clinical and structural determinants. Patients with diverticulitis are admitted to various services, with variable disease severities. They, therefore, represent a unique group to delineate relationships between these factors and satisfaction. We examined the factors that impact hospital satisfaction in patients with diverticulitis. Materials and methodsPatients admitted between 2009 and 2012 were identified using International Classification of Diseases 9th Revision (ICD-9) codes. The primary outcome of patient satisfaction was the Press Ganey Survey overall hospitalization satisfaction question because of a high response rate. This is a precursor survey to the widely available Hospital Consumer Assessment of Healthcare Systems and Providers Survey. There was high concordance between these items. Clinical and structural variables were collected retrospectively. Patients were divided into two groups based on whether they gave the topbox response for the overall hospital rating. ResultsSixty-six patients were identified (56% female, 63 ± 14 years, length of stay: 5 ± 5 d). Seventy-four percent patients rated the hospitalization as topbox. Forty-four percent were admitted to a surgical service, and 21% of all patients underwent an operation. When comparing the topbox to the nontopbox group, demographics and disease severity were similar. Treatment modality, admitting service, and outpatient intravenous antibiotics did not influence patient satisfaction. ConclusionsClinical and structural variables did not impact overall hospital satisfaction for patients admitted with diverticulitis. This indicates that less-tangible aspects of in-hospital care may be the primary determinants of hospital satisfaction in this group. Efforts aimed at defining these variables are needed to improve patient satisfaction.

Infectious diseases specialist management improves outcomes for outpatients diagnosed with cellulitis in the emergency department: a double cohort study

Three hospital emergency rooms (ERs) routinely referred all cases of cellulitis requiring outpatient intravenous antibiotics, to a central ER-staffed cellulitis clinic. We performed a retrospective cohort study of all patients seen by the ER clinic in the last 4months preceding a policy change (ER management cohort [ERMC]) (n=149) and all those seen in the first 3months of a new policy of automatic referral to an infectious disease (ID) specialist–supervised cellulitis clinic (ID management cohort [IDMC]) (n=136). Fifty-four (40%) of 136 patients in the IDMC were given an alternative diagnosis (noncellulitis), compared to 16 (11%) of 149 in the ERMC (P<0.0001). Logistic regression–demonstrated rates of disease recurrence were lower in the IDMC than the ERMC (hazard ratio [HR], 0.06; P=0.003), as were rates of hospitalization (HR, 0.11; P=0.01). There was no significant difference in mortality. Automatic ID consultation for cellulitis was beneficial in differentiating mimickers from true cellulitis, reducing recurrence, and preventing hospital admissions.

Initiation of a Limb Preservation Service at a Tertiary Care Community Hospital Utilizing a Clinical Care Coordinator

Category: Diabetes Introduction/Purpose: Lower extremity wounds and infections associated with diabetes result in significant use of health care resources and expenditures. Patients admitted to the hospital potentially require involvement of hospitalists and specialists from infectious diseases, orthopaedics, vascular and plastic surgery. Hospital services from the laboratory, radiology, and surgical departments may also be utilized, with case management for the complicated discharge planning of outpatient intravenous antibiotics and wound care. We hypothesized that utilization of a dedicated clinical care coordinator (CCC) would decrease patient length of stay and use of hospital resources for patients admitted to a tertiary care with a diabetes related lower extremity wound and/or infection. Methods: We initiated a Limb Preservation Service (LPS) utilizing a nurse practitioner with advanced training in wound care to act as the CCC. The CCC evaluates patients with diabetic lower extremity wounds and/or infections and coordinates specialty and/or surgical consults, vascular studies and advanced imaging. The CCC also supervises and directs all wound care personnel. The CCC remains the patient liaison throughout the hospitalization, being the point of contact for all specialties and discharge planning. Orthopaedic and vascular surgeons are consulted based on patient need, with the goal of expediting surgical management. Patients were identified over a six-month period before and after initiation of the LPS. We included patients with diagnosis and procedure codes customarily seen in the LPS service. We excluded patients with missing procedure information and diagnosis codes unrelated to diabetes and diabetic foot and ankle wounds. Comparative evaluation regarding hospitalization cost, length of stay, and hospital resource utilization were evaluated. Results: Sixty-six patients were identified for comparison after exclusion criteria. Overall length of stay (LOS) was shorter during the LPS period relative to the pre-LPS period (8.6 vs. 9.2 days). The LPS period was associated with a decreased LOS for patients with private insurance, self-pay, and workers compensation payment sources (6.3 vs 8.3 days). Greater numbers of orthopaedic and/or vascular consults were requested for patients during the LPS period (82 vs. 75%) and were associated with shorter LOS (8.1 vs. 10.4 days). Consults received in the pre-LPS period resulted in longer hospital stays. Patients discharged to home had shorter LOS after the LPS service was implemented relative to before the LPS was implemented (7.1 vs 7.7 days). Conclusion: Initiation of a limb preservation service with utilization of a CCC having advanced training and experience in wound care demonstrated an improvement in patient care efficiency and hospital costs associated with the management of patients admitted to the hospital with diabetes-related lower extremity wounds and/or infections. The LPS, under the supervision of the CCC, demonstrated decreased hospital resource utilization, expedited referrals and surgical treatment, and facilitated disposition from the hospital.