Outpatient Parenteral Antimicrobial Therapy in Vulnerable Populations-- People Who Inject Drugs and the Homeless

Outpatient parenteral antimicrobial therapy (OPAT) programs can provide high-value care but may be challenging in people who inject drugs (PWID) and homeless individuals. We conducted a single-center, retrospective, cohort study of adults who received OPAT at an urban, public health hospital from January 1, 2015 to April 30, 2016, grouped by PWID and housing status. Outcomes included clinical cure, length of stay, secondary bacteremia, line-tampering, and readmission. A total of 596 patients (homeless PWID (9%), housed PWID (8%), homeless non-PWID (8%), and housed non-PWID (75%), received OPAT. Assuming that patients lost to follow-up failed therapy, homeless PWID were least likely to achieve cure compared with housed non-PWID, (odds ratio [OR] = 0.33, 95% CI 0.18-0.59; P < .001). Housed PWID were also less likely to achieve cure (OR = 0.37, 95% CI 0.20-0.67; P = .001). Cure rates did not differ in patients not lost to follow-up. OPAT can be effective in PWID and the homeless, but loss to follow-up is a significant barrier.

325. Neurosyphilis Management in the Post-Procaine Penicillin Era

Background

Neurosyphilis (NS) is an infection of the central nervous system caused by Treponema pallidum. Intramuscular (IM) penicillin (PCN) G procaine is a treatment option for those who cannot receive or decline intravenous (IV) therapy. Since August 24, 2016, it has been unavailable from the manufacturer, necessitating the use of IV PCN for NS. Our institutions organized a multidisciplinary, coordinated care system to expedite outpatient treatment of NS upon diagnosis. We report successful management of NS at an urban safety-net hospital in the post-procaine PCN era.

Methods

We identified patients with suspected NS from the King County Public Health STD and Harborview Infectious Disease clinics from October 2016 to February 2018. Demographics, clinical symptoms, diagnostics, treatment, and outcomes were collected by chart review. Successful NS treatment was defined as resolution of cerebrospinal fluid (CSF) pleocytosis or elevated protein, improvement in neurologic symptoms or appropriate decrease in serum rapid plasma reagin (RPR) or CSF Venereal Disease Research Laboratory (VDRL) titers.

^aRepresents more than one payer per patient.

Results

We identified 43 cases of suspected NS. The most common symptoms were blurred vision, headache, and tinnitus. All had a lumbar puncture (LP). Median days from LP to treatment initiation was 6—many starting on day of diagnosis. Fourteen patients (33%) required admission for treatment. Two patients declined therapy. IV PCN G was used in 93% of cases; one received IM ceftriaxone. Treatment was successful in 32 of 41 (78%) cases, with 23 of these (72%) managed as outpatients. Three cases were treatment failures for incomplete therapy adherence or equivocal response and uncertain diagnosis.

Conclusion

Without available IM procaine PCN, neurosyphilis is challenging to manage in vulnerable populations or those wishing to avoid inpatient admission. Employing a multidisciplinary, coordinated care approach can lead to successful treatment of NS using IV PCN in the outpatient setting.

Disclosures

All authors: No reported disclosures.

A Little Bit of Dalba Goes a Long Way: Dalbavancin Use in a Vulnerable Patient Population

Background

Serious staphylococcal infections require prolonged courses of intravenous (IV) antibiotics. Weekly IV dalbavancin is an alternative to more frequent IV antimicrobial dosing for homeless patients or persons who inject drugs (PWID), for whom creating a treatment plan can be challenging. We examined the clinical outcomes in patients who were treated with dalbavancin compared with a similar population treated with alternative antibiotics.

Methods

We identified 18 patients who received dalbavancin from June 1, 2015 to December 31, 2016 using pharmacy records and 89 patients receiving IV antibiotics for similar infections treated at Harborview Medical Center from January 1, 2015 to May 31, 2015, before dalbavancin was available. Medical records were reviewed, and patient demographics, length of stay (LOS), readmission, and outcomes were abstracted using REDCap, linked to the University of Washington’s Clinical Data Repository.

Results

Basic demographics in Table 1. The types of infections are in Figure 1. Clinical cure rates were similar between the two groups (Figure 2) although 21% and 28% of the patients were lost to follow-up in the pre and post dalbavancin period. Among the subgroup of PWID, those who received dalbavancin had higher rates of clinical cure (64.7% vs. 29.4%, P = 0.01), a trend toward decreased LOS (11.4 ± 5.8 vs. 20.2 ± 15.1 days, P = 0.04), and fewer 30-day readmissions (0% vs. 29.4%, P = 0.02) (Figure 2). Fewer PWID in the dalbavancin group were lost to follow-up (23.5% vs. 70.6%).

Conclusion

Patients treated with dalbavancin had similar outcomes compared with patients treated in the pre-dalbavancin time period. Among PWID, dalbavancin use led to significantly improved outcomes including a higher clinical cure rate, lower readmission rate, and shorter hospital LOS, which offset the cost of the drug. Dalbavancin is an option for the treatment of serious staphylococcal infections in selected patients.

Disclosures

All authors: No reported disclosures.

Clostridium butyricum sepsis in an injection drug user with an indwelling central venous catheter

Clostridium novyi has been associated with a large outbreak of severe infections in injection drug users. A case of bacteraemia with Clostridium butyricum in an injection drug user is reported. During treatment for Staphylococcus aureus osteomyelitis, the patient used an indwelling central venous catheter to inject cocaine. He was admitted with C. butyricum sepsis that responded to broad spectrum antibiotics, including vancomycin. Local investigation for other cases was unrevealing; however, growth of an unusual pathogen in clinical specimens should be investigated as it may represent a sentinel event with public health implications.