Outpatient Parenteral Antibiotic Therapy Program Research Articles

Quantitative analysis of the impact of infectious disease physicians on patients in the emergency department fast-track parenteral antibiotics program

IntroductionThe outpatient parenteral antibiotic therapy (OPAT) program of Vancouver General Hospital (VGH) was supervised by emergency physicians (EPs) until 2017 when infectious disease (ID) physicians began assisting in management. We designed a retrospective study to determine whether ID involvement led to improved outcomes.MethodsThis study analyzes the impact of ID involvement by comparing the mean days patients spent on OPAT with ID involvement versus EPs alone through a retrospective chart review. Secondary research objectives were to compare patient care decisions, e.g., antibiotic choice, tests ordered, and final diagnosis.ResultsThere was no difference between the mean number of days on OPAT between physician types. Compared to historic patterns, patients seen in OPAT after increased ID consultation spent an average of 0.5 fewer days in the program. However, when grouped by the first day of ID assessment, the average total days in OPAT was closely aligned with the day of first ID assessment, implying that ID frequently discharged patients close to initial assessment. Patients seen by ID were less likely to return within one month of discharge compared to those not seen by ID. Secondary findings include ID physicians prescribing a greater range of antibiotics, providing more varied final diagnoses, prescribing antibiotics less frequently, as well as ordering more cultures, diagnostic imaging and specialist consults.DiscussionThe findings of this study support the hypothesis that ID involvement in OPAT programs leads to changes in care that may have beneficial outcomes for patients and the healthcare system.

Creation and Validation of an Automated Registry for Outpatient Parenteral Antibiotics.

Existing outpatient parenteral antibiotic therapy (OPAT) registries are resource intensive, and OPAT programs struggle to produce objective data to show the value of their work. We describe the building and validation of an automated OPAT registry within our electronic medical record and provide objective data on the value of the program. Variables and outcomes include age, sex, race, ethnicity, primary insurance payor, antibiotic names, infection syndromes treated, discharge disposition, 30-day all-cause readmission and death rates, complications, and an estimate of the hospital days saved. Records for 146 OPAT episodes were reviewed manually to validate the registry. Data were displayed in a dashboard within the electronic medical record. Over the 4-year time frame, our registry collected 3956 unique patients who completed 4710 episodes (approximately 1200 episodes per year). A total of 400 complications during OPAT were identified. All variables had an accuracy of >90% on validation. The OPAT program resulted in a reduction in hospital length of stay by 88 820 days, or roughly 22 000 days per year. We intend our registry to serve as a blueprint for similar OPAT programs with limited administrative resources. Wider application of our system would allow for easier aggregation and comparisons of OPAT practice and address the lack interinstitutional standardization of OPAT data and outcomes.

Making the EHR Work for You-Modifications of an Electronic Health Record System to Improve Tracking and Management of Patients Receiving Outpatient Parenteral Antibiotic Therapy.

Managing the complex needs of outpatient parenteral antibiotic therapy (OPAT) patients is challenging and time-consuming. We describe development of multimodal interventions to facilitate patient management within an Epic® (Epic Systems Corporation)-based electronic health record (EHR) platform. During 2016-2018, a multidisciplinary team created several modifications in our local EHR to improve gaps in OPAT care, including shared note templates, shared patient lists, automatically triggered notifications, and comprehensive order sets. A SmartForm was created, allowing collection of discrete, self-contained extractable data about each OPAT episode. We reviewed OPAT episodes from January 2019 through December 2022. The multimodal EHR interventions culminated in the creation of a patient report, the "OPAT Monitoring View" collating OPAT-relevant data from multiple sections of the chart onto 1 screen display. This view is accessible both within the patient chart and from multiple list-based, in-basket, and snapshot-anchored preview functions in the EHR. Implementation of the EHR bundle facilitated management of 3402 OPAT episodes from 2019 to 2022 (850 episodes/year), about 50% higher than anticipated based on 540 OPAT courses in 2016. The OPAT EHR bundle allowed efficient (<3 hours) multidisciplinary rounds for management of 130-145 patients each week, streamlining of care transitions, and increasing staff satisfaction. Bundled multimodal modifications to the local EHR increased patient care efficiency and staff satisfaction and facilitated data collection to support a large OPAT program. These modifications apply commonly available EHR functionalities to OPAT care and could be adapted to other settings with different EHR platforms.

Electronic health record-based readmission risk model performance for patients undergoing outpatient parenteral antibiotic therapy (OPAT).

Outpatient Parenteral Antibiotic Therapy (OPAT) provides coordinated services to deliver parenteral antibiotics outside of the acute care setting. However, the reduction in monitoring and supervision may impact the risks of readmission to the hospital. While identifying those at greatest risk of hospital readmission through use of computer decision support systems could aid in its prevention, validation of such tools in this patient population is lacking. The primary aim of this study is to determine the ability of the electronic health record-embedded EPIC Unplanned Readmission Model 1 to predict all-cause 30-day hospital unplanned readmissions in discharged patients receiving OPAT through the Duke University Heath System (DUHS) OPAT program. We then explored the impact of OPAT-specific variables on model performance. This retrospective cohort study included patients ≥ 18 years of age discharged to home or skilled nursing facility between July 1, 2019 -February 1, 2020 with OPAT care initiated inpatient and coordinated by the DUHS OPAT program and with at least one Epic readmission score during the index hospitalization. Those with a planned duration of OPAT < 7 days, receiving OPAT administered in a long-term acute care facility (LTAC), or ongoing renal replacement therapy were excluded. The relationship between the primary outcome (unplanned readmission during 30-day post-index discharge) and Epic readmission scores during the index admission (discharge and maximum) was examined using multivariable logistic regression models adjusted for additional predictors. The performance of the models was assessed with the scaled Brier score for overall model performance, the area under the receiver operating characteristics curve (C-index) for discrimination ability, calibration plot for calibration, and Hosmer-Lemeshow goodness-of-fit test for model fit. The models incorporating maximum or discharge Epic readmission scores showed poor discrimination ability (C-index 0.51, 95% CI 0.45 to 0.58 for both models) in predicting 30-day unplanned readmission in the Duke OPAT cohort. Incorporating additional OPAT-specific variables did not improve the discrimination ability (C-index 0.55, 95% CI 0.49 to 0.62 for the max score; 0.56, 95% CI 0.49 to 0.62 for the discharge score). Although models for predicting 30-day unplanned OPAT-related readmission performed slightly better, discrimination ability was still poor (C-index 0.54, 95% CI 0.45 to 0.62 for both models). EPIC Unplanned Readmission Model 1 scores were not useful in predicting either all-cause or OPAT-related 30-day unplanned readmission in the DUHS OPAT cohort. Further research is required to assess other predictors that can distinguish patients with higher risks of 30-day unplanned readmission in the DUHS OPAT patients.

From sea to shining IV: the current state of OPAT in the United States.

First described in the United States, outpatient parenteral antibiotic therapy (OPAT) has become an indispensable part of treating serious infections. The proportion of infectious disease (ID) physicians utilizing a formal OPAT program has increased in recent years, but remains a minority. In addition, many ID physicians have indicated that OPAT programs have inadequate financial and administrative support. Given the medical complexity of patients receiving OPAT, as well as the challenges of communicating with OPAT providers across health care facilities and systems, OPAT programs ideally should involve a multidisciplinary team. The majority of patients in the United States receive OPAT either at home with assistance from home infusion companies and visiting nurses or at a skilled nursing facility (SNF), though the latter has been associated with lower rates of patient satisfaction. Current and future opportunities and challenges for OPAT programs include providing OPAT services for people who inject drugs (PWID) and incorporating the increasing use of oral antibiotics for infections historically treated with parenteral therapy. In this review, we will discuss the current practice patterns and patient experiences with OPAT in the United States, as well as identify future challenges and opportunities for OPAT programs.

999. Clinical Outcomes of Off-label Dalbavancin Use within an Outpatient Parenteral Antibiotic Therapy (OPAT) Program

Abstract Background Dalbavancin is approved for the treatment of acute bacterial skin and soft structure infections (ABSSSI). There is less data on outcomes of off-label use of dalbavancin for orthopedic and other complex infections. In this case series, we aim to analyze clinical outcomes of deep-seated infections treated with IV dalbavancin instead of long-term IV antibiotics post-discharge. Methods We conducted a retrospective review of adult patients treated with off-label IV dalbavancin between January 2020 and February 2022 at an academic center in the Bronx, NY within a long-standing outpatient parenteral antibiotic therapy (OPAT) program. Outcomes of interest included 90-d infection recurrence, prothesis retention, mortality, adverse events, and characteristics of antibiotic regimens. Results Nineteen patients received dalbavancin for off-label indications. Dalbavancin was used primarily for hardware, bone and joint, and complicated soft tissue infections (table 1). The predominant pathogen was Staphylococcus aureus. Source control was achieved in 12 (63%) patients via debridement alone (5), debridement with prosthetic device retention (4), or debridement and complete hardware removal (3). The most common dosing regimen was two-doses (1000-mg, 500-mg) one week apart. Two (11%) patients (both with initial prosthesis retention) had infection recurrence within 90 days of dalbavancin and eventually required removal (table 2). One patient experienced recurrence after 90 days and required removal. The remaining patient with prothesis retention has not experienced infection recurrence to date. Concomitant antibiotics while on dalbavancin and suppressive antibiotics following therapy were common. No patient died within 90 days of therapy and no adverse drug effects were reported. Conclusion Dalbavancin use for hardware infections, osteomyelitis, complicated soft tissue infections, and spinal infections is associated with favorable cure rates, safety profile, and tolerability. Improved outcomes may be achieved with hardware removal. Dalbavancin off-label use within an OPAT program may facilitate early discharge or prevent admissions in eligible patients, although further study is needed. Disclosures All Authors: No reported disclosures.

Stretococcus gallolyticus infective endocarditis, a different presentation-a case report

We present a case (57-year-old man) of infective endocarditis caused by Streptococcus gallolyticus in a patient with incident early-stage colon cancer. Benzylpenicillin treatment was immediately initiated to control bacteremia, and curative cancer resection was conducted 1 week later. The patient was discharged and placed on a 6-week outpatient parenteral anti-biotic therapy program for infective endocarditis but was rehospitalized 2 months later for heart failure. Transesophageal echocardiography revealed multiple large vegetations and perforation of the aortic valve. Valve replacement was conducted successfully, and heart failure was alleviated. This case highlights the dilemma of prioritizing the management of two competing interests, one for heart failure caused by valve regurgitation and the other for early-stage colon cancer with a curative intent. In this case, curative resection of the colon cancer was conducted after reasonable control of the endocarditis. Perforation of the aortic valve and heart failure could have been avoided if valve replacement was conducted first, but at the risk of cancer progression.

Evaluate the Effectiveness of Outpatient Parenteral Antimicrobial Therapy (OPAT) Program in Saudi Arabia: A Retrospective Study.

(1) Background: Outpatient parenteral antibiotic therapy (OPAT) is a well-established and cost-effective measure that improves the efficient use of healthcare resources and increases bed availability. Only limited published data is available to illustrate OPAT implementation and outcomes in Saudi Arabia. The main objective of this study was to evaluate the effectiveness of OPAT in a tertiary center in Saudi Arabia. (2) Methods: In this retrospective study, clinical charts of enrolled patients were reviewed in a tertiary care center from the initial month of November 2017 to March 2020. All admitted patients with a central line and who enrolled in the OPAT of the hospital during this study period were included. The primary outcome was the 30-days readmission rate of OPAT patients. Secondary outcomes were factors associated with OPAT failure. Descriptive analysis of the data was used to express the results. (3) Results: We enrolled 90 patients; 54 (60%) were male; the mean age was 55.16 (±17.7) years old. The mean duration of the antimicrobial treatment was 21.9 (+24.6) days. All patients completed the intended course of therapy. Ertapenem was the most frequently used antimicrobial (43%), followed by vancomycin (11.2%). Urinary tract infections (UTIs) are some of the most common bacterial infections in 25 patients (26.9%), followed by osteomyelitis in 16 patients (17.2%). Extended-spectrum beta-lactamase E.coli was the highest common isolated microorganism (44.9%), followed by methicillin-resistant Staphylococcus aureus MRSA (16.9%). The readmission to the hospital during therapy was required for 12 patients (13.3%). Shifting from hospital care to OPAT care resulted in cost savings of 18 million SAR in the overall assessment period and avoided a total of 1984 patient days of hospitalization. (4) Conclusion: The findings have shown that OPAT therapy was effective with minimum hospital readmissions and therapy complications. OPAT programs can reduce healthcare costs and should be integrated into practice.

Clinical Outcomes of an Innovative Cefazolin Delivery Program for MSSA Infections in OPAT.

Cefazolin is a recommended treatment for methicillin-susceptible Staphylococcus aureus (MSSA) infections that has been successfully used in outpatient parenteral antibiotic therapy (OPAT) programs. The aim of this study was to assess the clinical outcomes of cefazolin delivered each day (Group 24) vs. every two days (Group 48) for MSSA infections in OPAT programs. It was a prospective observational study with retrospective analysis of a cohort of MSSA infections attended in OPAT. The primary outcome was treatment success, defined as completing the antimicrobial regimen without death, treatment discontinuation, or readmission during treatment and follow-up. A univariate and multivariate logistic regression model was built. A two-sided p < 0.05 was considered statistically significant. Of the 149 MSSA infections treated with cefazolin 2 g/8 h in OPATs, 94 and 55 patients were included in the delivery Group 24 and Group 48, respectively. Treatment failure and unplanned readmission rates were similar in both groups (11.7% vs. 7.3% p = 0.752 and 8.5% vs. 5.5% p = 0.491). There was a significant increase in vascular access complications in Group 24 (33.0%) with respect to Group 48 (7.3%) (p < 0.001). Treating uncomplicated MSSA infection with cefazolin home-delivered every two days through an OPAT program is not associated with an increased risk of treatment failure and entails a significant reduction in resource consumption compared to daily delivery.

Outcomes among patients with Staphylococcus aureus bacteremia enrolled in a postdischarge outpatient parenteral antibiotic therapy program at an academic medical center.

We compared patients with Staphylococcus aureus bacteremia enrolled in outpatient parenteral antibiotic therapy monitoring program (OPAT-MP) upon hospital discharge with patients not enrolled. OPAT-MP patients were more likely to attend infectious diseases follow-up appointments. OPAT-related emergency room visits and/or readmissions were more common among non-OPAT-MP patients, but differences were not statistically significant.

Characteristics, safety and cost-effectiveness analysis of self-administered outpatient parenteral antibiotic therapy via a disposable elastomeric continuous infusion pump at two county hospitals in Houston, Texas, United States.

Outpatient parenteral antibiotic therapy (OPAT) is an attractive option for patients who require parenteral antimicrobials as outpatients. Few OPAT studies have assessed the impact of IV antibiotic therapy via elastomeric continuous pumps, with most having been conducted outside the United States and few in county hospitals. The OPAT program in Harris Health system, the county hospital system of Houston, Texas, United States, has implemented a disposable elastomeric continuous infusion pump (eCIP) for self-administered intravenous antibiotics (s-OPAT) since December 2018. Our goal was to describe the clinical characteristics of patients discharged with an eCIP, as well as the safety and cost-effectiveness of this pump. We retrospectively analysed patients discharged from Harris Health hospitals between 12/2018 and 02/2021 with s-OPAT via eCIP at home. We extracted various patient characteristics and outcomes related to OPAT. Among 481 OPAT patients during the study period, 91 patients received s-OPAT via eCIP. A total of 1925days of s-OPAT were administered at home, with a median duration of 12days. Eighty-three patients (93.4%) achieved a cure from infection, six patients (6.6%) had side effects, and nine patients (9.9%) experienced 30-day hospital readmission. Twenty-two patients (24.2%) presented to the ED during s-OPAT, with 13 patients (14.3%) presenting with PICC line concerns. We estimated that s-OPAT via eCIP saved $2,360,500 to $3,503,900 compared to inpatient-only therapy. Our study showed that patients with s-OPAT via eCIP had a high cure rate with a relatively low incidence of side effects and 30-day hospital readmission. ED visits during therapy were relatively high, which indicates the necessity of close patient monitoring via the OPAT program. eCIP appears to be a good option to facilitate an early disposition of patients in county hospitals.

591. A Model for assessing staffing needs for an Outpatient Parenteral Antibiotic Therapy (OPAT) program

BackgroundManagement of patients needing OPAT is complex, and requires a multidisciplinary team for transitioning patients from inpatient to outpatient care, ongoing monitoring of labs, antibiotic levels, managing complications of the drugs and intravenous access, and communicating with patients, family, home infusion pharmacies, home care nursing agencies, and the patients’ physicians and other providers. In addition, documentation of each of these activities in the EMR is necessary. Guidance on how to determine number of staff needed for an OPAT program is lacking.MethodsWe created a detailed step by step list of the various activities done by our OPAT nurse (RN) and determined the time needed to perform each activity. We calculated how many hours of nursing time would be needed per week to perform all the activities for patient care based on our OPAT volume.ResultsIn 2019 we enrolled 767 patients in 835 episodes of OPAT. Our weekly census averages about 120–135 patients. Median duration on OPAT was 30 days. We calculated that our OPAT RN workload was an average of 47.5 hours/week (range of 40–55 hours/week), with time per activity ranging from 5 minutes to 3 hours (table). As this calculated to more than one full time RN position, additional staff were requested.Assessment of Staffing Requirements for an OPAT Program ConclusionWe have assessed the workload for OPAT RN(s) in our program based on our 2019 patient volume. We recommend that one RN can safely manage about 500–550 patients per year. Based on this analysis we were successfully able to justify the need for a second RN for our program.Any OPAT Program can do such analysis to determine their OPAT staffing needs, and also plan for the anticipated increases in OPAT volume because of increasing longevity of the population, increase in diabetes incidence, invasive procedures such as arthroplasties, cardiac devices, etc.LimitationsThis analysis does not include time spent by inpatient staff to arrange for home care and home infusion services. It also does not account for an ID pharmacist time, or the physicians and APP time for management of these patients outside of the billable visit.Disclosures All Authors: No reported disclosures

619. Quantifying the non-billable workload of Outpatient Parenteral Antibiotic Therapy (OPAT) services in a University Infectious Diseases (ID) Clinic

BackgroundOPAT service has health and economic benefits for the patient, health care facility and the general community. Management of patients receiving OPAT requires an interdisciplinary team approach and complex care coordination and has been shown to decrease adverse reaction, and rehospitalizations. Much of the work involved in caring for patients on OPAT occurs outside of a billable office visit. Describing and quantifying this workload is important to justify staffing and to advocate for change in reimbursement structure.MethodsPatients enrolled in OPAT program at our clinic in 2019 were identified from the electronic medical record (EMR) and information was extracted on all EMR encounters by ID faculty and staff occurring from the start of OPAT monitoring until 14 days after OPAT ended, or until March 31, 2020 for patients still on OPAT on that date.ResultsDuring 2019, 835 unique OPAT courses were monitored for 767 patients. Activities include a sign-on process, monitoring labs, drug levels, coordinating care, weekly review by OPAT team (Medical Director or an ID attending, nurse practitioner (NP), nurse (RN) and ID pharmacist). We identified 7,640 encounters; 1,072 were office visits. Thus, 86% (N=6569) of encounters were for managing and coordinating care. The OPAT RN created 3435 of 6568 (52%) encounters, 2034 (31%) were by physicians and nurse practitioners, 500 by other clinic RNs and 599 were by administrative staffConclusionOur results quantify the immense care for OPAT patients that is not compensated by insurance. However, this work contributes to patient safety and satisfaction. Our data does not account for time spent by the multidisciplinary team on weekly review of all active OPAT patients which lasts about 3 hours and is essential to ensuring patient safety. This data also does not quantify the contribution of the ID pharmacist who is consulted by OPAT team for multiple issues but whose recommendations are documented by the providers. The total time involved in all this work could not be determined. The quantification of the uncompensated workload of such monitoring is important as it can be justification for modernization of reimbursement for OPAT patient care, making the establishment and maintenance of such programs more financially solvent for health care organizations.Disclosures All Authors: No reported disclosures

Inpatient Antibiotic Costs Associated With Switching From Vancomycin to Daptomycin for Outpatient Parenteral Antibiotic Therapy.

Purpose: The common practice of changing patients to daptomycin for outpatient parenteral antibiotic therapy (OPAT) can increase inpatient daptomycin use and impact inpatient pharmacy expenses. The purpose of this study was to quantify the additional inpatient antibiotic expenditures associated with changing patients from vancomycin to daptomycin for OPAT. Methods: This study examined patients who were discharged from January 1, 2018 to June 30, 2019. Patients were included if they were ≥18 years old, transitioned from vancomycin to daptomycin prior to discharge, and were cared for by the Infectious Diseases OPAT program. Patients switched to daptomycin for therapeutic reasons were excluded. A cost analysis evaluating the vancomycin regimen prior to changing to daptomycin and the daptomycin doses given prior to discharge and during readmissions for the first 6 weeks after discharge was performed using Wholesale Acquisition Costs. The primary outcome was the inpatient antibiotic expense associated with changing to daptomycin for OPAT. Results: Sixty-eight patients met study criteria. The mean number of inpatient doses of daptomycin administered prior to discharge was 4.3. Twelve patients were readmitted and received a mean of 5.3 additional doses. The estimated cost difference between the inpatient daptomycin doses and equivalent vancomycin therapy was $2647 per patient. Limiting patients to only 1 pre-discharge dose of daptomycin would reduce this cost difference to $926 per patient. Conclusion: Switching from vancomycin to daptomycin for OPAT can be associated with substantial inpatient pharmacy costs. These excessive costs can be mitigated if only 1 dose of daptomycin is given before discharge.

Is Once-Daily High-Dose Ceftriaxone plus Ampicillin an Alternative for Enterococcus faecalis Infective Endocarditis in Outpatient Parenteral Antibiotic Therapy Programs?

Ceftriaxone administered as once-daily high-dose short infusion combined with ampicillin has been proposed for the treatment of Enterococcus faecalis infective endocarditis in outpatient parenteral antibiotic therapy programs (OPAT). This combination requires synergistic activity, but the attainment of ceftriaxone synergic concentration (Cs) with the regimen proposed for OPAT has not been studied. This phase II pharmacokinetic study enrolled healthy adult volunteers who underwent two sequential treatment phases. During phase A, volunteers received 2 g of ceftriaxone each 12 h during 24 h followed by a 7-day wash-out. Then the participants received phase B, which consisted of a single dose of 4 g of ceftriaxone. Throughout both phases, each volunteer underwent intensive pharmacokinetic (PK) sampling over 24 h. Ceftriaxone total and unbound concentrations were measured. Twelve participants were enrolled and completed both phases. Mean ceftriaxone total and free concentrations 24 h after the administration of 2 g each 12 h were 86.44 ± 25.90 mg/liter and 3.59 ± 1.35 mg/liter, respectively, and after the 4-g single dose were 34.60 ± 11.16 mg/liter and 1.40 ± 0.62 mg/liter, respectively. Only 3 (25%) patients in phase A maintained unbound plasma concentrations superior to the suggested Cs = 5 mg/liter during 24 h, and none (0%) in phase B. No grade 3 to 4 adverse events or laboratory abnormalities were observed. Ceftriaxone optimal exposure combined with ampicillin to achieve maximal synergistic activity against E. faecalis required for the treatment of infective endocarditis remains unknown. However, the administration of a single daily dose of 4 g of ceftriaxone implies a reduction in the time of exposure to the proposed Cs. (This study has been registered in the European Union Drug Regulating Authorities Clinical Trials [EudraCT] database under identifier 2017-003127-29.).

763. 30 Day Readmission Outcomes in Patients Over 80 Years of Age Enrolled in an Outpatient Parenteral Antibiotic Therapy (OPAT) Program

BackgroundOPAT is a well-established model of care for the monitoring of patients requiring long-term IV antibiotics1. We have previously reported a reduction in the 30-day readmission rate to our facility for patients managed in our OPAT program. However, little has been published to date regarding outcomes in OPAT patients over 80 years of age 2–3. Our OPAT program was established in 2013. Patients can be discharged to a facility or home to complete their course of antibiotics.MethodsWe conducted a retrospective chart review of all OPAT patients discharged from our facility from 2015 to 2018. Patients were divided into two groups based on age, <80 (n = 4618) and >80 (n = 562).ResultsPatient demographics are listed in Table 1. The overall 30-day readmission rate for patients older than 80 was 27.8%. For patients over 80 that had a follow-up ID clinic appointment, the 30-day readmission rate decreased to 15.7%. For patients younger than 80, the 30-day readmission rate was 36.0% with a decrease to 16.2% if patients were evaluated in the outpatient clinic. Figure 1. Staphylococcus Aureus was the predominant organism in both age categories. Vancomycin was the most common antibiotic used in both age groups followed by β lactams.ConclusionIn general, patients aged over 80 years were more likely to be discharged to a facility to complete their antibiotic course than younger patients. These patients also were more likely to have other comorbidities. The 30-day readmission rate in each age group was relatively similar. OPAT in patients over age 80 can have similar 30-day readmission rates as for patients less than 80 years of age Disclosures All authors: No reported disclosures.

753. Outpatient Parenteral Antibiotic Therapy (OPAT) in a Large Urban Safety Net Hospital Setting: Therapy for Vulnerable Populations at Home

BackgroundAdoption of outpatient parenteral antibiotic therapy (OPAT) is accelerating due to proven safety and value, but experience in safety-net settings remains limited, especially in those with history of illicit drug use. Emerging reports from safety-net settings have featured OPAT delivered in nursing facilities, respite care centers, and infusion centers (including some persons who inject drugs [PWID]), but literature is sparse on home-based OPAT for vulnerable patients. In a new home antibiotics program at San Francisco General Hospital, we sought to describe early safety and efficacy outcomes among adults without active injection drug use but with high rates of substance use and comorbid illnesses.MethodsWe conducted a cohort study of patients discharged from a large urban county medical center and enrolled in an outpatient IV antibiotics program from September 2017 to January 2019. We collected demographic and clinical data and computed outcomes of safety (30- and 90-day readmission for infection, vascular access complications, and death) and efficacy (completion of antibiotic therapy).ResultsOverall, 47 courses of antibiotics were given to 45 patients. Of these, 39/47 (83%) of antibiotic courses were administered in a residential setting, and 8/47 (17%) via the hospital outpatient infusion center. Comorbid conditions were common, including 9/45 (20%) with hepatitis B/C and 8/45 (18%) with HIV (Table 1). Present or prior illicit drug use was seen in 17/45 patients (38%), including recent or active illicit drug use in 11/45 (24%) (Table 1). Most common indications for antibiotics were osteomyelitis and bacteremia (Table 2). Efficacy in the OPAT program was high: overall, 44/47 (94%) courses of outpatient IV antibiotics were completed, and the 30-day and 90-day readmission rates were 13% and 20% respectively, with zero 30-day readmissions related to OPAT (Table 3).ConclusionAn OPAT program embedded within a safety net hospital system delivering care in patients’ homes had high completion rate and low readmission rate, despite patients’ high prevalence of underlying comorbid conditions and noninjection illicit drug use. Home-based OPAT should be considered for broader adoption in safety-net hospital systems. Disclosures All authors: No reported disclosures.

Evaluation of an emergency department to outpatient parenteral antibiotic therapy program for cellulitis

ObjectiveEmergency department (ED) patients with non-purulent skin and soft tissue infections (SSTIs) requiring intravenous antibiotics may be managed via outpatient parenteral antibiotic therapy (OPAT). Prospective studies describing the performance of an ED-to-OPAT clinic program are lacking. The primary objective was to determine the OPAT treatment failure rate for ED patients with non-purulent SSTIs. MethodsWe conducted a prospective observational cohort study of adults with non-purulent SSTIs managed via an ED-to-OPAT clinic program. OPAT treatment failure was defined as hospitalization after a minimum of 48 h of OPAT for: worsening infection; intravenous line complications; or adverse antibiotic effects. Secondary outcomes were to describe OPAT clinic processes, patient satisfaction, and physician rationale for selecting intravenous antibiotics. ResultsWe enrolled a consecutive sample of 153 patients [mean age 60.5 years, 82 male (53.6%)]; 137 patients (89.5%) attended their clinic appointment. OPAT treatment failure was 4.4%. None of the adverse intravenous line (10.9%) and adverse antibiotic (8.0%) events required hospitalization. Patients reported high satisfaction with timeliness of referral (median score 9 out of 10) and overall care received (median score of 10). The top five reasons given by physicians for selecting intravenous therapy were: clinical impression (52.9%); failed oral therapy (41.8%); diabetes (17.6%); severe pain (7.8%); and peripheral vascular disease (7.8%). ConclusionsThis prospective study demonstrates that an ED-to-OPAT clinic program for non-purulent SSTIs is safe, has a low rate of treatment failures and results in high patient satisfaction. The rationale for selecting intravenous antibiotics showed significant variability among ED physicians.

1942. Expansion of Outpatient Parenteral Therapy Program with Addition of Advanced Practice Providers Can Lead to Reduced Readmission Rates

BackgroundThe addition of Advanced Practice Providers (APPs) such as Nurse Practitioners or Physician Assistants as hospital-based service providers has been shown to increase efficiency of care, provide for better continuity of care across the inpatient and outpatient settings, and facilitate interdisciplinary collaboration. As healthcare systems attempt to not only increase access to care but also improve quality, the addition of APPs is becoming an option to meet division-specific goals. To decrease readmissions and increase access to care for patients discharged on intravenous (IV) antibiotics and in the Outpatient Parenteral Antibiotic Therapy (OPAT) Program, the Division of Infectious Diseases at UPMC Presbyterian hired two APPs in early 2017. Our aim was to compare readmission and follow-up rates from the time before expansion of the program with APPs to after expansion.MethodsWe completed a retrospective study of all OPAT patients seen by any Infectious Diseases (ID) provider (MD or APP) n the period from January to May 2017 (prior to APP outpatient clinics with OPAT patients) and in the period from January to February 2018. The total number of patients seen by an ID provider and the 30-day readmission rates were collected and evaluated. A comparison of proportions was done with a two-tailed z-test for the percentage of readmissions prior to program expansion compared with the percentage of readmissions after program expansion.ResultsFollowing the expansion of the OPAT program with the addition of two APPs in 2017, there was a decrease, from 14.7% to 9.6%, in 30-day readmissions for all patients who were seen for follow-up (P = 0.0461, 95% CI 0.0672–9.3164). The percentage of patients who were seen for follow-up increased after expansion of the program from 29.5% to 39.3% (P = 0.0051, 95% CI 2.8714–16.9153).ConclusionExpansion of the OPAT program within the Division of Infectious Diseases at UPMC with the addition of two APPs has significantly increased access to care and significantly decreased 30-day readmissions when the patient was seen for follow-up by an ID provider (MD or APP).Disclosures All authors: No reported disclosures.

1940. Outcomes Among Patients Enrolled in an Outpatient Parenteral Antibiotic Therapy Program at an Academic Medical Center

BackgroundOutpatient parenteral antibiotic therapy (OPAT) is a key part of the treatment of severe infection. One indication for OPAT is methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Few data have been published regarding long-term follow-up and outcomes among patients in an OPAT program (OPAT-P). We describe OPAT-P outcomes at an academic medical center with a focus on MRSA bacteremia (MRSA-B).MethodsA retrospective chart review was performed. Two cohorts of patients were studied. The first comprised all adult inpatients enrolled in OPAT-P at discharge from July 2016 to December 2017. The second cohort was a subset of these patients treated for MRSA-B. Outcomes (including readmissions, emergency room [ER] visits, microbiological recurrences, and death) were compared with outcomes among non-OPAT-P patients discharged on IV antibiotics for MRSA-B between January 2015 and December 2017. Statistical measures including chi squared tests or Fisher’s exact tests were used.ResultsFive hundred sixty-one patients were enrolled in OPAT-P from July 2016 to December 2017. Common indications were osteomyelitis (n = 219, 39%), bacteremia (n = 73, 13%), and endocarditis (n = 73, 13%); 22% had polymicrobial infection. Sixty-one (11%) were rehospitalized and 24 (4%) had an ER visit for an infectious or OPAT issue while on therapy. Fifty-one adverse events occurred that did not result in ER visit or a readmission. Ninety-three (17%) required antibiotic dose changes. Twenty-five patients were treated for MRSA-B; 83 additional non-OPAT-P patients were discharged on IV therapy for MRSA-B from January 2015 to December 2017. Common sources of bacteremia included central line (n = 24, 22%), cellulitis (n = 18, 16%), and osteomyelitis (n = 9, 8%). No MRSA-B patients died within 30 days of discharge. Overall 6-month readmission and ER visit rates did not differ based on OPAT-P enrollment (54%, P = 0.46 and 57%, P = 0.43, respectively). Three of 25 (12%) MRSA-B OPAT-P patients and 9/83 (74%) MRSA-B non-OPAT-P patients were readmitted for OPAT or infectious complications (P = NS). Microbiological recurrence was rare.ConclusionAdverse events in OPAT are common and antibiotic monitoring is crucial for OPAT safety. A dedicated OPAT-P has the potential to proactively identify adverse events and change therapy to prevent unplanned admission or ER visit. Further data are needed to clarify whether an OPAT-P may improve MRSA-B post-discharge outcomes.Disclosures All authors: No reported disclosures.