Repeated Blood Cultures Research Articles

ODP519 Thyroid Cyst Grows E. coli

Abstract Background Thyroid abscesses are extremely rare, representing less than 1% of all thyroiddiseases. The thyroid gland is very robust against infections due to its vastlymphatic drainage, dual blood supply, encapsulation, and iodine concentration. Immunocompromised patients are at greater risk of developing thyroid abscesses. 1 Case: A 51-year-old female presented to her primary care provider with acute onset ofpainful right neck mass with associated cough, hoarseness, fever, and fatigue. She was seen by an Otolaryngologist who aspirated 6 cc of brown purulentmaterial from a suspected thyroid mass. The thyroid fluid was sent for culture,and she was empirically started on Augmentin. CT neck demonstrated a cysticlesion of the right thyroid gland, retropharyngeal edema, and mass effect withleftward deviation of the larynx and trachea without airway obstruction. Due tothese findings, the patient was admitted to the hospital where initial two setsof blood cultures were negative but repeat blood cultures revealed 2 of 2positive for E. coli. Thyroid cyst fluid also grew E. coli. Urine culture hadno growth. She was found to have a suppressed TSH of 0.24 uIU/mL, elevated free T4 of 1.80 ng/dL, and suppressed total T3 of 0.52 ng/mL. Previous TSH was within normal limits, 0.82 uIU/mL. The suppressed TSH and suppressed T3 were thought to be secondary to euthyroid sick syndrome. She was maintained onCeftriaxone while admitted and discharged on Ciprofloxacin. Pathology from theright thyroid cyst revealed acute inflammatory cells only consistent with anabscess, negative for malignancy. The patient elected to undergo a righthemithyroidectomy with isthmusectomy. Discussion Thyroiditis is defined as inflammation of the thyroid gland and has a variety ofetiologies. Suppurative thyroiditis, which includes thyroid abscess as in thiscase we have described, is an infrequent cause of thyroiditis. It is usuallycaused by hematogenous spread or direct inoculation of a pathogen. Treatmentincludes systemic antibiotics targeting the causative organism; although thegold standard remains surgical drainage. Surgical management is the mainstay ofmanaging patients with thyroid abscesses. 2

Reducing Repeat Blood Cultures in Febrile Neutropenia: A Single-Center Experience.

Limited data exist to guide blood culture ordering in persistent febrile neutropenia (FN), resulting in substantial variation in practice. Unnecessary repeat blood cultures have been associated with patient harm including increased antimicrobial exposure, hospital length of stay, catheter removal, and overall cost. We conducted a single-center study of adult hematology-oncology patients with ≥3 days of FN. The yield of blood cultures was first evaluated in a 2-year historical cohort. Additionally, a pilot pre-/postintervention study was performed in non-stem cell transplant (SCT) patients following a change in our population clinical practice guideline from a recommendation of daily blood cultures to a clinically guided approach. The primary outcome was cultures collected per days of FN after day 3 of persistent FN. One hundred forty-six episodes of ≥3 days of FN in 108 patients were identified during the historical period. Day 1 blood cultures were positive in 23 of 146 (16%) episodes. Blood cultures were drawn on 374 of 513 (73%) subsequent episode-days (day 2-12) and were negative in 366 of 374 (98%). After the intervention, a 53% decrease was observed in the rate of total blood cultures collected (1.4 preintervention vs 0.7 postintervention; P = .03). Blood cultures obtained after 48 hours rarely yielded clinically significant organisms. Repeat blood cultures are low-yield in persistent FN without new clinical change. A pilot intervention in non-SCT patients successfully reduced the frequency of blood culture collection.

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.

Bacteremia and Late-Term Abortion Secondary to Salmonellosis in a Dog.

A 5 yr old, 54-day-pregnant whippet presented for hyperthermia, lethargy, and spontaneous abortion of multiple fetuses. Blood work and clinical signs raised concern for uterine sepsis; therefore, the dog underwent an emergency ovariohysterectomy. Blood and uterine samples cultured a Salmonella species. Following ovariohysterectomy and oral antibiotic therapy, the dog had no further systemic signs. Repeat blood cultures and Salmonella testing were negative. To the authors' knowledge, this is the first report of a Salmonella species causing bacteremia in conjunction with late-term abortion in a dog.

A Comparison of Outcomes With and Without Infectious Diseases Consultation for Enterococcal Bacteraemia in a Multicenter Healthcare System

IntroductionIt is unknown whether infectious diseases consultation improves outcomes for enterococcal bacteraemia in a multicentre healthcare system. MethodsThis retrospective multicentre observational cohort study included 250 adult patients with enterococcal bacteraemia between July 2016 and December 2020. The primary endpoint was a composite of clinical failure, including persistent bacteraemia, persistent fever, and in-hospital mortality. Secondary endpoints included adherence to a treatment bundle (appropriate empiric and definitive antibiotics, appropriate planned treatment duration, obtaining repeat blood cultures and an echocardiogram). ResultsClinical failure occurred in 35 of 155 patients (22.6%) with an infectious diseases consultation and 16 of 95 patients (16.8%) without an infectious diseases consultation (P = 0.274). Multivariate analysis identified vasopressors as the only independent predictor of the primary outcome. Infectious diseases consultation resulted in higher adherence to a treatment bundle, including echocardiogram (75.5% vs. 34.7%; P < 0.0001), repeat blood cultures (85.2% vs. 68.4%; P = 0.002), appropriate definitive antibiotics (70.5% vs. 91.6%; P < 0.0001) and appropriate planned durations of therapy (81.1% vs. 94.2%; P = 0.001). More patients in the consult group were treated with ampicillin (47.1% vs. 22.1%; P < 0.0001) and fewer were treated with vancomycin (17.4% vs. 24.2%; P = 0.068). ConclusionDespite finding no difference in clinical failure between groups, this study highlights important benefits of infectious diseases consultation in enterococcal bacteraemia.

SINGLE-CENTER EXPERIENCE WITH THE USE OF THE SERAPH-100 MICROBIND AFFINITY BLOOD FILTER IN-PARALLEL WITH EXTRACORPOREAL MEMBRANE OXYGENATION CIRCUIT IN SEPTIC PATIENTS

TYPE: Late Breaking Case Report TOPIC: Critical Care INTRODUCTION: Patients who require extracorporeal membrane oxygenation (ECMO) have a high mortality if they develop septic shock. With the emergence of novel and resistant pathogens, new therapies are needed to treat septic patients. The Seraph–100 Microbind Affinity Blood Filter was granted Emergency Use Authorization by the FDA to treat severe COVID-19. The Seraph-100 filter contains microbeads that can bind bacteria, fungi, viruses and cytokines. Recommended configurations for the Seraph–100 utilize hemodialysis or continuous renal replacement therapy (CRRT) machines in a stand-alone fashion or in-combination with a hemodialysis filter. In this series, we explore a new configuration for the Seraph-100 for patients requiring ECMO. CASE PRESENTATION: Five septic patients underwent treatment with the Seraph-100 in-parallel with ECMO. This configuration allowed for pressures generated by the ECMO circuit to drive blood flow through the Seraph-100. All five patients were on multiple high dose vasopressors prior to therapy with the Seraph-100. Within 12-24 hours of treatment, vasopressor support significantly decreased and repeat blood cultures showed clearance of pathogens. DISCUSSION: All our patients treated with Seraph–100 in-parallel with ECMO had significant reduction in vasopressor support. Benefits of this configuration include limiting need for additional vascular access and need for dialysis circuits, along with the associated risks of renal replacement therapy. CONCLUSIONS: The Seraph-100 represents an innovative solution for the treatment of septic patients. This case series demonstrated the effectiveness and safety of a new configuration for the Seraph-100 in patients requiring ECMO. Further studies are needed to elucidate the optimal use of the Seraph-100 blood filter. DISCLOSURE: Nothing to declare. KEYWORD: Seraph-100 Blood Filter

A Culture of Too Many Blood Cultures.

A Culture of Too Many Blood Cultures.

Undifferentiated pleomorphic sarcoma of the breast with neoplastic fever: case report and genomic characterization

PurposePrimary breast sarcomas are extraordinary rare, in particular undifferentiated pleomorphic sarcoma (UPS). UPS with neoplastic fever (UPS-NF) of the breast has not been reported yet. Here, we present an extended UPS-NF of the breast including its comprehensive molecular workup.MethodsA 58-year-old female presented with general malaise, fever spikes, weight loss, and a massively swollen left breast. C-reactive protein and blood leucocytes were significantly increased. However, repeated blood cultures and smears were all sterile. Histopathology of the abscess-forming tumor revealed an undifferentiated malignancy with numerous of tumor giant cells as well as spindle-shaped cells with nuclear pleomorphism and hyperchromasia. Immunohistochemistry demonstrated partial, patchy desmin staining and weak heterogonous neuron-specific enolase immunoreactivity of tumor cells, but a focal staining for Melan-A.ResultsNeither common melanoma driver mutations nor an ultraviolet mutational signature was detected by whole genome sequencing. Using FISH and RT-PCR we also excluded translocations characteristic for clear cell sarcoma. Thus, the diagnosis of inflammatory UPS-NF of the breast was considered highly probable. Despite a complete mastectomy, the tumor recurred after only three months. This recurrence was treated with a combination of ipilimumab and nivolumab based on the primary tumor’s TPS score for PD-L1 of 30%. After an initial response, however, the tumor was progressive again.ConclusionWe describe here the first case of UPS-NF of the breast, which shows great clinical and histopathologic resemblances to previously reported UPS-NF of other anatomic localizations.

Abstract 272: Infective Endocarditis Of Unicuspid-unicommisural Aortic Valve

Approximately, 75% of patients with infective endocarditis have underlying structural heart disease at the time of diagnosis. Aortic valve disease is associated with up to a quarter of patients, with aortic regurgitation being the most common abnormality. A unicuspid aortic valve (UAV) is an extremely rare congenital anomaly with a prevalence of 0.02%. We present a unique case of UAV with a devastating association. Case Summary: A 32-year-old male intravenous drug abuser presented with weakness after 18-hours of symptom onset. He was afebrile but tachycardic, with left-sided hemiparesis and sensory loss. Brain CT-scan revealed a hypodensity within the right cerebral hemisphere, a CTA of head-neck revealed an acute right MCA infarct with malignant cerebral edema. Due to deteriorating clinical condition, he was intubated for airway protection and underwent emergent hemi-craniectomy. Blood cultures grew enterococcus faecalis. Transthoracic echocardiogram showed abnormal aortic valve with severe regurgitation. Transesophageal echocardiography (TEE) demonstrated unicuspid unicommissural aortic valve with a small mobile echodensity attached to the left ventricular outflow tract aspect. Decision Making: He received a 6-weeks course of ceftriaxone and vancomycin with negative repeat blood cultures. Given poor clinical state, he was deemed poor candidate for valve replacement and was discharged to long-term rehabilitation facility. Four-months later, he was re-admitted with fevers. Repeat TEE demonstrated multiple aortic valve vegetations. He subsequently underwent successful minimally invasive aortic valve replacement. Conclusion: Unicuspid unicommisural aortic valve is an extremely rare condition that can be complicated by aortic stenosis more often than regurgitation. Infective endocarditis has been reported in 11% among UAV patients and can lead to valvular destruction with severe regurgitation which can be catastrophic in some patients

Case report: Vascular graft infection due to Aspergillus species presenting with recurrent vascular occlusion

BackgroundAn aortic graft implantation is an effective therapeutic method for various aortic diseases. However, it is known that sometimes these implanted grafts can be the foci of infections. Here we report a rare case of graft infection that presented multiple embolisms of aortic branches and peripheral organs.Case presentationA 63-year-old Japanese woman with a history of aortic graft implantation presented with occlusions of large arteries in different loci and time points, with elevation of non-specific inflammatory markers. Thoracic contrast-computed tomography (CT) captured vegetation in the descending aortic graft and the [18F]fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG PET/CT) showed accumulation of FDG in the same site, suggesting a graft infection. Despite all these suspicious findings, repeated blood culture examinations never detected any microorganisms. A diagnosis of Aspergillus graft infection was made based on an elevated serum β-D glucan (βDG) and a positive Aspergillus galactomannan (GM) antigen test. The patient subsequently had surgery with replacement of the descending aortic graft and anti-fungal drugs were instituted with significant improvement noted.ConclusionIn the present case, the patient’s specific feature in the anatomical vascular construction, past operation, and basal fundamental diseases collaboratively contributed to the pathogenesis of the present infection. It is important to recognize the risk of graft infection and conduct imaging studies when indicative symptoms emerge. The negativity in blood culture studies often makes detection of pathogenic microbes extremely difficult. This case suggests that non-cultural tests such as bDG and GM can be useful for diagnosis and starting appropriate anti-fungal drugs in the early stages.

Fever, Rash, Cytopenia, and Disseminated Intravascular Coagulation in a 6-year-old.

Fever, Rash, Cytopenia, and Disseminated Intravascular Coagulation in a 6-year-old.

Co-infections in patients with COVID: A case series.

Dear Editor, Respiratory viruses may be associated with varying rates of microbial co-infections. There is previous evidence to show lack of bacterial co-infections following Middle East respiratory syndrome and only a small incidence with the severe acute respiratory syndrome-associated coronavirus-1.[1] We are reporting three patients of severe acute respiratory illness (fever and bilateral pneumonitis) with laboratory-confirmed (RT-PCR) COVID, who developed microbial co-infections. All had received protocolized pharmacological therapy including remdesivir/oral hydroxychloroquine, subcutaneous low molecular weight heparin, intravenous dexamethasone, prophylactic antibiotics as well as vitamin C and oral zinc supplementation in the ICU. All three patients had presented with raised total leucocytic count (TLC: 19,600; 23,600; and 23,400/mm3, respectively) in contrast to the expected immunosuppression and decreased TLC associated with COVID. The microbial organisms detected in the patients upon blood culture included Enterococcus faecium (sensitive to vancomycin, teicoplanin, and linezolid); Staphylococcus xylosus (resistant to erythromycin, ceftriaxone, ciprofloxacin, and tetracycline; sensitive to teicoplanin, vancomycin, linezolid, and cotrimoxazole) and non-albicans candida without any bacterial growth, respectively. An adequate response was seen with vancomycin in a patient with E. faecium, and with teicoplanin to S. xylosus as evidenced by an improvement in clinical condition, fall in TLC, and negative repeat blood cultures. The patient with candidemia, however, succumbed to COVID-induced acute respiratory distress syndrome within next couple of days. A systematic review showed a 14% incidence of laboratory-confirmed bacterial co-infection among the patients with COVID admitted to ICU.[1] Thus, our findings help to emphasize that co-infections in patients with COVID are a clinical problem. The bacterial organisms detected by us are not commonly encountered otherwise. E. faecium was reported as the least common of co-infections in COVID with an incidence of 1/3834 patients.[1] Within the Enterococcus species, only 10% of infections are constituted by E. faecium.[2] It is more likely to be seen in immunosuppressed, elderly, critically ill, those on mechanical ventilation or long-term antibiotic therapy, for causing infections and multi-systemic manifestations.[23] S. xylosus-induced sepsis also presents an uncommon occurrence. The organism is usually incriminated in infections among animals, with very few case reports amongst humans. It is a normal commensal on the skin and mucosa and becomes a cause of infections either as part of nosocomial pathology or in immunosuppressed individuals.[4] Lastly, invasive candidemia reported in the third case by us is also known to have a predisposition for immunosuppressed patients. Thus, it is possible that the microbial co-infections in COVID are preferential of flora that thrives in immunocompromised patients. It is interesting to note that all of these patients with co-infections during COVID illness presented with raised TLC, even though the neutrophil–lymphocyte ratio was high and suggestive of COVID. There are previous data to show that raised TLC in COVID is associated with a poor prognosis.[5] Thus, surveillance for microbial co-infections, even uncommon ones, is required in patients with COVID and the role of raised TLC remains pertinent for the same. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Case Report: Echinocandin-Resistance Candida glabrata FKS Mutants From Patient Following Radical Cystoprostatectomy Due to Muscle-Invasive Bladder Cancer

Invasive Candida glabrata infections are not common complications after radical cystoprostatectomy. Furthermore, resistance to echinocandins arising during the course of a patient’s treatment is rarely recognised. We described a case of development of echinocandin resistance in a patient with muscle-invasive bladder cancer (pT2b N0 M0, high grade) diagnosis, subjected to radical cystoprostatectomy and exposed to echinocandins. A male patient with a previous surgical history after a traffic accident, who was operated on due to bladder cancer, underwent an episode of candidemia and mixed postoperative wound and urinary tract infection caused by C. glabrata and extended spectrum β-lactamase (ESBL)-producing Escherichia coli during hospital treatment. The patient was started on caspofungin. Repeat blood cultures showed clearance of the bloodstream infection; however, infection persisted at the surgical site. Resistance to echinocandins developed within 2 months from the day of initiation of therapy with caspofungin in the C. glabrata strain obtained from the surgical site. The isolates sequentially obtained during the patient’s treatment demonstrated resistance to echinocandins due to the mutation in hotspot 1 FKS2. Although resistance to echinocandins is relatively rare, it should be considered in oncological patients with increased complexity of treatment and intestinal surgery.

84. A Survey Based Assessment of Provider Practice Around Obtaining Repeat Blood Cultures

Abstract Background Apart from Staphylococcus aureus and Candida species, there is little guidance on whether to obtain repeat blood cultures after an initial positive set. We have noted heterogeneity in practice amongst our Infectious Disease (ID) group at Oregon Health and Science University (OHSU) and suspect there is heterogeneity amongst adult hospitalist providers as well. Methods We created a survey using clinical vignettes encompassing commonly encountered scenarios among hospitalized patients on medical wards to assess provider practices in obtaining repeat blood cultures. The survey was sent to adult ID providers and adult hospitalist providers at OHSU. These vignettes represented 9 of the most common bacteria seen in positive blood cultures and asked the question of whether providers would obtain repeat blood cultures after an initial positive set. The organisms included beta hemolytic streptococcus, Enterococcus faecalis, Streptococcus gallolyticus, coagulase-negative staphylococci, alpha hemolytic strep, E coli, Proteus mirabilis, Pseudomonas aeruginosa, and Bacteroides fragilis. We then asked questions around repeat blood culture practices for Staphylococcus aureus and Candida species, understanding that while repeat blood cultures for these organisms is recommended, the manner in which individual providers implement this may vary. Results The survey response rate was ~45%. Results were heterogenous with only 3 questions having inter- and intra- group agreement. Those 3 questions represented a case of E faecalis bacteremia without known source, a case of asymptomatic Staphylococcus epidermidis blood culture positivity, and a case of E. coli bacteremia from a pyelonephritis. All other vignettes had inter- and intra- group differences signifying clinical uncertainty around the practice of obtaining repeat blood cultures. There was similar heterogeneity among the responses asking how providers obtain repeat blood cultures around S. aureus and Candida bloodstream infections. Clinical vignette survey answers Answers from 10 clinical vignettes on obtaining repeat blood cultures after an initial positive set for stable patients on medical wards. Staphylococcus aureus Candida sp Conclusion There is significant heterogeneity amongst adult ID and hospitalist providers on what organisms and situations should prompt repeat blood cultures. There are differences around how repeat blood cultures should be obtained, including for Staphylococcus aureus and Candida sp. Disclosures All Authors: No reported disclosures

185. Does an Infectious Diseases Consultation Improve Clinical Outcomes and Treatment Bundle Adherence for Enterococcal Bacteremia in a Multicenter Healthcare System?

BackgroundInfectious diseases consultation (IDC) for Staphylococcus aureus bacteremia has a known mortality benefit, but for other gram positive bacteremias the benefit is not known. This study examined differences in outcomes for enterococcal bacteremia when management includes IDC.MethodsThis retrospective multicenter observational cohort study included adults with at least 1 positive blood culture with Enterococcus species. Patients who died or transferred to palliative care within 2 days of positive blood cultures were excluded. The primary outcome was a composite of clinical failure, including persistent blood cultures or fever for 5 days and in-hospital mortality. Secondary outcomes included adherence to a treatment bundle (appropriate empiric/definitive antibiotics, echocardiography (ECHO), duration of treatment, and repeat blood cultures).ResultsA total of 250 patients were included. IDC was obtained in 62.0% of patients. More patients in the IDC group had endocarditis (20% vs 0%, p < 0.0001) and bone and joint infections (13.5% vs 1.1%, p = 0.001), compared to more UTI (16.8% vs 39.0%, p < 0.0001) in the non-IDC group. Patients in the IDC group had more murmurs on initial exam (21.3% vs 6.3%, p = 0.002), prosthetic device (49.7% vs 27.4%, p = 0.001), and NOVA scores of ≥ 4 (40.6% vs 18.9%, p < 0.0001). Most infections were due to E. faecalis (78.4%) and most were susceptible to vancomycin and ampicillin at 90.4% and 92.4%, respectively. The composite of clinical failure occurred in 22.6% of patients with IDC and 16.8% in the non-IDC group (p=0.274). There was higher adherence to the treatment bundle in the IDC group (Figure 1). More patients in the IDC group were treated with ampicillin (47.1% vs 22.1%, p < 0.0001), and numerically more patients received treatment with vancomycin in the non-IDC group (17.4% vs 24.2%, p = 0.068). In the multivariate analysis, vasopressors were the only independent predictor of the primary outcome (OR 9.3, 95% CI 3.5-24.8, p < 0.0001). Figure 1. Adherence to treatment bundle. IDC = infectious diseases consultation, Echo = echocardiogram, * = p < 0.05 ConclusionThere was no difference in rates of composite failure in patients with or without IDC; however, adherence to a treatment bundle was higher in the IDC group. IDC demonstrated stewardship benefits with regards to vancomycin usage. Disclosures All Authors: No reported disclosures

10. Impact of Infectious Disease Consultation and Theoretical Management Bundle in Patients with Candidemia

BackgroundCandidemia is associated with significant morbidity and mortality. The impact of infectious diseases consultation (IDC) on clinical outcomes in patients with candidemia is not well established. We evaluated the impact of IDC and a management bundle on clinical outcomes in patients with candidemia.MethodsA retrospective chart review of adult (age ≥ 18 years) patients with at least 1 blood culture growing Candida species identified at Alberta Precision Laboratories between December 1, 2019 to November 30, 2020 and hospitalized at the University of Alberta Hospital, Edmonton, Canada were included. Patients who died within 48 hours and those who left against medical advice within 24 hours of initial positive blood culture result were excluded. Demographics, management, and outcome data were collected. A complete management bundle was defined as having all the following elements performed: IDC, repeat blood cultures, empiric echinocandin therapy, ophthalmology consult, and echocardiogram.ResultsThirty-one patients were included for study; mean age was 56 ± 17 years and 65% were male. 14 (45%) cases were admitted under critical care, 7 (23%) surgery, and 10 (32%) medicine. 3/17 (18%) required intensive care unit admission following candidemia diagnosis. Candida albicans was identified in more than half the cases. The primary source was intra-abdominal in 12 (39%), central-line associated in 8 (26%), and urinary in 6 (19%). IDC occurred in 27 cases (87%), echocardiogram in 22 (71%), ophthalmology consult in 10 (32%), and follow-up blood cultures in 30 (97%). 20 (65%) patients received empiric echinocandin. Of the remainder who received empiric fluconazole, 4 (36%) grew non albicans Candida species.Higher in-hospital mortality was observed in cases without IDC than those with IDC (4/4, 100% vs 8/27, 29.6%, p=0.016) and in those that did not have a complete bundle (12/25, 48% vs 0/6, p=0.059). However, IDC was not associated with the receipt of individual bundle components nor the complete bundle (p=NS).ConclusionIn patients with candidemia, lower in-hospital mortality was observed in patients who received IDC. Larger studies are required to confirm our findings and assess whether the implementation of a candidemia management bundle is beneficial. Disclosures Dima Kabbani, MD, AVIR Pharma (Grant/Research Support, Other Financial or Material Support, Speaker)Edesa Biotech (Scientific Research Study Investigator)Merck (Scientific Research Study Investigator)

81. Reducing Unnecessary Blood Cultures Through Diagnostic Stewardship

BackgroundAt our institution, we learned the frequency of blood cultures was sometimes being changed from “Once” to “Daily” without a defined number of days. We hypothesized this led to unnecessary blood cultures being performed.MethodsOver a 3 month period from 12/6/2019-3/6/2020, we retrospectively evaluated the charts of patients who had a blood culture frequency changed to “Daily”. We evaluated if there was an initial positive blood culture within 48 hours of the “Daily” order being placed and the number of positive, negative, or “contaminant” sets of cultures drawn with the order. Contaminant blood cultures were defined as a contaminant species, present only once in the repeat cultures, and not present in initial positive cultures.Results95 unique orders were placed with 406 sets of cultures drawn from 89 adults. ~20% of the time (17 orders) the order was placed without an initial positive blood culture. This led to 62 sets of cultures being drawn, only 1 of which came back positive. 78/95 orders had an initial positive blood culture. The most common initial organisms were Staphylococcus aureus (SA) (38), Candida sp (10), Enterobacterales sp (10), and coagulase negative staphylococci (7). 43/78 (55%) orders with an initial positive set had positive repeat cultures. SA (26) and Candida sp (8) were most common to have positive repeats. Central line associated bloodstream infections (CLABSI) were found in 5 of the orders and contaminant species were found in 4 of the orders. 54% of the patients who had a “Daily” order placed did not have positive repeat cultures. The majority of the cultures were drawn from Surgical (40 orders) and Medical (35 orders) services. Assuming that SA and Candida sp require 48 hours of negative blood cultures to document clearance and other species require 24 hours, it was estimated that 51% of the cultures drawn using the "Daily" frequency were unnecessary. Cost savings over a year of removing the "Daily" frequency would be ~&14,000. Data from "Daily" blood culture orders drawn at Oregon Health & Science University from 12/6/2019-3/6/2020ConclusionUnnecessary blood cultures are drawn when the frequency of blood cultures is changed to "Daily". Repeat blood cultures had the greatest utility in bloodstream infections due to SA or Candida sp, and with CLABSI where the line is still in place. These results led to a stewardship intervention to change blood culture ordering at our institution.Disclosures All Authors: No reported disclosures

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

213. Assessment of Compliance with Order Set and Bundle for Management of Staphylococcus aureus Bacteremia

Background Staphylococcus aureus (S. aureus) is an aerobic gram-positive coccus that causes a variety of infections. S. aureus bloodstream infections, also known as bacteremias, have significant morbidity and mortality and are difficult to eradicate. A single-center study showed a 9.4% recurrence rate for S. aureus bacteremia, despite adequate treatment. The Infectious Disease Society of America (IDSA) recognizes the seriousness of S. aureus infections, particularly methicillin-resistant S. aureus (MRSA), and has released guidance for treatment of these infections. Guidance for S. aureus bacteremias include identification and removal of the source and early optimization of antibiotics. Serial imaging and laboratory monitoring, including repeat blood cultures, are also necessary to establish the duration of therapy, ensure microbiologic eradication, and reduce the risk of long-term complications. Due to the complexity of S. aureus bacteremia, early involvement of infectious diseases (ID) specialists is strongly recommended. MethodsThis retrospective, single-center study was designed to evaluate the current management of S. aureus bacteremias, including compliance to the elements of the S. aureus order set and bundle. Patients 18 years and older who had a positive blood culture for S. aureus were included in this study. Recurrence of S. aureus infection was assessed at 6 months. Data was analyzed to compare patients with and without ID consults.ResultsEighty-four patients met inclusion criteria. ID consultation resulted in a higher percentage of patients achieving 100% compliance with the bundle elements compared to patients without ID consults (73% vs 25%, respectively; p=0.009). For further breakdown of compliance see Table 1. No statistical difference was detected in recurrence rates (11% vs 33%, respectively; p=0.18) or mortality (8% vs 25%, respectively; p= 0.17) possibly due to the small sample size. Table 1. Outcomes ConclusionID specialist involvement for the treatment of S. aureus bacteremia resulted in greater compliance with the S. aureus bacteremia bundle. No statistical difference in recurrence or mortality rates was detected.Disclosures All Authors: No reported disclosures

166. Evaluation of Daptomycin Prescribing Practices Based on Microbiologic Susceptibility Determination of “Susceptible-Dose Dependent” (SDD)

BackgroundRecent changes in CLSI microbiologic interpretations of daptomycin and enterococci include the “susceptible-dose dependent” (SDD) category. The effectiveness of SDD for directing clinicians to employ higher dosing of daptomycin is unknown. The study objective was to determine if implementation of SDD paired with a comment recommending higher doses of daptomycin (8-12mg/kg) and ID consultation in 2019 was associated with changes in rates of daptomycin use and prescribed doses for enterococcal bloodstream infections (BSI). MethodsSingle-center, retrospective cohort study of adult inpatients with enterococcal BSI and daptomycin susceptibility results reported from Aug 2016-Jul 2020. Chart review was performed to collect demographics, source of infection, and clinical management strategy. Rate of daptomycin use for definitive therapy (antimicrobial on day 4 after final susceptibilities) and median prescribed dose were compared for BSI caused by S and SDD isolates. Annual (Aug 1-Jul 31) trends in infections and daptomycin use were tabulated. Results189 blood cultures were reviewed, yielding 56 unique episodes of enterococcal BSI. Patients had a mean age of 59 years and majority had an immunocompromising disease or medication. Of the cases in which it was a clinically appropriate option, clinicians selected daptomycin for definitive treatment in 81% of S and 71% of SDD cases (p = 0.46, Chi-square). Median daptomycin dose prescribed was 10mg/kg for both interpretations; dose range was 6-12mg/kg for S and 9.5-12mg/kg for SDD isolates. No temporal trend in prescribed dose noted over the 4-year study period. Repeat blood cultures performed in 50/56 (89%). Within 90 days, rates of relapse were low but mortality was 26/56 (46%). Table 1. Infection and Treatment Characteristics Chart 1. Frequency of prescribed daptomycin dose (mg/kg) for susceptible (A) and SDD (B) enterococci BSI isolates. ConclusionNo difference detected in rate of daptomycin use nor median prescribed dose based on microbiologic interpretation. While the majority of doses were adequate (10mg/kg) based on current guidance for enterococcal BSI, the use of a directive comment to guide dosing and ID consultation may have recused outliers. Additional data is needed to characterize the impact of specific microbiologic interpretations on clinician prescribing and determine the most effective messaging strategies. Disclosures David J. Weber, MD, MPH, PDI (Consultant)