Impact of diagnostic stewardship interventions in the collection process of fungal blood cultures

We implemented 2 interventions to improve utilization and contamination at our institution: kits to improve appropriate sample collection and an electronic order alert displaying appropriate indications of fungal blood cultures. An electronic order alert when ordering fungal blood cultures was associated with decreased utilization without decrease in positivity rate.

Epidemiology and preventability of hospital-onset bacteremia and fungemia in 2 hospitals in India

OBJECTIVE

Studies evaluating the incidence, source, and preventability of hospital-onset bacteremia and fungemia (HOB), defined as any positive blood culture obtained after 3 calendar days of hospital admission, are lacking in low- and middle-income countries (LMICs).

DESIGN, SETTING, AND PARTICIPANTS

All consecutive blood cultures performed for 6 months during 2020-2021 in 2 hospitals in India were reviewed to assess HOB and National Healthcare Safety Network (NHSN) reportable central-line-associated bloodstream infection (CLABSI) events. Medical records of a convenience sample of 300 consecutive HOB events were retrospectively reviewed to determine source and preventability. Univariate and multivariable logistic regression analyses were performed to identify factors associated with HOB preventability.

RESULTS

Among 6,733 blood cultures obtained from 3,558 hospitalized patients, there were 409 and 59 unique HOB and NHSN-reportable CLABSI events, respectively. CLABSIs accounted for 59 (14%) of 409 HOB events. There was a moderate but non-significant correlation (r = 0.51; P = .070) between HOB and CLABSI rates. Among 300 reviewed HOB cases, CLABSIs were identified as source in only 38 (13%). Although 157 (52%) of all 300 HOB cases were potentially preventable, CLABSIs accounted for only 22 (14%) of these 157 preventable HOB events. In multivariable analysis, neutropenia, and sepsis as an indication for blood culture were associated with decreased odds of HOB preventability, whereas hospital stay ≥7 days and presence of a urinary catheter were associated with increased likelihood of preventability.

CONCLUSIONS

HOB may have utility as a healthcare-associated infection metric in LMIC settings because it captures preventable bloodstream infections beyond NHSN-reportable CLABSIs.

Impact of measurement and feedback on chlorhexidine gluconate bathing among intensive care unit patients: A multicenter study

OBJECTIVE

To assess whether measurement and feedback of chlorhexidine gluconate (CHG) skin concentrations can improve CHG bathing practice across multiple intensive care units (ICUs).

DESIGN

A before-and-after quality improvement study measuring patient CHG skin concentrations during 6 point-prevalence surveys (3 surveys each during baseline and intervention periods).

SETTING

The study was conducted across 7 geographically diverse ICUs with routine CHG bathing.

PARTICIPANTS

Adult patients in the medical ICU.

METHODS

CHG skin concentrations were measured at the neck, axilla, and inguinal region using a semiquantitative colorimetric assay. Aggregate unit-level CHG skin concentration measurements from the baseline period and each intervention period survey were reported back to ICU leadership, which then used routine education and quality improvement activities to improve CHG bathing practice. We used multilevel linear models to assess the impact of intervention on CHG skin concentrations.

RESULTS

We enrolled 681 (93%) of 736 eligible patients; 92% received a CHG bath prior to survey. At baseline, CHG skin concentrations were lowest on the neck, compared to axillary or inguinal regions (P < .001). CHG was not detected on 33% of necks, 19% of axillae, and 18% of inguinal regions (P < .001 for differences in body sites). During the intervention period, ICUs that used CHG-impregnated cloths had a 3-fold increase in patient CHG skin concentrations as compared to baseline (P < .001).

CONCLUSIONS

Routine CHG bathing performance in the ICU varied across multiple hospitals. Measurement and feedback of CHG skin concentrations can be an important tool to improve CHG bathing practice.

The role of procalcitonin and Clinical Pulmonary for Infection Score (CPIS) score to reduce inappropriate antibiotics use among moderate to severe coronavirus disease 2019 (COVID-19) pneumonia: A quasi-experimental multicenter study

In this quasi-experimental study, implementing a procalcitonin and Clinical Pulmonary Infection Score (CPIS) successfully reduced inappropriate antibiotic use among severely-to-critically ill COVID-19 patients, multidrug-resistant organisms, and invasive fungal infections during the intervention period in 2 medical centers. However, this strategy did not improve inappropriate antibiotic use among mildly-to-moderately ill COVID-19 patients.

The impact on central line-associated bloodstream infection rates following the introduction of a closed system transfer device in oncology wards

Prevention of hazardous drug exposure is essential in averting unnecessary health risks to health care workers (HCW). To address the risk to HCWs when handling hazardous drugs, engineering controls can be utilized to reduce the exposure. A closed system transfer device (CSTD) was introduced for hazardous drugs administration in 6 oncology wards; this new CSTD was associated with a significant increase in CLABSI rates.

2037. Epidemiology and Preventability of Hospital Onset Bacteremia and Fungemia in two Hospitals in India

Background

The National Healthcare Safety Network (NHSN) central line-associated bloodstream infection (CLABSI) is a widely accepted quality measure. However, studies from the United States indicate that NHSN reportable CLABSIs account for less than 20% of all hospital-onset bacteremia and fungemia (HOB, i.e., any positive blood culture obtained at least 3 calendar days after hospital admission) events and about 66% of all HOB events are potentially preventable. The incidence and overall preventability of HOB is unknown in low and middle-income countries (LMICs). This study evaluated the epidemiology and preventability of HOB in two hospitals in India.

Methods

Six months data on all consecutive blood cultures processed in two hospitals (Hospital A- 8.16.2020 to 2.15.2021; Hospital B- 1.1.2021 to 6.30.2021) were collected prospectively to calculate HOB and CLABSI incidence. Correlation between HOB and CLABSI rates was assessed using Spearman’s rank correlation. Medical records of 300 consecutive HOB events were retrospectively reviewed to determine the source and preventability of HOB utilizing a structured guide developed for the study.

Results

Among 3,558 hospitalized patients from whom blood cultures were obtained, 10.4% developed HOB with 409 unique HOB events (HOB incidence: 2.87 per 1000 patient-days). Only 15% (59 of 409) of HOB events were reported as CLABSI as per hospital CLABSI surveillance programs. The CLABSI rate was 4.4 per 1000 central line-days. There was a moderation correlation (r=0.51; p=0.07) between HOB and CLABSI rates. Among the 300 HOB events for which medical records were reviewed, the most common organism isolated was Klebsiella pneumoniae and 75% of K. pneumoniae were carbapenem resistant (Figure 1). The most common source of HOB was CLABSI (26.3%) (Figure 2). Fifty-two percent of all HOB events and 45% of HOB events not attributable to contaminants were potentially preventable (Figure 3). CLABSIs accounted for 69% of non-contaminant HOB preventable events.

Conclusion

We found that 69% of the non-contaminant related HOB preventable events were due to CLABSI. Prevention efforts in these hospitals could focus on CLABSI to reduce HOB rates while additional studies are performed to better understand the epidemiology of HOB in LMICs.

Microorganisms identified from 300 Hospital Onset Bacteremia and Fungemia Events in Two Hospitals in India.

Source of Hospital Onset Bacteremia and Fungemia Events in Two Hospitals in India (n=300).

Preventability Rating Source of Hospital Onset Bacteremia and Fungemia events in Two Hospitals in India (n=300).

Disclosures

All Authors: No reported disclosures.

An Open Label Randomized Controlled Trial of Ivermectin Plus Favipiravir-Based Standard of Care versus Favipiravir-Based Standard of Care for Treatment of Moderate COVID-19 in Thailand

BACKGROUND

The role of ivermectin in the treatment of moderate coronavirus disease 2019 (COVID-19) is controversial. We performed an open label randomized controlled trial to evaluate the role of ivermectin plus favipiravir-based standard of care versus favipiravir-based standard of care for the treatment of moderate COVID-19 infection.

MATERIALS AND METHODS

An open-label randomized control trial was performed at Thammasat Field Hospital and Thammasat University Hospital from October 1st, 2021 to May 31st, 2022. Patients with moderate COVID-19 infections were randomized to the intervention (ivermectin plus favipiravir-based standard of care) or control group (favipiravir-based standard of care alone). Patients were followed up to 21 days. The primary outcome was the improvement in World Health Organization (WHO) category ordinal scale by 2 points. Secondary outcomes included duration of illness, development of severe COVID-19, and adverse reactions.

RESULTS

There were 157 patients in the intervention and 160 patients in the control group. Characteristics, underlying diseases, and risk factors for severe COVID-19 were comparable in both groups. Improvement in the WHO-category ordinal scale by 2 points was achieved in 98.7% of the intervention group and in 99.4% of the control group (relative risk [RR]: 0.487; 95% confidence interval [CI]: 0.044-5.430). The median illness duration was 5.0 days (range, 3 - 28 days) in intervention group versus 5.2 days (range, 3 - 28 days) in control group (P = 0.630). Severe COVID-19 that required intensive care occurred in 2 patients (1.3%) in the intervention group and 1 patient (0.6%) in the control group (RR: 2.052; 95% CI: 0.184 - 22.857). No significant difference in serious drug adverse events was seen.

CONCLUSION

In this study ivermectin plus standard of care was not associated with improvement in the WHO-category ordinal scale, reduced illness duration, or development of severe COVID-19 in moderately ill COVID-19 patients.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: TCTR20220427005.

Blood culture utilization practices among febrile and/or hypothermic inpatients

Background

Predictors associated with the decision of blood culture ordering among hospitalized patients with abnormal body temperature are still underexplored, particularly non-clinical factors. In this study, we evaluated the factors affecting blood culture ordering in febrile and hypothermic inpatients.

Methods

We performed a retrospective study of 15,788 adult inpatients with fever (≥ 38.3℃) or hypothermia (< 36.0℃) from January 2016 to December 2017. We evaluated the proportion of febrile and hypothermic episodes with an associated blood culture performed within 24h. Generalized Estimating Equations were used to determine independent predictors associated with blood culture ordering among febrile and hypothermic inpatients.

Results

We identified 21,383 abnormal body temperature episodes among 15,788 inpatients (13,093 febrile and 8,290 hypothermic episodes). Blood cultures were performed in 36.7% (7,850/ 21,383) of these episodes. Predictors for blood culture ordering among inpatients with abnormal body temperature included fever ≥ 39℃ (adjusted odd ratio [aOR] 4.17, 95% confident interval [CI] 3.91–4.46), fever (aOR 3.48, 95% CI 3.27–3.69), presence of a central venous catheter (aOR 1.36, 95% CI 1.30–1.43), systemic inflammatory response (SIRS) plus hypotension (aOR 1.33, 95% CI 1.26–1.40), SIRS (aOR 1.26, 95% CI 1.20–1.31), admission to stem cell transplant / medical oncology services (aOR 1.09, 95% CI 1.04–1.14), and detection of abnormal body temperature during night shift (aOR 1.06, 95% CI 1.03–1.09) or on the weekend (aOR 1.05, 95% CI 1.01–1.08).

Conclusion

Blood culture ordering for hospitalized patients with fever or hypothermia is multifactorial; both clinical and non-clinical factors. These wide variations and gaps in practices suggest opportunities to improve utilization patterns.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07748-x.

Postdischarge prophylactic antibiotics following mastectomy with and without breast reconstruction

BACKGROUND

Prophylactic antibiotics are commonly prescribed at discharge for mastectomy, despite guidelines recommending against this practice. We investigated factors associated with postdischarge prophylactic antibiotic use after mastectomy with and without immediate reconstruction and the impact on surgical-site infection (SSI).

STUDY DESIGN

We studied a cohort of women aged 18-64 years undergoing mastectomy between January 1, 2010, and June 30, 2015, using the MarketScan commercial database. Patients with nonsurgical perioperative infections were excluded. Postdischarge oral antibiotics were identified from outpatient drug claims. SSI was defined using International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnosis codes. Generalized linear models were used to determine factors associated with postdischarge prophylactic antibiotic use and SSI.

RESULTS

The cohort included 38,793 procedures; 24,818 (64%) with immediate reconstruction. Prophylactic antibiotics were prescribed after discharge after 2,688 mastectomy-only procedures (19.2%) and 17,807 mastectomies with immediate reconstruction (71.8%). The 90-day incidence of SSI was 3.5% after mastectomy only and 8.8% after mastectomy with immediate reconstruction. Antibiotics with anti-methicillin-sensitive Staphylococcus aureus (MSSA) activity were associated with decreased SSI risk after mastectomy only (adjusted relative risk [aRR], 0.74; 95% confidence interval [CI], 0.55-0.99) and mastectomy with immediate reconstruction (aRR, 0.80; 95% CI, 0.73-0.88), respectively. The numbers needed to treat to prevent 1 additional SSI were 107 and 48, respectively.

CONCLUSIONS

Postdischarge prophylactic antibiotics were common after mastectomy. Anti-MSSA antibiotics were associated with decreased risk of SSI for patients who had mastectomy only and those who had mastectomy with immediate reconstruction. The high numbers needed to treat suggest that potential benefits of postdischarge antibiotics should be weighed against potential harms associated with antibiotic overuse.

Longitudinal analysis of risk factors associated with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among hemodialysis patients and healthcare personnel in outpatient hemodialysis centers

In this prospective, longitudinal study, we examined the risk factors for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among a cohort of chronic hemodialysis (HD) patients and healthcare personnel (HCPs) over a 6-month period. The risk of SARS-CoV-2 infection among HD patients and HCPs was consistently associated with a household member having SARS-CoV-2 infection.

Factors associated with intensified infection prevention and vaccination practice among Thai health care personnel: A multicenter survey during COVID-19 pandemic

Intensified infection prevention (IP) and health care personnel (HCP) vaccination programs could enhance HCP safety during COVID-19 pandemic. A multi-center survey regarding on intensified IP practices and vaccination uptake among HCP was performed. Working in the emergency medicine department was associated with wearing a double mask and face shield (P = .04). Despite having more confidence in care of COVID-19 patients, there was no significant improvement of intensified IP practices, COVID-19 and influenza vaccination programs among “high-risk” HCP.

Strategies to limit invasive fungal infection in a coronavirus disease 2019 (COVID-19) intensive care unit: The role of infection prevention for renovation and construction in resource-limited settings

Hospital construction and renovation activities are the main cause of healthcare-associated fungal outbreaks. Infection control risk assessments (ICRAs) for renovation and construction decrease the risk of healthcare-associated fungal outbreaks, but they are typically not performed in developing countries. We reviewed an outbreak investigation to limit the construction-related fungal infections in a COVID-19 ICU in a resource-limited setting.

The feasibility of procalcitonin and CPIS score to reduce inappropriate antibiotics use among severe-critically ill COVID-19 pneumonia patients: A pilot study

Antibiotics have been extensively used in COVID-19 patients without a clear indication. We conducted a study to evaluate the feasibility of procalcitonin along with the "Clinical Pulmonary for Infection Score" (CPIS) as a strategy to reduce inappropriate antibiotic use. Using procalcitonin and CPIS score (PCT-CPIS) successfully reduced inappropriate antibiotics use among severe-critically ill COVID-19 pneumonia patients (45% vs 100%; P < .01). Compared to "non PCT-CPIS" group, "PCT-CPIS" group was associated with a reduction in the incidence of multidrug-resistant organisms and invasive fungal infections (18.3% vs 36.7%; P = .03), shorter antibiotic duration (2 days vs 7 days; P < .01) and length of hospital stay (10 days vs 16 days; P < .01).

Lack of association of post-discharge prophylactic antibiotics with decreased risk of surgical site infection following spinal fusion

OBJECTIVES

To determine the prevalence and factors associated with post-discharge prophylactic antibiotic use after spinal fusion and whether use was associated with decreased risk of surgical site infection (SSI).

METHODS

Persons aged 10-64 years undergoing spinal fusion between 1 January 2010 and 30 June 2015 were identified in the MarketScan Commercial Database. Complicated patients and those coded for infection from 30 days before to 2 days after the surgical admission were excluded. Outpatient oral antibiotics were identified within 2 days of surgical discharge. SSI was defined using ICD-9-CM diagnosis codes within 90 days of surgery. Generalized linear models were used to determine factors associated with post-discharge prophylactic antibiotic use and with SSI.

RESULTS

The cohort included 156 446 fusion procedures, with post-discharge prophylactic antibiotics used in 9223 (5.9%) surgeries. SSIs occurred after 2557 (1.6%) procedures. Factors significantly associated with post-discharge prophylactic antibiotics included history of lymphoma, diabetes, 3-7 versus 1-2 vertebral levels fused, and non-infectious postoperative complications. In multivariable analysis, post-discharge prophylactic antibiotic use was not associated with SSI risk after spinal fusion (relative risk 0.98; 95% CI 0.84-1.14).

CONCLUSIONS

Post-discharge prophylactic oral antibiotics after spinal fusion were used more commonly in patients with major medical comorbidities, more complex surgeries and those with postoperative complications during the surgical admission. After adjusting for surgical complexity and infection risk factors, post-discharge prophylactic antibiotic use was not associated with decreased SSI risk. These results suggest that prolonged prophylactic antibiotic use should be avoided after spine surgery, given the lack of benefit and potential for harm.

Predictors of humoral response to SARS-CoV-2 mRNA vaccine BNT162b2 in patients receiving maintenance dialysis

Objective

Patients on dialysis are at high risk for severe COVID-19 and associated morbidity and mortality. We examined the humoral response to SARS-CoV-2 mRNA vaccine BNT162b2 in a maintenance dialysis population.

Design

Single-center cohort study.

Setting and participants

Adult maintenance dialysis patients at 3 outpatient dialysis units of a large academic center.

Methods

Participants were vaccinated with 2 doses of BNT162b2, 3 weeks apart. We assessed anti-SARS-CoV-2 spike antibodies (anti-S) ∼4-7 weeks after the second dose and evaluated risk factors associated with insufficient response. Definitions of antibody response are as follows: nonresponse (anti-S level, <50 AU/mL), low response (anti-S level, 50-839 AU/mL), and sufficient response (anti-S level, ≥840 AU/mL).

Results

Among the 173 participants who received 2 vaccine doses, the median age was 60 years (range, 28-88), 53.2% were men, 85% were of Black race, 86% were on in-center hemodialysis and 14% were on peritoneal dialysis. Also, 7 participants (4%) had no response, 27 (15.6%) had a low response, and 139 (80.3%) had a sufficient antibody response. In multivariable analysis, factors significantly associated with insufficient antibody response included end-stage renal disease comorbidity index score ≥5 and absence of prior hepatitis B vaccination response.

Conclusions

Although most of our study participants seroconverted after 2 doses of BNT162b2, 20% of our cohort did not achieve sufficient humoral response. Our findings demonstrate the urgent need for a more effective vaccine strategy in this high-risk patient population and highlight the importance of ongoing preventative measures until protective immunity is achieved.

Stopping Hospital Infections With Environmental Services (SHINE): A Cluster-randomized Trial of Intensive Monitoring Methods for Terminal Room Cleaning on Rates of Multidrug-resistant Organisms in the Intensive Care Unit

BACKGROUND

Multidrug-resistant organisms (MDROs) frequently contaminate hospital environments. We performed a multicenter, cluster-randomized, crossover trial of 2 methods for monitoring of terminal cleaning effectiveness.

METHODS

Six intensive care units (ICUs) at 3 medical centers received both interventions sequentially, in randomized order. Ten surfaces were surveyed each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services staff in real time with failing surfaces recleaned. We measured monthly rates of MDRO infection or colonization, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and MDR gram-negative bacilli (MDR-GNB) during a 12-month baseline period and sequential 6-month intervention periods, separated by a 2-month washout. Primary analysis compared only the randomized intervention periods, whereas secondary analysis included the baseline.

RESULTS

The ATP method was associated with a reduction in incidence rate of MDRO infection or colonization compared with the UV/F period (incidence rate ratio [IRR] 0.876; 95% confidence interval [CI], 0.807-0.951; P = .002). Including the baseline period, the ATP method was associated with reduced infection with MDROs (IRR 0.924; 95% CI, 0.855-0.998; P = .04), and MDR-GNB infection or colonization (IRR 0.856; 95% CI, 0.825-0.887; P < .001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turnaround time increased by a median of 1 minute with the ATP intervention and 4.5 minutes with UV/F compared with baseline.

CONCLUSIONS

Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a reduction of MDRO infection and colonization.

3. Stopping Hospital Infections with Environmental Services (SHINE): A Cluster-Randomized Trial of Intensive Monitoring Methods for Terminal Room Cleaning on Rates of Multidrug-Resistant Organisms (MDROs) in the Intensive Care Unit (ICU)

Background

MDROs frequently contaminate hospital environments. We performed a multicenter cluster-randomized, crossover trial of two methods for intensive monitoring of terminal cleaning effectiveness at reducing infection and colonization with MDROs within ICUs.

Methods

Six medical and surgical ICUs at three medical centers received both intensive monitoring interventions sequentially, in a randomized order. The intervention included surveying a minimum of 10 surfaces each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services (EVS) staff in real-time, with failing surfaces recleaned. The primary study outcome was the monthly rate of infection or colonization with MDROs, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and multidrug-resistant gram-negative bacilli (MDR-GNB), assessed during a 12-month baseline comparison period and sequential 6-month intervention periods, separated by a 2-month washout. Outcomes during each intervention period were compared to the combined baseline period plus the alternative intervention period using mixed-effects Poisson regression, with study hospital as a random effect.

Results

The primary outcome rate varied by hospital and ICU (Figure 1). The ATP method was associated with a relative reduction in the incidence rate of infection or colonization with MDROs (incidence rate ratio (IRR) 0.887, 95% confidence-interval (CI) 0.811–0.969, P=0.008) (Table 1), infection with MDROs (IRR 0.924, 95% CI 0.855–0.998, P=0.04), and infection or colonization limited to multidrug-resistant MDR-GNB (IRR 0.856, 95% CI 0.825–0.887, P< 0.001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turn-around time was increased by a median of one minute with the ATP intervention and 4.5 minutes with the UV/F intervention compared to baseline.

Conclusion

Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a relative reduction of infection and colonization with MDROs with a negligible impact on TAT.

Disclosures

Hilary Babcock, MD, MPH, FIDSA, FSHEA (nothing to disclose), David K. Warren, MD, MPH, Homburg & Partner (consultant), Ebbing Lautenbach, MD, MPH, MSCE (nothing to disclose), Jennifer Han, MD, MSCE, GlaxoSmithKline (employee, shareholder).

Removal of a Penetrating Tree Branch in the Orbitofrontal Region-A Unique Application of an Orbitofrontal Craniotomy Through a Supraciliary Brow Approach

BACKGROUND AND IMPORTANCE

Orbitocranial penetrating injury (OPI) is associated with neurological, infectious, and vascular sequalae. This report describes unique application of an orbitofrontal craniotomy through a supraciliary approach to remove a wooden stick penetrating through the orbit and frontal lobe, postoperative management, and antimicrobial therapy.

CLINICAL PRESENTATION

A 51-yr-old male presented after a tree branch penetrated beneath his eye. He had no loss of consciousness and was neurologically intact with preserved vision and ocular motility. Computed tomography (CT) and CT angiogram revealed an isodense hollow cylindrical object penetrating though the left orbit and left frontal lobe. The object extended into the right lateral ventricle, abutting the left anterior cerebral artery. There was minimal intraventricular hemorrhage without arterial injury. The patient was treated with broad-spectrum antimicrobial coverage. The foreign body was removed and the dural defect repaired via an orbitofrontal craniotomy through a supraciliary eyebrow incision. He was treated with an extended course of antimicrobial therapy, and after 18 mo remained neurologically intact.

CONCLUSION

OPI are a subset of penetrating brain injuries with potential for immediate injury to neurovascular structures and delayed complications including cerebrospinal fluid leak and infection. Treatment includes attempted complete removal of the foreign body and antimicrobial therapy. An orbitofrontal craniotomy through a supraciliary eyebrow incision may be effective in selected patients.

SARS-CoV-2 Infection Risk Factors among Maintenance Hemodialysis Patients and Health Care Personnel In Outpatient Hemodialysis Centers

Increased risk of SARS-CoV-2 infection was associated with community prevalence.Increased risk of SARS-CoV-2 infection was associated with exposure to infected family members and personal infection prevention measures.

Impact of no-touch ultraviolet light room disinfection systems on Clostridioides difficile infections

Ultraviolet light (UVL) room disinfection has emerged as an adjunct to manual cleaning of patient rooms. Two different no-touch UVL devices were implemented in 3 health system hospitals to reduce Clostridioides difficile infections (CDI). CDI rates at all 3 facilities remained unchanged following implementation of UVL disinfection. Preintervention CDI rates were generally low, and data from one hospital showed high compliance with manual cleaning, which may have limited the impact of UVL disinfection.

A Comparison of Medication for Opioid Use Disorder Treatment Strategies for Persons Who Inject Drugs With Invasive Bacterial and Fungal Infections

BACKGROUND

Patients with opioid use disorder (OUD) are frequently admitted for invasive infections. Medications for OUD (MOUD) may improve outcomes in hospitalized patients.

METHODS

In this retrospective cohort of 220 admissions to a tertiary care center for invasive infections due to OUD, we compared 4 MOUD treatment strategies: methadone, buprenorphine, methadone taper for detoxification, and no medication to determine whether there were differences in parenteral antibiotic completion and readmission rates.

RESULTS

The MOUDs were associated with increased completion of parenteral antimicrobial therapy (64.08% vs 46.15%; odds ratio [OR] = 2.08; 95% CI, 1.23-3.61). On multivariate analysis, use of MOUD maintenance with either buprenorphine (OR = 0.38; 95% CI, .17-.85) or methadone maintenance (OR = 0.43; 95% CI, .20-.94) and continuation of MOUD on discharge (OR = 0.35; 95% CI, .18-.67) was associated with lower 90-day readmissions. In contrast, use of methadone for detoxification followed by tapering of the medication without continuation on discharge was not associated with decreased readmissions (OR = 1.87; 95% CI, .62-5.10).

CONCLUSIONS

Long-term MOUDs, regardless of selection, are an integral component of care in patients hospitalized with OUD-related infections. Patients with OUD should have arrangements made for MOUDs to be continued after discharge, and MOUDs should not be discontinued before discharge.

650. Clinical Performance Evaluation of Virtuo Blood Culture System in a Tertiary Care Hospital

Background

Bloodstream infections are a major cause of morbidity and mortality. BACT/ALERT VIRTUO (VIRTUO) blood culture system is an automated, closed system used with resin-containing media which may enhance the growth of microorganisms. Our objective was to assess the real-world performance of the VIRTUO system.

Methods

We retrospectively reviewed all blood cultures performed between January-December 2018 (VersaTREK) and January-December 2019 (VIRTUO) at a 1250-bed academic medical center. Blood culture positivity rates, contamination rates, and time from collection to arrival in the laboratory were compared pre- versus post-VIRTUO implementation. Contamination was defined as a single blood culture with common skin microbiota.

Results

A total of 101803 blood cultures were performed during the study period: 48969 (48.1%) were processed with VersaTREK system and 52834 (51.9%) with VIRTUO system. A decreased median time from collection until arrival to the laboratory was seen post-implementation (2.0 pre- vs. 0.8 hours post-implementation, p&lt; 0.001). The positivity rate increased from 3987 (8.1%) pre-implementation to 6141 (11.6%) post-implementation (p &lt; 0.001) (Table and Figure). Staphylococcus aureus was the most frequently isolated species for both periods and had higher recovery rate with the VIRTUO system (717 (1.5%) pre- vs. 1764 (3.3%) post-implementation, p&lt; 0.001). Higher recovery rate was also noted for other Staphylococcus spp. in the post-implementation period (985 (2.0%) pre- vs. 1644 (3.1%) post-implementation, p&lt; 0.001). No difference in the organism recovery rate was noted for Streptococcus spp., Enterococcus faecium, E. faecalis, Pseudomonas aeruginosa, Enterobacterales, and Candida spp. The inpatient contamination rate was higher post-implementation (1.5% pre- vs. 1.9% post-implementation, p &lt; 0.001).

Comparison of blood culture positivity rate pre- vs. post-implementation, by culture location

Conclusion

The VIRTUO system showed a higher rate of positive blood cultures compared to the VersaTREK system primarily from a higher detection of Staphylococcus spp. Further studies are needed to assess whether an increased rate of positive blood cultures is associated with changes in management and clinical outcomes.

Disclosures

All Authors: No reported disclosures

292. Impact of the BACT/ALERT VIRTUO blood culture system in the management of Staphylococcus aureus bacteremia

Background

Staphylococcus aureus bacteremia (SAB) is a major cause of mortality. Recovery of SA may be enhanced with new blood culture systems resulting in a longer observed duration of bacteremia.

Methods

We performed a 24-month retrospective study of adults hospitalized with SAB at a 1250-bed academic hospital. Between 1/2018-12/2018 the VersaTREK system was used and 1/2019-12/2019 the BACT/ALERT VIRTUO (VIRTUO) system was used. We excluded patients without an Infectious Diseases (ID) consult. We defined SAB duration as short (1–2 days), intermediate (3–6 days), or prolonged (>7 days). We compared SAB detection and management pre- and post-implementation of VIRTUO.

Results

456 patients had SAB during study period; 420 (92%) had ID consultation: 178 (42%) pre- and 242 (58%) post-implementation. Similar proportion of methicillin-resistant SAB was seen (44.9% pre- vs. 36.8% post-implementation, p=0.09). Post-implementation, patients were more likely to have intermediate (22.4% pre- vs. 40.1% post-implementation; p< 0.001) and prolonged SAB duration (3.9% pre- vs. 13.6% post-implementation; p< 0.001). Median time to positivity for the index blood culture was shorter (19.9 pre- vs. 15.0 hours post-implementation, p< 0.001). Dual anti-staphylococcal therapy was used more frequently in the post-implementation period (6.2% pre- vs. 15.7% post-implementation, p=0.003). No difference was noted in frequency of diagnostic studies (transesophageal echocardiography, magnetic resonance imaging, and computed tomography). Source control was similar (46.1% pre- vs. 45.0% post-implementation; p=0.84) but the median time to source-control was shorter post-implementation (4 pre- vs. 2 days post-implementation; p=0.02). Median planned duration of intravenous antibiotics did not vary between pre- and post-implementation periods (6 vs. 6 weeks, p=0.31). There was no difference in 90-day readmissions (38.2% pre- vs. 34.3% post-implementation; p=0.41).

Conclusion

VIRTUO blood culture system decreased time to positivity and increased frequency of prolonged SAB compared to the VersaTREK system. This resulted in increased use of dual anti-staphylococcal therapy and shorter time to source-control, but no difference in interventions, planned duration of antibiotics, or readmissions.

Disclosures

All Authors: No reported disclosures

Evaluation of Partial Oral Antibiotic Treatment for Persons Who Inject Drugs and Are Hospitalized With Invasive Infections

BACKGROUND

Persons who inject drugs (PWID) are at risk of invasive infections; however, hospitalizations to treat these infections are frequently complicated by against medical advice (AMA) discharges. This study compared outcomes among PWID who (1) completed a full course of inpatient intravenous (IV) antibiotics, (2) received a partial course of IV antibiotics but were not prescribed any antibiotics on AMA discharge, and (3) received a partial course of IV antibiotics and were prescribed oral antibiotics on AMA discharge.

METHODS

A retrospective, cohort study of PWID aged ≥18 years admitted to a tertiary referral center between 01/2016 and 07/2019, who received an infectious diseases consultation for an invasive bacterial or fungal infection.

RESULTS

293 PWID were included in the study. 90-day all-cause readmission rates were highest among PWID who did not receive oral antibiotic therapy on AMA discharge (n = 46, 68.7%), compared with inpatient IV (n = 43, 31.5%) and partial oral (n = 27, 32.5%) antibiotics. In a multivariate analysis, 90-day readmission risk was higher among PWID who did not receive oral antibiotic therapy on AMA discharge (adjusted hazard ratio [aHR], 2.32; 95% confidence interval [CI], 1.41-3.82) and not different among PWID prescribed oral antibiotic therapy on AMA discharge (aHR, .99; 95% CI, .62-1.62). Surgical source control (aHR, .57; 95% CI, .37-.87) and addiction medicine consultation (aHR, .57; 95% CI, .38-.86) were both associated with reduced readmissions.

CONCLUSIONS

Our single-center study suggests access to oral antibiotic therapy for PWID who cannot complete prolonged inpatient IV antibiotic courses is beneficial.

Effect of Prophylactic Negative Pressure Wound Therapy vs Standard Wound Dressing on Surgical-Site Infection in Obese Women After Cesarean Delivery: A Randomized Clinical Trial

IMPORTANCE

Obesity increases the risk of both cesarean delivery and surgical-site infection. Despite widespread use, it is unclear whether prophylactic negative pressure wound therapy reduces surgical-site infection after cesarean delivery in obese women.

OBJECTIVE

To evaluate whether prophylactic negative pressure wound therapy, initiated immediately after cesarean delivery, lowers the risk of surgical-site infections compared with standard wound dressing in obese women.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter randomized trial conducted from February 8, 2017, through November 13, 2019, at 4 academic and 2 community hospitals across the United States. Obese women undergoing planned or unplanned cesarean delivery were eligible. The study was terminated after 1624 of 2850 participants were recruited when a planned interim analysis showed increased adverse events in the negative pressure group and futility for the primary outcome. Final follow-up was December 18, 2019.

INTERVENTIONS

Participants were randomly assigned to either undergo prophylactic negative pressure wound therapy, with application of the negative pressure device immediately after repair of the surgical incision (n = 816), or receive standard wound dressing (n = 808).

MAIN OUTCOMES AND MEASURES

The primary outcome was superficial or deep surgical-site infection according to the Centers for Disease Control and Prevention definitions. Secondary outcomes included other wound complications, composite of surgical-site infections and other wound complications, and adverse skin reactions.

RESULTS

Of the 1624 women randomized (mean age, 30.4 years, mean body mass index, 39.5), 1608 (99%) completed the study: 806 in the negative pressure group (median duration of negative pressure, 4 days) and 802 in the standard dressing group. Superficial or deep surgical-site infection was diagnosed in 29 participants (3.6%) in the negative pressure group and 27 (3.4%) in the standard dressing group (difference, 0.36%; 95% CI, -1.46% to 2.19%, P = .70). Of 30 prespecified secondary end points, 25 showed no significant differences, including other wound complications (2.6% vs 3.1%; difference, -0.53%; 95% CI, -1.93% to 0.88%; P = .46) and composite of surgical-site infections and other wound complications (6.5% vs 6.7%; difference, -0.27%; 95% CI, -2.71% to 2.25%; P = .83). Adverse skin reactions were significantly more frequent in the negative pressure group (7.0% vs 0.6%; difference, 6.95%; 95% CI, 1.86% to 12.03%; P < .001).

CONCLUSIONS AND RELEVANCE

Among obese women undergoing cesarean delivery, prophylactic negative pressure wound therapy, compared with standard wound dressing, did not significantly reduce the risk of surgical-site infection. These findings do not support routine use of prophylactic negative pressure wound therapy in obese women after cesarean delivery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03009110.

A 2.5-Year Longitudinal Assessment of Naturalistic Driving in Preclinical Alzheimer's Disease

BACKGROUND

Emerging evidence shows that cognitively normal older adults with preclinical Alzheimer's disease (AD) make more errors and are more likely to receive a marginal/fail rating on a standardized road test compared to older adults without preclinical AD, but the extent to which preclinical AD impacts everyday driving behavior is unknown.

OBJECTIVE

To examine self-reported and naturalistic longitudinal driving behavior among persons with and without preclinical AD.

METHOD

We prospectively followed cognitively normal drivers (aged 65 + years) with (n = 10) and without preclinical AD (n = 10) for 2.5 years. Preclinical AD was assessed using amyloid positron emission tomography (PET) with Pittsburgh Compound B. The Driving Habits Questionnaire assessed self-reported driving outcomes. Naturalistic driving was captured using a commercial GPS data logger plugged into the on-board diagnostics II port of each participant's vehicle. Data were sampled every 30 seconds and all instances of speeding, hard braking, and sudden acceleration were recorded.

RESULTS

Preclinical AD participants went to fewer places/unique destinations, traveled fewer days, and took fewer trips than participants without preclinical AD. The preclinical AD group reported a smaller driving space, greater dependence on other drivers, and more difficulty driving due to vision difficulties. Persons with preclinical AD had fewer trips with any aggression and showed a greater decline across the 2.5-year follow-up period in the number of days driving per month and the number of trips between 1-5 miles.

CONCLUSION

Changes in driving occur even during the preclinical stage of AD.

Addiction Medicine Consultations Reduce Readmission Rates for Patients With Serious Infections From Opioid Use Disorder

The opioid epidemic has increased hospital admissions for serious infections related to opioid abuse. Our findings demonstrate that addiction medicine consultation is associated with increased treatment for opioid use disorder (OUD), greater likelihood of completing antimicrobial therapy, and reduced readmission rates among patients with OUD and serious infections requiring hospitalization.

572. Relationship Between Chlorhexidine Gluconate (CHG) Skin Concentrations and Microbial Skin Colonization among Medical Intensive Care Unit (MICU) Patients

Background

CHG bathing is used to suppress patients’ microbial skin colonization, in order to prevent infections and transmission of multidrug-resistant organisms. Prior work has suggested that microbial growth is inhibited when CHG skin concentrations exceed threshold levels.

Methods

We conducted 6 single-day surveys from January 2018 to February 2019 in 7 academic hospital MICUs with established CHG patient bathing. Adult patients were eligible to have skin swabbed from adjacent 25 cm2 areas on the neck, axilla, and inguinal region for culture and CHG concentration determination. CHG skin concentrations were measured by a semi-quantitative colorimetric assay. Selective media were used to isolate targeted microorganisms (Table 1). Species were confirmed by matrix-assisted laser desorption ionization time-of-flight mass spectrometry; antibiotic susceptibility was determined by MicroScan (Beckman Coulter). We modeled the relationship between CHG skin concentrations (log2-transformed) and microorganism recovery (yes/no as primary outcome) using multilevel models controlling for clustering of body sites within patients and within ICUs, assessing slope and threshold effects.

Results

We enrolled 736/759 (97%) patients and sampled 2176 skin sites. Gram-positive bacteria were detected most frequently (Table 1). The adjusted odds of identifying gram-positive organisms decreased linearly as CHG skin levels increased (Figure 1a), without evidence of a threshold effect. We also found significant negative linear slopes without evidence of threshold effects for other pathogens tested (Table 2; Figure 1), with the exception of gram-negative bacteria and vancomycin-resistant enterococci. When modeling quantitative culture results (colony-forming units) for gram-positive organisms as a continuous outcome variable, a similar relationship was found.

Conclusion

Higher concentrations of CHG were associated with less frequent recovery of gram-positive bacteria and Candida species on the skin of MICU patients who were bathed routinely with CHG. For microbial inhibition, we did not identify a threshold concentration of CHG on the skin; rather, increasing CHG skin concentrations led to additional gains in inhibition. For infection prevention, aiming for high CHG skin levels may be beneficial.

Disclosures

All authors: No reported disclosures.

895. Impact of Measurement and Results Feedback of Chlorhexidine Gluconate (CHG) Skin Concentrations in Medical Intensive Care Unit (MICU) Patients Receiving CHG Bathing

Background

Higher CHG skin levels may be needed to adequately control infection and transmission of pathogens in the ICU. We assessed whether measurement and feedback of patient CHG skin concentrations could improve CHG bathing quality and identified factors associated with higher CHG skin concentrations.

Methods

We conducted 6 one-day surveys from January 2018 to February 2019 in 7 academic hospital MICUs with established daily CHG bathing. Adults admitted >1 day were assessed for CHG skin levels with a semi-quantitative colorimetric assay using swabbed 25 cm² areas of anterior neck, axilla, and inguinal skin. Prior to survey 4, results from the first 3 surveys (baseline) were reported to ICU leadership and front-line staff to retrain and reeducate on bathing technique. Feedback of results from prior surveys also occurred before surveys 5 and 6. For statistical analysis, mixed-effects models accounted for clustering of CHG measurements within patients and ICUs. We categorized CHG product type as “cloth” for no-rinse 2% CHG-impregnated cloth and “liquid” for 4% CHG liquid or foam.

Results

In total, 681 of 704 (97%) patients were enrolled. Three ICUs used CHG cloth, 3 ICUs used CHG liquid, and 1 ICU switched from liquid to cloth after the second survey. Median CHG skin concentrations were higher in both the baseline and feedback period for institutions using CHG cloth, as compared with liquid (table). Across all time points, axillary and inguinal regions had higher skin CHG concentrations than the neck (median 39.1, 78.1, 19.5 µg/mL, respectively, P < 0.001). After controlling for age, mechanical ventilation, presence of a central venous catheter, body site, and hours since last CHG bath, institutions that used CHG cloth had a 3-fold increase in adjusted CHG skin concentrations in the feedback period compared with the baseline period (P = 0.001, Figure). There was no significant change in CHG skin concentrations from baseline to feedback period for institutions that used liquid CHG.

Conclusion

CHG skin concentrations on MICU patients receiving daily CHG bathing varied by body site and CHG product type. The use of CHG cloth was associated with higher CHG skin levels, compared with CHG liquid. For ICUs using CHG cloth, feedback of CHG skin concentration results to ICU staff improved CHG bathing quality.

Disclosures

All Authors: No reported Disclosures.

213. A Comparison of Medication Assisted Therapy Treatment Strategies for Opioid Use Disorder in Persons who Inject Drugs and are Hospitalized with Serious Infections

Background

Persons who inject drugs (PWID) with opioid use disorder (OUD) are at increased risk of invasive bacterial and fungal infections, which warrant prolonged, inpatient parenteral antimicrobial therapy. Such admissions are complicated by opioid cravings and withdrawal. Comparisons of medications for OUD during prolonged admissions for these patients have not been previously reported. The aim of this study was to evaluate the impact of different OUD treatment strategies in this population, and their impact on ED and hospital readmissions.

Methods

We retrospectively analyzed consecutive admissions for invasive bacterial or fungal infections in PWID, admitted between January 2016 and January 2019 at Barnes-Jewish Hospital. Patients in our cohort were required to receive an infectious diseases consult, and an anticipated antibiotic treatment duration of >2 weeks. We collected data on demographics, comorbidities, length of stay, microbiologic data, medications prescribed for OUD, mortality, and readmission rates. We compared 90-day readmission rates by OUD treatment strategies using Kaplan–Meier curves.

Results

In our cohort of 237 patients, treatment of OUD was buprenorphine (17.5%), methadone (25.3%), or none (56.2%). Among patients receiving OUD treatment, 30% had methadone tapers and/or methadone discontinued upon discharge. Patient demographics were similar for each OUD treatment strategy. Infection with HIV (2.8%), and hepatitis B (3%), and hepatitis C (67%) were similar between groups. Continuation of medications for OUD was associated with increased completion of parenteral antibiotics (odds ratio 2.11; 95% confidence interval 1.70–2.63). When comparing medications for OUD strategies, methadone had the lowest readmission rates, followed by buprenorphine, and no treatment (P = 0.0013) (figure). Discontinuation of methadone during the admission or upon discharge was associated with the highest readmission rates.

Conclusion

Continuation of OUD treatment without tapering, was associated with improved completion of parenteral antimicrobials in PWID with invasive bacterial or fungal infections lower readmission rates. Tapering OUD treatment during admission was associated with higher readmission rates.

Disclosures

All authors: No reported disclosures.

2097. Antimicrobial Stewardship Programs in Missouri Hospitals: Facilitators, Barriers, and Complexity of Implementation

Background

Antibiotic stewardship programs (ASPs) in acute care hospitals reduce unnecessary antibiotic use and attendant complications. In the state of Missouri, all hospitals are required to have an ASP. Additionally, the Joint Commission mandates ASP implementation for accreditation based on core elements defined by the Centers for Disease Control (CDC). No studies have evaluated the uptake of ASP since the Missouri state law and Joint Commission mandate. Furthermore, data are limited examining barriers to implementation across hospitals with variable resources. We evaluated ASP uptake across Missouri hospitals, assessed differences in program complexity, and identified facilitators and barriers to implementation.

Methods

A 94-question survey was administered electronically in the spring of 2019 to 130 Missouri hospitals. Information was collected regarding implementation details of CDC-defined ASP core elements and tools used to overcome implementation barriers. Results were self-reported by the stewardship pharmacist, the director of pharmacy, or the person most familiar with antimicrobial stewardship if the former were not available.

Results

Preliminary results have been collected from 37 hospitals ranging in size from 15 to 1303 beds (IQR: 54, 274). 16% were critical access hospitals. 54% of hospitals had ASPs adherent to all 7 CDC core elements. Another 27% had implemented 6 of the core elements, with all of those reporting that they lacked a single pharmacist leader. All facilities had implemented at least some measures to improve antibiotic use, ranging from 4 to 13 measures. 45% of programs used state-based antimicrobial stewardship collaboratives, and 52% of those found such programs to be “very” or “extremely” useful.

Conclusion

All hospitals surveyed are performing ASP activities in concordance with Missouri state law. However, only half contain the 7 core elements required by the Joint Commission. Furthermore, ASP implementation and activities vary widely. While physician leadership was commonly defined, appropriate pharmacist support was frequently lacking. State-based collaboratives are the most widely used resource, and at least half who use them find them to be helpful.

Disclosures

All authors: No reported disclosures.

Clinical Impact of Revised Cefepime Breakpoint in Patients With Enterobacteriaceae Bacteremia

The impact of the revised Clinical and Laboratory Standards Institute interpretative criteria for cefepime in Enterobacteriaceae remains unclear. We applied the new breakpoint on 644 previously defined cefepime-susceptible Enterobacteriaceae isolates. We found no differences in mortality or microbiological failure, regardless of isolates being susceptible or cefepime-susceptible dose-dependent by current criteria.

Lack of Additional Diagnostic Yield of 16s rRNA Gene PCR for Prosthetic Joint Infections

INTRODUCTION

Medical management of prosthetic joint infections (PJIs) relies on the identification of causative organisms through traditional culture-based approaches to guide therapy. However, diagnosis of many PJIs remains challenging, with many clinically apparent infections remaining culture-negative. Molecular diagnostics have the potential to increase diagnostic yield, particularly among culture-negative PJIs.

METHODS

Bone, tissue, or synovial fluid from patients with clinically identified PJIs were collected for inclusion in this study. Samples were assessed with traditional cultures and classified as culture-positive or -negative after 48 h. Samples subsequently underwent a Staphylococcus aureus-/Kingella kingae-specific PCR followed by a 16s rRNA gene PCR.

RESULTS

A total of 77 unique patients with clinically identified PJIs contributed a total of 89 samples for inclusion in the study. There were 54 culture-negative and 35 culture-positive samples evaluated. The sensitivity and specificity of S. aureus PCR in culture-positive samples was 57.1% (95% CI, 34.1%-78.1%) and 92.9% (95% CI, 66.1%-98.9%), respectively. Among culture-positive samples, 16s rRNA gene PCR correctly identified 3 of 21 (14.3%) samples with S. aureus and 2 of 5 (40%) samples with Streptococcus spp. All molecular tests were negative in those with clinically identified, culture-negative PJI.

CONCLUSIONS

Our study suggests that these diagnostic tools have a limited role in PJI diagnosis.

A Naturalistic Study of Driving Behavior in Older Adults and Preclinical Alzheimer Disease: A Pilot Study

A clinical consequence of symptomatic Alzheimer's disease (AD) is impaired driving performance. However, decline in driving performance may begin in the preclinical stage of AD. We used a naturalistic driving methodology to examine differences in driving behavior over one year in a small sample of cognitively normal older adults with ( n = 10) and without ( n = 10) preclinical AD. As expected with a small sample size, there were no statistically significant differences between the two groups, but older adults with preclinical AD drove less often, were less likely to drive at night, and had fewer aggressive behaviors such as hard braking, speeding, and sudden acceleration. The sample size required to power a larger study to determine differences was calculated.

Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals

IMPORTANCE

Sepsis is present in many hospitalizations that culminate in death. The contribution of sepsis to these deaths, and the extent to which they are preventable, is unknown.

OBJECTIVE

To estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality in acute care hospitals.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study in which a retrospective medical record review was conducted of 568 randomly selected adults admitted to 6 US academic and community hospitals from January 1, 2014, to December 31, 2015, who died in the hospital or were discharged to hospice and not readmitted. Medical records were reviewed from January 1, 2017, to March 31, 2018.

MAIN OUTCOMES AND MEASURES

Clinicians reviewed cases for sepsis during hospitalization using Sepsis-3 criteria, hospice-qualifying criteria on admission, immediate and underlying causes of death, and suboptimal sepsis-related care such as inappropriate or delayed antibiotics, inadequate source control, or other medical errors. The preventability of each sepsis-associated death was rated on a 6-point Likert scale.

RESULTS

The study cohort included 568 patients (289 [50.9%] men; mean [SD] age, 70.5 [16.1] years) who died in the hospital or were discharged to hospice. Sepsis was present in 300 hospitalizations (52.8%; 95% CI, 48.6%-57.0%) and was the immediate cause of death in 198 cases (34.9%; 95% CI, 30.9%-38.9%). The next most common immediate causes of death were progressive cancer (92 [16.2%]) and heart failure (39 [6.9%]). The most common underlying causes of death in patients with sepsis were solid cancer (63 of 300 [21.0%]), chronic heart disease (46 of 300 [15.3%]), hematologic cancer (31 of 300 [10.3%]), dementia (29 of 300 [9.7%]), and chronic lung disease (27 of 300 [9.0%]). Hospice-qualifying conditions were present on admission in 121 of 300 sepsis-associated deaths (40.3%; 95% CI 34.7%-46.1%), most commonly end-stage cancer. Suboptimal care, most commonly delays in antibiotics, was identified in 68 of 300 sepsis-associated deaths (22.7%). However, only 11 sepsis-associated deaths (3.7%) were judged definitely or moderately likely preventable; another 25 sepsis-associated deaths (8.3%) were considered possibly preventable.

CONCLUSIONS AND RELEVANCE

In this cohort from 6 US hospitals, sepsis was the most common immediate cause of death. However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved.

2123. High Utilization of Post-Discharge Antibiotics After Mastectomy in a Nationwide Cohort of Commercially Insured Women

Background

Methods

Results

Conclusion

Disclosures

1659. Variation in Identifying Sepsis and Organ Dysfunction Using Administrative Versus Clinical Data and Impact on Hospital Outcome Comparisons

Background

Administrative claims data are commonly used for sepsis surveillance, research, and quality improvement. However, variations in diagnosis, documentation, and coding practices may confound efforts to benchmark hospital sepsis outcomes using claims data.

Methods

We evaluated the sensitivity of claims data for sepsis and organ dysfunction relative to clinical data from the electronic health records of 193 US hospitals. Sepsis was defined clinically using markers of presumed infection (blood cultures and antibiotic administrations) and concurrent organ dysfunction. Organ dysfunction was measured using laboratory data (acute kidney injury, thrombocytopenia, hepatic injury), vasopressor administrations (shock), or mechanical ventilation (respiratory failure). Correlations between hospitals’ sepsis incidence and mortality rates by claims (using “explicit” ICD-9-CM codes for severe sepsis or septic shock) versus clinical data were measured by the Pearson correlation coefficient (r) and relative hospital rankings using either data source were compared. All estimates were reliability-adjusted to account for random variation using hierarchical logistic regression modeling.

Results

The study cohort included 4.3 million adult hospitalizations in 2013 or 2014. The sensitivity of hospitals’ claims data for sepsis and organ dysfunction was low and variable: median sensitivity 30% (range 5–54%) for sepsis, 66% (range 26–84%) for acute kidney injury, 39% (range 16–60%) for thrombocytopenia, 36% (range 29–44%) for hepatic injury, and 66% (range 29–84%) for shock (Figure 1). There was only moderate correlation between claims and clinical data for hospitals’ sepsis incidence (r = 0.64) and mortality rates (r = 0.61), and relative hospital rankings for sepsis mortality differed substantially using either method (Figure 2). Of 48 (46%) hospitals, 22 ranked in the lowest sepsis mortality quartile by claims shifted to higher mortality quartiles using clinical data.

Conclusion

Variation in the completeness and accuracy of claims data for identifying sepsis and organ dysfunction limits their use for comparing hospital sepsis rates and outcomes. Sepsis surveillance using objective clinical data may facilitate more meaningful hospital comparisons.

Disclosures

All authors: No reported disclosures.

110. The Burden and Preventability of Sepsis-Associated Mortality in 6 US Acute Care Hospitals

Background

Sepsis is considered a leading cause of preventable death, but the actual burden of sepsis mortality is difficult to measure using administrative data or death certificates. We analyzed the prevalence, underlying causes, and preventability of deaths due to sepsis in acute care hospitals using detailed medical record reviews.

Methods

We randomly selected 577 adult patients who died in-hospital or were discharged to hospice in 2014–2015 at 6 US academic and community hospitals for medical record review. Cases were reviewed by experienced clinicians for sepsis during hospitalization (using Sepsis-3 criteria), terminal conditions on admission (defined using hospice-qualifying criteria), immediate and underlying causes of death, and suboptimal sepsis care (delays in antibiotics, inappropriate antibiotic therapy, inadequate source control, or other medical errors). The overall preventability of death was rated on a 6-point Likert scale (from definitely not preventable to definitely preventable) taking into account comorbidities, severity of illness, and quality of care.

Results

Sepsis was present in 302/577 (52%) hospitalizations ending in death or discharge to hospice and was the immediate cause of death in 199 cases (35%) (Figure 1A). Underlying causes of death in sepsis patients included solid cancer (21%) and chronic heart disease (15%), and hematologic cancer (10%) (Figure 1B). The median age of sepsis patients who died was 73 (IQR 62–84). Terminal conditions were present in 122/302 (40%) sepsis deaths, most commonly end-stage cancer (26% of cases). Suboptimal care was identified in 68 (23%) of sepsis deaths, most commonly delays in antibiotics (11% of cases). However, only 4% of sepsis deaths were definitely or likely preventable and an additional 8% were considered possibly preventable with optimal clinical care (Figures 2 and 3).

Conclusion

Our findings affirm that sepsis is the most common cause of death in hospitalized patients. Most patients that died with sepsis were elderly with severe comorbidities, but up to 1 in 8 sepsis deaths were felt to be potentially preventable with better hospital-based care. These findings may inform resource allocation and expectations surrounding the impact of hospital-based sepsis treatment initiatives.

Disclosures

All authors: No reported disclosures.

Compliance With the National SEP-1 Quality Measure and Association With Sepsis Outcomes: A Multicenter Retrospective Cohort Study

OBJECTIVES

Many septic patients receive care that fails the Centers for Medicare and Medicaid Services' SEP-1 measure, but it is unclear whether this reflects meaningful lapses in care, differences in clinical characteristics, or excessive rigidity of the "all-or-nothing" measure. We compared outcomes in cases that passed versus failed SEP-1 during the first 2 years after the measure was implemented.

DESIGN

Retrospective cohort study.

SETTING

Seven U.S. hospitals.

PATIENTS

Adult patients included in SEP-1 reporting between October 2015 and September 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 851 sepsis cases in the cohort, 281 (33%) passed SEP-1 and 570 (67%) failed. SEP-1 failures had higher rates of septic shock (20% vs 9%; p < 0.001), hospital-onset sepsis (11% vs 4%; p = 0.001), and vague presenting symptoms (46% vs 30%; p < 0.001). The most common reasons for failure were omission of 3- and 6-hour lactate measurements (228/570 failures, 40%). Only 86 of 570 failures (15.1%) had greater than 3-hour delays until broad-spectrum antibiotics. Cases that failed SEP-1 had higher in-hospital mortality rates (18.4% vs 11.0%; odds ratio, 1.82; 95% CI, 1.19-2.80; p = 0.006), but this association was no longer significant after adjusting for differences in clinical characteristics and severity of illness (adjusted odds ratio, 1.36; 95% CI, 0.85-2.18; p = 0.205). Delays of greater than 3 hours until antibiotics were significantly associated with death (adjusted odds ratio, 1.94; 95% CI, 1.04-3.62; p = 0.038), whereas failing SEP-1 for any other reason was not (adjusted odds ratio, 1.10; 95% CI, 0.70-1.72; p = 0.674).

CONCLUSIONS

Crude mortality rates were higher in sepsis cases that failed versus passed SEP-1, but there was no difference after adjusting for clinical characteristics and severity of illness. Delays in antibiotic administration were associated with higher mortality but only accounted for a small fraction of SEP-1 failures. SEP-1 may not clearly differentiate between high- and low-quality care, and detailed risk adjustment is necessary to properly interpret associations between SEP-1 compliance and mortality.

Inadequate empiric antimicrobial therapy and mortality in geriatric patients with bloodstream infection: A target for antimicrobial stewardship

BACKGROUND

Bloodstream infections are responsible for a large proportion of deaths among geriatric patients. Japan is a rapidly aging society; however, little is known about the epidemiology of bloodstream infections in geriatric patients in Japanese institutions.

METHODS

We conducted a retrospective cohort study of patients aged ≥65 years old with a bloodstream infection in a Japanese tertiary care hospital in 2013. We defined inadequate empiric antimicrobial therapy as either antimicrobial treatment that was ineffective against subsequently isolated organisms or treatment initiated after notification of a positive culture. Predictors of inadequate antimicrobial therapy and 30-day mortality among geriatric patients with bloodstream infections were evaluated.

RESULTS

We identified 275 patients with a bloodstream infection, of which 42.2% of cases (116/275) were healthcare-associated, hospital-onset. The most common source of bloodstream infection was hepatobiliary (28.0%). Inadequate empiric antimicrobial therapy occurred in 29.8% of the patients. Factors associated with inadequate empiric therapy included a history of surgery prior to bloodstream infection during index hospitalization (adjusted odds ratio [aOR] 3.27; 95% confidence interval [CI] 1.18-9.12). In 275 patients, 38 (13.8%) died within 30 days after the first positive blood culture. Predictors of 30-day mortality was Pitt bacteremia score >6 (aOR 9.80; 95% CI 4.72-20.36).

CONCLUSION

Inadequate empiric antimicrobial therapy occurred in approximately one-third of episodes of bloodstream infection in geriatric patients. Severity at the time of bloodstream infection was likely to have contributed to mortality. The initiation of adequate empiric antimicrobial therapy may have important implications for antimicrobial stewardship even in the elderly population.

Impact of order set design on urine culturing practices at an academic medical centre emergency department

BACKGROUND

Urinalysis and urine culture are commonly ordered tests in the emergency department (ED). We evaluated the impact of removal of order sets from the 'frequently ordered test' in the computerised physician order entry system (CPOE) on urine testing practices.

METHODS

We conducted a before (1 September to 20 October 2015) and after (21 October to 30 November 2015) study of ED patients. The intervention consisted of retaining 'urinalysis with reflex to microscopy' as the only urine test in a highly accessible list of frequently ordered tests in the CPOE system. All other urine tests required use of additional order screens via additional mouse clicks. The frequency of urine testing before and after the intervention was compared, adjusting for temporal trends.

RESULTS

During the study period, 6499 (28.2%) of 22 948 ED patients had ≥1 urine test ordered. Urine testing rates for all ED patients decreased in the post intervention period for urinalysis (291.5 pre intervention vs 278.4 per 1000 ED visits post intervention, P=0.03), urine microscopy (196.5vs179.5, P=0.001) and urine culture (54.3vs29.7, P<0.001). When adjusted for temporal trends, the daily culture rate per 1000 ED visits decreased by 46.6% (-46.6%, 95% CI -66.2% to -15.6%), but urinalysis (0.4%, 95% CI -30.1 to 44.4%), microscopy (-6.5%, 95% CI -36.0% to 36.6%) and catheterised urine culture rates (17.9%, 95% CI -16.9 to 67.4) were unchanged.

CONCLUSIONS

A simple intervention of retaining only 'urinalysis with reflex to microscopy' and removing all other urine tests from the 'frequently ordered' window of the ED electronic order set decreased urine cultures ordered by 46.6% after accounting for temporal trends. Given the injudicious use of antimicrobial therapy for asymptomatic bacteriuria, findings from our study suggest that proper design of electronic order sets plays a vital role in reducing excessive ordering of urine cultures.

Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014

IMPORTANCE

Estimates from claims-based analyses suggest that the incidence of sepsis is increasing and mortality rates from sepsis are decreasing. However, estimates from claims data may lack clinical fidelity and can be affected by changing diagnosis and coding practices over time.

OBJECTIVE

To estimate the US national incidence of sepsis and trends using detailed clinical data from the electronic health record (EHR) systems of diverse hospitals.

DESIGN, SETTING, AND POPULATION

Retrospective cohort study of adult patients admitted to 409 academic, community, and federal hospitals from 2009-2014.

EXPOSURES

Sepsis was identified using clinical indicators of presumed infection and concurrent acute organ dysfunction, adapting Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria for objective and consistent EHR-based surveillance.

MAIN OUTCOMES AND MEASURES

Sepsis incidence, outcomes, and trends from 2009-2014 were calculated using regression models and compared with claims-based estimates using International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe sepsis or septic shock. Case-finding criteria were validated against Sepsis-3 criteria using medical record reviews.

RESULTS

A total of 173 690 sepsis cases (mean age, 66.5 [SD, 15.5] y; 77 660 [42.4%] women) were identified using clinical criteria among 2 901 019 adults admitted to study hospitals in 2014 (6.0% incidence). Of these, 26 061 (15.0%) died in the hospital and 10 731 (6.2%) were discharged to hospice. From 2009-2014, sepsis incidence using clinical criteria was stable (+0.6% relative change/y [95% CI, -2.3% to 3.5%], P = .67) whereas incidence per claims increased (+10.3%/y [95% CI, 7.2% to 13.3%], P < .001). In-hospital mortality using clinical criteria declined (-3.3%/y [95% CI, -5.6% to -1.0%], P = .004), but there was no significant change in the combined outcome of death or discharge to hospice (-1.3%/y [95% CI, -3.2% to 0.6%], P = .19). In contrast, mortality using claims declined significantly (-7.0%/y [95% CI, -8.8% to -5.2%], P < .001), as did death or discharge to hospice (-4.5%/y [95% CI, -6.1% to -2.8%], P < .001). Clinical criteria were more sensitive in identifying sepsis than claims (69.7% [95% CI, 52.9% to 92.0%] vs 32.3% [95% CI, 24.4% to 43.0%], P < .001), with comparable positive predictive value (70.4% [95% CI, 64.0% to 76.8%] vs 75.2% [95% CI, 69.8% to 80.6%], P = .23).

CONCLUSIONS AND RELEVANCE

In clinical data from 409 hospitals, sepsis was present in 6% of adult hospitalizations, and in contrast to claims-based analyses, neither the incidence of sepsis nor the combined outcome of death or discharge to hospice changed significantly between 2009-2014. The findings also suggest that EHR-based clinical data provide more objective estimates than claims-based data for sepsis surveillance.