962. Pediatric Antimicrobial Stewardship at Colorado Hospitals

Background

Although antibiotics are essential to pediatric care, many pediatric antimicrobial prescriptions are inappropriate. Antimicrobial stewardship programs (ASPs) are implemented to mitigate these instances of inappropriate prescription, but little is known about how these programs are applied to pediatric care. To better understand extension of ASP to pediatric patients, barriers to pediatric stewardship, and desired resources for pediatric stewardship, we assessed stewardship practices as applied to pediatric patients and identified barriers to including this vulnerable population across Colorado hospitals.

Methods

We conducted a mixed-methods evaluation including a survey and semi-structured interviews with the objective of characterizing and assisting Colorado ASPs. Forty-one hospitals responded to the survey and 24 programs were interviewed, of 103 possible hospitals.

Results

Of the 41 hospitals responding to the survey and 23 hospitals interviewed, 35 (85%) and 23 (90%) cared for pediatric patients respectively. Of hospitals caring for neonatal and general pediatric patients, only 17% and 14% employed rigorous stewardship practices for the action, tracking, and reporting stewardship core elements for these populations (compared to 50% and 31% for their adult patients).

Notably, we found many programs inaptly combined adult and pediatric ASP efforts (18 hospitals, 81%), including frequent combining of adult and pediatric antibiotic use data, versus separating these patient populations (3 hospitals, 14%).

Barriers to priority pediatric stewardship included lack of pediatric expertise and perceived low priority for pediatric stewardship due to lower volumes. The most desired pediatric resources were clinical care guidelines and pediatric stewardship education.

Conclusion

Though most hospitals in Colorado care for pediatric patients, priority stewardship in pediatrics is rare. Resources to assist pediatric ASP are uncommon, and incentive to develop such resources may be low. Public health departments and pediatric hospitals can help combat antimicrobial resistance and improve pediatric care in community settings by providing easier access to pediatric expertise.

Disclosures

All Authors: No reported disclosures.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on antimicrobial stewardship programs in Colorado hospitals

Using a mixed-methods approach, we assessed the effect of the coronavirus disease 2019 (COVID-19) pandemic on antimicrobial stewardship programs (ASPs) in Colorado hospitals. ASP leaders reported decreased time and resources, reduced rigor of stewardship interventions, inability to complete new initiatives, and interpersonal challenges. Stewardship activities may be threatened during times of acute resource pressure.

Sequential Intravenous-Oral Therapy for Pediatric Streptococcus anginosus Intracranial Infections

Background

Streptococcus anginosus group is a common cause of pediatric intracranial infections but treatment recommendations, including use of oral therapy, are poorly defined.

Methods

We performed a retrospective review from 2004 to 2019 of all patients with S anginosus group pyogenic intracranial infections at Children's Hospital Colorado, highlighting patients transitioned to oral therapy. The primary endpoint was worsening infection necessitating intravenous antibiotics or a source control procedure after transition to oral therapy.

Results

Of 107 patients with S anginosus intracranial infections, 61 were transitioned to exclusive oral therapy after a median intravenous duration of 37 days, overwhelmingly with a levofloxacin-based regimen. Only 1 treatment failure was noted in a patient who did not fill their prescription. Patients with epidural infections were more likely to be transitioned to oral therapy within the first 28 days of treatment (defined as "early"). Patients with parenchymal infections, bacteremia, co-pathogens, higher inflammatory markers, and requiring >1 source control procedure were less likely to be transitioned early to oral therapy. Complications of a central catheter and/or intravenous medications contributed to 56% of oral transitions.

Conclusions

Levofloxacin-based oral regimens were effective and well tolerated. Patients with less severe infections were more likely to be transitioned early to oral therapy. Criteria for transitioning patients to oral antibiotics for intracranial infections should be established to minimize risks inherent with central catheters.

345. Early Oral Therapy for Streptococcus anginosus Purulent Brain Infections: A Single Center Experience

Background

Pediatric Streptococcus anginosus intracranial pyogenic are commonly treated with prolonged intravenous (IV) antibiotics, exposing patients to risks of a long-term central catheter. Antibiotics with high oral bioavailability, such as levofloxacin, may allow early oral transition.

Methods

To characterize patients with S. anginosus intracranial infections transitioned to oral therapy, we performed a retrospective review at Children’s Hospital Colorado from 1/2004 to 2/2019. Inclusion criteria were radiologic evidence of an infected parenchymal, subdural, or epidural fluid collection AND a positive culture for S. anginosus from an intracranial source, specific extracranial sources (sinus, scalp, orbit), or blood. The primary endpoint was oral antibiotic failure defined as worsening infection on oral therapy. Comparisons were done using Fisher’s exact test.

Results

94 patients met inclusion criteria, 57 of whom were transitioned to oral therapy during treatment. Oral levofloxacin was used in 54 of the 57. 12% of oral transitions occurred in the first 14 days of therapy (range 3–8 days), and 35% in the first 28 days. Patients transitioned in the first 28 days were more likely to have an epidural collection (p:< 0.01), and less likely to have a subdural collection (p: 0.03) or brain abscess (p:< 0.01). Of the 57, none had oral antibiotic failure. Contributing reasons for oral transition included central line complications (18%), IV medication reaction (18%), hematologic abnormality presumed secondary to IV antibiotics (33%), and provider judgement (56%). Two patients required re-introduction of IV therapy for reasons other than clinical failure (one for medication non-adherence and one for adverse reaction to levofloxacin).

Conclusion

We observed success and tolerance of levofloxacin-based oral therapy for pediatric pyogenic intracranial S. anginosus brain infections and confirmed the frequent occurrence of adverse events associated with IV treatment. Transition to oral therapy should be considered, particularly if complications of IV therapy arise in treatment of an epidural infection. A subset of patients in our study transitioned within the first 14 days of therapy; prospective studies are needed to characterize the safety of such very early transition.

Disclosures

All Authors: No reported disclosures

Vancomycin-Nonsusceptible Enterococci Mediated by vanC at a Large Children's Hospital: Prevalence, Susceptibility, and Impact on Care of Enterococcal Bacteremia

Enterococcus gallinarum and casseliflavus have inherent vancomycin resistance and, though known as pathogens, have not been well characterized in pediatric patients. We identified a significant prevalence of these enterococcal species among immunocompromised patients at a large pediatric institution and describe the impact on patient care, antibiotic stewardship, and infection control.

634. Incidence of vanC-Mediated Vancomycin-Resistant Enterococcus Bloodstream Infections at Children’s Hospital of Colorado and Implications for Empiric Enterococcal Therapy

Background

The most well-known Enterococcal species, E. faecium and E. faecalis, can harbor high-level vancomycin resistance mediated by acquired vanA and vanB operons. However, other Enterococcal species such as E. gallinarum and E. casseliflavus (VCE), harbor intrinsic low-level vancomycin resistance mediated by an intrinsic vanC operon, and the incidence of these pathogens among pediatric patients is not clear. As the antibiotic resistance pattern of VCE is different than E. faecium and E. faecalis, a high prevalence of VCE may have implications for antibiotic therapy. We describe the incidence and susceptibility of VCE bloodstream infections at a large children’s hospital and compare to E. faecalis and E. faecium.

Methods

Positive blood culture results from 2013 to 2018 were obtained from the Children’s Hospital of Colorado data warehouse. All first-time positive cultures for Enterococcus were analyzed for species, susceptibility, and hospital unit location. First-time positive was defined as being at least 2 weeks after any previous positive Enterococcus blood culture. Susceptibilities were categorized by clinical laboratories standards institute (CLSI) guidelines.

Results

Of 240 positive isolates, 7% were ampicillin susceptible and vancomycin nonsusceptible (resistant or intermediate), vs. 6% that were ampicillin resistant and vancomycin susceptible. An additional 3% of isolates were not susceptible to either antibiotic; all of these were E. faecium. VCE accounted for 12% of our isolates while E. faecalis and E. faecium accounted for 66% and 16%, respectively. All VCE were susceptible to ampicillin, but 52% were nonsusceptible to vancomycin. VCE incidence, ampicillin resistance, and vancomycin nonsusceptibility were most prevalent in our hematology, oncology, and bone marrow transplant (BMT) units.

Conclusion

At our institution, an as yet unspeciated Enterococcus is equally likely to be ampicillin susceptible and vancomycin nonsusceptible as ampicillin resistant and vancomycin susceptible. This is driven by a significant incidence of VCE, especially on our hematology, oncology, and BMT units. Therefore, vancomycin may not provide adequate empiric Enterococcal coverage on these units, and the addition of ampicillin will be recommended.

Disclosures

All authors: No reported disclosures.

Parent and public interest in whole-genome sequencing

OBJECTIVE

The aim of this study was to assess the baseline interest of the public in whole-genome sequencing (WGS) for oneself, parents' interest in WGS for their youngest children, and factors associated with such interest.

METHODS

A random sample of adults from a probability-based nationally representative online panel was surveyed. All participants were provided basic information about WGS and then asked about their interest in WGS for themselves. Those participants who were parents were additionally asked about their interest in WGS for their children. The order in which parents were asked about their interest in WGS for themselves and for their child was randomized. The relationship between parent/child characteristics and interest in WGS was examined.

RESULTS

The overall response rate was 62% (55% among parents). 58.6% of the total population (parents and nonparents) was interested in WGS for themselves. Similarly, 61.8% of the parents were interested in WGS for themselves and 57.8% were interested in WGS for their youngest children. Of note, 84.7% of the parents showed an identical interest level in WGS for themselves and their youngest children. Mothers as a group and parents whose youngest children had ≥2 health conditions had significantly more interest in WGS for themselves and their youngest children, while those with conservative political ideologies had considerably less.

CONCLUSIONS

While US adults have varying interest levels in WGS, parents appear to have similar interests in genome testing for themselves and their youngest children. As WGS technology becomes available in the clinic and private market, clinicians should be prepared to discuss WGS risks and benefits with their patients.