Myelin Oligodendrocyte Glycoprotein Antibody Disease Optic Neuritis: A Structure-Function Paradox?

BACKGROUND

Myelin oligodendrocyte glycoprotein antibody disease (MOGAD) is a demyelinating disorder that most commonly presents with optic neuritis (ON) and affects children more often than adults. We report 8 pediatric patients with MOG-associated ON and characterize focal optical coherence tomography (OCT) abnormalities over time that help distinguish this condition from the trajectories of other demyelinating disorders. These OCT findings are examined in the context of longitudinal visual function testing.

METHODS

This is a retrospective case series of 8 pediatric patients with MOG-associated ON who were referred for neuro-ophthalmic evaluation. Longitudinal data for demographics, clinical history, physical examination, and OCT obtained in the course of clinical evaluations were collected through retrospective medical record review.

RESULTS

Patients demonstrated acute peripapillary retinal nerve fiber layer (RNFL) thickening in one or both eyes, consistent with optic disc swelling. This was followed by steady patterns of average RNFL thinning, with 9 of 16 eyes reaching significantly low RNFL thickness using OCT platform reference databases ( P < 0.01), accompanied by paradoxical recovery of high-contrast visual acuity (HCVA) in every patient. There was no correlation between HCVA and any OCT measures, although contrast sensitivity (CS) was associated with global thickness, PMB thickness, and nasal/temporal (N/T) ratio, and color vision was associated with PMB thickness. There was a lower global and papillomacular bundle (PMB) thickness ( P < 0.01) in clinically affected eyes compared with unaffected eyes. There was also a significantly higher N:T ratio in clinically affected eyes compared with unaffected eyes in the acute MOG-ON setting ( P = 0.03), but not in the long-term setting.

CONCLUSIONS

MOG shows a pattern of prominent retinal atrophy, as demonstrated by global RNFL thinning, with remarkable preservation of HCVA but remaining deficits in CS and color vision. These tests may be better clinical markers of vision changes secondary to MOG-ON. Of the OCT parameters measured, PMB thickness demonstrated the most consistent correlation between structural and functional measures. Thus, it may be a more sensitive marker of clinically significant retinal atrophy in MOG-ON. The N:T ratio in acute clinically affected MOG-ON eyes in our study was higher than the N:T ratio of neuromyelitis optica (NMO)-ON eyes and similar to the N:T ratio in multiple sclerosis (MS)-ON eyes as presented in the prior literature. Therefore, MOG may share a more similar pathophysiology to MS compared with NMO.

Racial/Ethnic Differences in Long-COVID-Associated Symptoms among Pediatrics Population: Findings from Difference-in-differences Analyses in RECOVER Program

Racial/ethnic differences are associated with the potential symptoms and conditions of post-acute sequelae SARS-CoV-2 infection (PASC) in adults. These differences may exist among children and warrant further exploration. We conducted a retrospective cohort study for children and adolescents under the age of 21 from the thirteen institutions in the RECOVER Initiative. The cohort is 225,723 patients with SARS-CoV-2 infection or COVID-19 diagnosis and 677,448 patients without SARS-CoV-2 infection or COVID-19 diagnosis between March 2020 and October 2022. The study compared minor racial/ethnic groups to Non-Hispanic White (NHW) individuals, stratified by severity during the acute phase of COVID-19. Within the severe group, Asian American/Pacific Islanders (AAPI) had a higher prevalence of fever/chills and respiratory symptoms, Hispanic patients showed greater hair loss prevalence in severe COVID-19 cases, while Non-Hispanic Black (NHB) patients had fewer skin symptoms in comparison to NHW patients. Within the non-severe group, AAPI patients had increased POTS/dysautonomia and respiratory symptoms, and NHB patients showed more cognitive symptoms than NHW patients. In conclusion, racial/ethnic differences related to COVID-19 exist among specific PASC symptoms and conditions in pediatrics, and these differences are associated with the severity of illness during acute COVID-19.

Diagnostic value of intereye difference metrics for optic neuritis in aquaporin-4 antibody seropositive neuromyelitis optica spectrum disorders

BACKGROUND

The novel optic neuritis (ON) diagnostic criteria include intereye differences (IED) of optical coherence tomography (OCT) parameters. IED has proven valuable for ON diagnosis in multiple sclerosis but has not been evaluated in aquaporin-4 antibody seropositive neuromyelitis optica spectrum disorders (AQP4+NMOSD). We evaluated the diagnostic accuracy of intereye absolute (IEAD) and percentage difference (IEPD) in AQP4+NMOSD after unilateral ON >6 months before OCT as compared with healthy controls (HC).

METHODS

Twenty-eight AQP4+NMOSD after unilateral ON (NMOSD-ON), 62 HC and 45 AQP4+NMOSD without ON history (NMOSD-NON) were recruited by 13 centres as part of the international Collaborative Retrospective Study on retinal OCT in Neuromyelitis Optica study. Mean thickness of peripapillary retinal nerve fibre layer (pRNFL) and macular ganglion cell and inner plexiform layer (GCIPL) were quantified by Spectralis spectral domain OCT. Threshold values of the ON diagnostic criteria (pRNFL: IEAD 5 µm, IEPD 5%; GCIPL: IEAD: 4 µm, IEPD: 4%) were evaluated using receiver operating characteristics and area under the curve (AUC) metrics.

RESULTS

The discriminative power was high for NMOSD-ON versus HC for IEAD (pRNFL: AUC 0.95, specificity 82%, sensitivity 86%; GCIPL: AUC 0.93, specificity 98%, sensitivity 75%) and IEPD (pRNFL: AUC 0.96, specificity 87%, sensitivity 89%; GCIPL: AUC 0.94, specificity 96%, sensitivity 82%). The discriminative power was high/moderate for NMOSD-ON versus NMOSD-NON for IEAD (pRNFL: AUC 0.92, specificity 77%, sensitivity 86%; GCIP: AUC 0.87, specificity 85%, sensitivity 75%) and for IEPD (pRNFL: AUC 0.94, specificity 82%, sensitivity 89%; GCIP: AUC 0.88, specificity 82%, sensitivity 82%).

CONCLUSIONS

Results support the validation of the IED metrics as OCT parameters of the novel diagnostic ON criteria in AQP4+NMOSD.

Where's the Vision? The Importance of Visual Outcomes in Neurologic Disorders: The 2021 H. Houston Merritt Lecture

Neurologists have long recognized the importance of the visual system in the diagnosis and monitoring of neurologic disorders. This is particularly true because approximately 50% of the brain's pathways subserve afferent and efferent aspects of vision. During the past 30 years, researchers and clinicians have further refined this concept to include investigation of the visual system for patients with specific neurologic diagnoses, including multiple sclerosis (MS), concussion, Parkinson disease (PD), and conditions along the spectrum of Alzheimer disease (AD, mild cognitive impairment, and subjective cognitive decline). This review highlights the visual "toolbox" that has been developed over the past 3 decades and beyond to capture both structural and functional aspects of vision in neurologic disease. Although the efforts to accelerate the emphasis on structure-function relationships in neurologic disorders began with MS during the early 2000s, such investigations have broadened to recognize the need for outcomes of visual pathway structure, function, and quality of life for clinical trials of therapies across the spectrum of neurologic disorders. This review begins with a patient case study highlighting the importance using the most modern technologies for visual pathway assessment, including optical coherence tomography. We emphasize that both structural and functional tools for vision testing can be used in parallel to detect what might otherwise be subclinical events or markers of visual and, perhaps, more global neurologic decline. Such measures will be critical because clinical trials and therapies become more available across the neurologic disease spectrum.

Normative Data and Conversion Equation for Spectral-Domain Optical Coherence Tomography in an International Healthy Control Cohort

BACKGROUND

Spectral-domain (SD-) optical coherence tomography (OCT) can reliably measure axonal (peripapillary retinal nerve fiber layer [pRNFL]) and neuronal (macular ganglion cell + inner plexiform layer [GCIPL]) thinning in the retina. Measurements from 2 commonly used SD-OCT devices are often pooled together in multiple sclerosis (MS) studies and clinical trials despite software and segmentation algorithm differences; however, individual pRNFL and GCIPL thickness measurements are not interchangeable between devices. In some circumstances, such as in the absence of a consistent OCT segmentation algorithm across platforms, a conversion equation to transform measurements between devices may be useful to facilitate pooling of data. The availability of normative data for SD-OCT measurements is limited by the lack of a large representative world-wide sample across various ages and ethnicities. Larger international studies that evaluate the effects of age, sex, and race/ethnicity on SD-OCT measurements in healthy control participants are needed to provide normative values that reflect these demographic subgroups to provide comparisons to MS retinal degeneration.

METHODS

Participants were part of an 11-site collaboration within the International Multiple Sclerosis Visual System (IMSVISUAL) consortium. SD-OCT was performed by a trained technician for healthy control subjects using Spectralis or Cirrus SD-OCT devices. Peripapillary pRNFL and GCIPL thicknesses were measured on one or both devices. Automated segmentation protocols, in conjunction with manual inspection and correction of lines delineating retinal layers, were used. A conversion equation was developed using structural equation modeling, accounting for clustering, with healthy control data from one site where participants were scanned on both devices on the same day. Normative values were evaluated, with the entire cohort, for pRNFL and GCIPL thicknesses for each decade of age, by sex, and across racial groups using generalized estimating equation (GEE) models, accounting for clustering and adjusting for within-patient, intereye correlations. Change-point analyses were performed to determine at what age pRNFL and GCIPL thicknesses exhibit accelerated rates of decline.

RESULTS

The healthy control cohort (n = 546) was 54% male and had a wide distribution of ages, ranging from 18 to 87 years, with a mean (SD) age of 39.3 (14.6) years. Based on 346 control participants at a single site, the conversion equation for pRNFL was Cirrus = -5.0 + (1.0 × Spectralis global value). Based on 228 controls, the equation for GCIPL was Cirrus = -4.5 + (0.9 × Spectralis global value). Standard error was 0.02 for both equations. After the age of 40 years, there was a decline of -2.4 μm per decade in pRNFL thickness ( P < 0.001, GEE models adjusting for sex, race, and country) and -1.4 μm per decade in GCIPL thickness ( P < 0.001). There was a small difference in pRNFL thickness based on sex, with female participants having slightly higher thickness (2.6 μm, P = 0.003). There was no association between GCIPL thickness and sex. Likewise, there was no association between race/ethnicity and pRNFL or GCIPL thicknesses.

CONCLUSIONS

A conversion factor may be required when using data that are derived between different SD-OCT platforms in clinical trials and observational studies; this is particularly true for smaller cross-sectional studies or when a consistent segmentation algorithm is not available. The above conversion equations can be used when pooling data from Spectralis and Cirrus SD-OCT devices for pRNFL and GCIPL thicknesses. A faster decline in retinal thickness may occur after the age of 40 years, even in the absence of significant differences across racial groups.

Evaluation of pharmacist time dedicated to vancomycin dosing in adult patients using a 24-hour AUC nomogram or trough monitoring approach: A time motion study

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Evidence-based guideline recommendations for vancomycin dosing recently shifted from a trough-based strategy to an area under the curve (AUC) approach. While several AUC dosing methods exist, the optimal approach has not been determined. Literature characterizing time requirements for various vancomycin dosing strategies remains limited.

METHODS

A time and motion study was conducted to measure the time spent by clinical pharmacists dosing vancomycin using an AUC nomogram. Pharmacists who dosed and monitored vancomycin for adult patients on the general medical ward (GMW) or intensive care unit (ICU) of a large academic medical center consented to study participation. Vulnerable patients and vancomycin orders for surgical infection prophylaxis were excluded. The primary outcome was the median amount of time clinical pharmacists dedicated to vancomycin-related clinical activities during an 8-hour weekday shift. Secondary outcomes included the proportion of patients prescribed vancomycin at the beginning of each shift and factors contributing to greater than average time spent on vancomycin-related responsibilities.

RESULTS

Seven clinical pharmacists collected data on 178 vancomycin orders. The estimated amount of time a clinical pharmacist spent on daily vancomycin responsibilities averaged 10.45 minutes (interquartile range [IQR], 6.94-15.8 minutes). The overall median time requirement per vancomycin assessment was 3.45 minutes (IQR, 1.95-6.7 minutes). The only factor independently associated with prolonged dosing time was follow-up dosing from a previous day.

CONCLUSION

The study elucidated time requirements associated with an AUC nomogram-based vancomycin dosing approach. This data could be used to compare time requirements associated with other existing vancomycin dosing strategies, which may help healthcare systems determine the optimal AUC dosing method for their specific practice model.

Low- Versus High-Dose Methylprednisolone in Adult Patients With Coronavirus Disease 2019: Less Is More

Background

Corticosteroids use in severe coronavirus disease 2019 (COVID-19) improves survival; however, the optimal dose is not established. We aim to evaluate clinical outcomes in patients with severe COVID-19 receiving high-dose corticosteroids (HDC) versus low-dose corticosteroids (LDC).

Methods

This was a quasi-experimental study conducted at a large, quaternary care center in Michigan. A corticosteroid dose change was implemented in the standardized institutional treatment protocol on November 17, 2020. All patients admitted with severe COVID-19 that received corticosteroids were included. Consecutive patients in the HDC group (September 1 to November 15, 2020) were compared to the LDC group (November 30, 2020 to January 20, 2021). High-dose corticosteroids was defined as 80 mg of methylprednisolone daily in 2 divided doses, and LDC was defined as 32–40 mg of methylprednisolone daily in 2 divided doses. The primary outcome was all-cause 28-day mortality. Secondary outcomes included progression to mechanical ventilation, hospital length of stay (LOS), discharge on supplemental oxygen, and corticosteroid-associated adverse events.

Results

Four-hundred seventy patients were included: 218 (46%) and 252 (54%) in the HDC and LDC groups, respectively. No difference was observed in 28-day mortality (14.5% vs 13.5%, P = .712). This finding remained intact when controlling for additional variables (odds ratio, 0.947; confidence interval, 0.515–1.742; P = .861). Median hospital LOS was 6 and 5 days in the HDC and LDC groups, respectively (P < .001). No differences were noted in any of the other secondary outcomes.

Conclusions

Low-dose methylprednisolone had comparable outcomes including mortality to high-dose methylprednisolone for the treatment of severe COVID-19.

147. Antibiotic Prescribing: Shorter is Also Better in the Emergency Department

Background

Published information suggests room for improvement in antibiotics prescribed on discharge from the emergency department (ED). The objective of this study was to evaluate antibiotic prescribing in the ED for uncomplicated infections of the lower respiratory tract (LRTI), urinary tract (UTI), and skin and skin structure (SSTI).

Methods

IRB-approved retrospective cross-sectional study of patients discharged from the ED from January to June 2019 at 6 locations. Inclusion: ≥ 18 years old and uncomplicated LRTI, UTI, or SSTI. Exclusion: hospital admission. Appropriate prescribing was defined having all three of the following correct per local and national guidelines: antibiotic selection, dose, and duration. Correct duration: 5 days for LRTI and SSTI; 3 days for trimethoprim-sulfamethoxazole (TMP-SMX), 5 days for nitrofurantoin (NFT), and 7 days for beta-lactams for UTIs. Endpoints within 7 days: antibiotic escalation, readmission to ED or hospital, any outpatient contact, and report of adverse drug event (ADE). Endpoints within 90 days: Clostridioides difficile infection (CDI). Descriptive and bivariable statistics were performed.

Results

Inappropriate prescribing: 77% (304) vs. appropriate 23% (89). Infection type: 47.8% SSTI, 30% UTI, and 22.1% LRTI. SSTI was associated with the greatest proportion of inappropriate prescribing at 89.4% (Figure 1). Comparisons for inappropriate vs. appropriate groups: 15.8% vs. 22.5% for beta-lactam allergy and 23.4% vs. 19.1% for cultures drawn in ED. Most common antibiotics for inappropriate vs. appropriate: first generation cephalosporin at 70.1% vs. 7.3% (p< 0.05), TMP-SMX at 14.3% vs. 12.2% (p=0.75), and NFT at 7.8% vs. 65.9% (p< 0.05). Prescriptions considered inappropriate were primarily driven by excess duration (Figure 2). Endpoints for inappropriate vs. appropriate groups: antibiotic escalation at 6.6% (2.8% were due to cultures drawn in the ED) vs. 1.1% (p=0.06), readmission at 8.6% vs. 9.0% (p=0.9), any outpatient contact at 18.4% vs. 19.1% (p=0.89), and report of ADE at 1.3% vs. 1.1%. No CDI in either group.

Figure 1. Appropriateness of Discharge Prescriptions by Infection Type, N = 393

Figure 2. Subset Analysis: Reasons for Inappropriate Prescribing, n = 304

Conclusion

The main reason for inappropriate prescribing in the ED was excess duration of therapy, making this an area of opportunity for future antibiotic stewardship improvement.

Disclosures

Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder) Susan L. Davis, PharmD, Nothing to disclose

753. Impact of COVID-19 on Healthcare Facility-Onset Clostridiodes difficile Infection

Background

It is estimated that the majority of hospitalized COVID-19 patients around the world received antibiotics despite the fact that bacterial co-infections are rare. This can lead to increased antimicrobial resistance and Clostridioides difficile infections (CDI). Gastrointestinal symptoms of COVID-19 may also contribute to increased testing. The objective of this study was to assess the impact of the COVID-19 pandemic on our healthcare facility-onset (HO) CDI rates.

Methods

This was a retrospective cross-sectional study comparing CDI rate per 1,000 patient days, C. diff order rate per 1,000 patient days, Standardized Antimicrobial Administration Ratio (SAAR), and Standardized Infection Ratio (SIR) in the pre-COVID-19 period from January 1, 2019 to December 31, 2019 to the COVID-19 period from April 1, 2020 to March 31, 2021 at a 877-bed tertiary care hospital in Detroit, Michigan. CDI and order rates were extracted from the electronic medical record (Epic™ Bugsy). SAAR and SIR data were extracted from National Healthcare Safety Network (NHSN).

Results

The average CDI rate per 1,000 patient days was 4.29 pre-COVID-19 compared to 1.98 during COVID-19 with a 54% reduction, and the C. diff order rate per 1,000 patient days also decreased from 130.89 to 93.03, resulting in a 29% reduction (Figure 1). The SIR was 0.383 compared to 0.308 during COVID-19 (P-value 0.404). SAAR decreased from 1.095 to 0.945 (P-value < 0.001). However, our institution experienced three COVID-19 waves, with peaks in April 2020, November 2020 and March 2021, that correlated with high risk CDI antibiotic utilization in intensive care unit (ICU) (Figure 2). The average hand hygiene rate increased from 82% to 92%.

Figure 1. Clostridioides difficile order and infection rates pre-and during COVID-19 pandemic.

Figure 2. Standardized Antimicrobial Administration Ratio (SAAR) pre-and during COVID-19 pandemic.

Conclusion

Despite the COVID-19 pandemic, the HO-CDI and C. diff order rates and overall SAAR decreased; however, antibiotic utilization increased in the ICU during the COVID-19 waves. The overall decrease may be multifactorial and related to increased hand hygiene compliance, isolation and personal protective equipment use and overall decreased antibiotic use and C. diff orders.

Disclosures

Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

157. Impact of Pharmacist-Generated Oral Antimicrobial Test Prescription on Discharge Medication Access and Outcome

Background

Cost barriers to accessing discharge oral antimicrobials (ABX) may delay discharges and result in suboptimal discharge ABX. Use of electronic test prescriptions (eTP) or “price checks” is controversial due to potential for erroneous dispensing. This study evaluated discharge ABX access and outcome after implementation of a standardized, inpatient pharmacist-initiated ABX eTP process in collaboration with discharge pharmacy.

Methods

IRB approved, retrospective, cross-sectional cohort pilot-study. Inclusion: home bound adults admitted for ≥ 72 hours from 1/1/18-2/28/19 and discharged on oral ABX. Patients with an ABX eTP prior to discharge were compared to those discharged on ABX but no eTP. Data were reported using descriptive statistics and bivariate analysis. Primary endpoint: discharge delay after medical stability. Secondary endpoints: medication access, unplanned encounters, and % of patients discharged on first-line ABX.

Results

84 patients included: 43 no-ETP and 41 eTP. 75 ABX eTP evaluated among 41 patients. Patients in the no-eTP group had higher Charlson comorbidity index (P = 0.004) and immunosuppression (24% vs. 12%; P = 0.014). Median length of stay, days: 6 (5 – 9) eTP vs. 8 (5 – 15) no-eTP (P = 0.026). Most common eTP requested by pharmacist: linezolid (17, 23%) and oral vancomycin (12, 16%) (Figure 1). eTP results were documented in the medical record in &lt; 24 hours for 66 (88%) of inquiries. 49 (65%) prescriptions were approved by insurance; 16 (21%) had no out of pocket cost and 8 (11%) required prior authorization (PA) (Table 1). Linezolid (5, 35%) and public insurance (10, 71%) were frequently associated with barriers. 29 (70%) patients were discharged on the same ABX as the eTP. There were no discharge delays or erroneous dispensing. 14 (33%) no-eTP and 15 (37%) eTP patients experienced unplanned healthcare encounters after discharge. 9/84 (11%) patients were discharged on suboptimal ABX. Non-white race 8/9 (89%) P = 0.047 and public insurance 8/9 (89%) P = 0.063 were associated with suboptimal discharge ABX.

Figure 1. Oral Antimicrobial Test Prescription Pattern (n=75)

Conclusion

A standardized eTP process appears to be a safe way to evaluate out of pocket cost without prolonging length of stay. Future work will focus on inequity in access to first line ABX.

Disclosures

Susan L. Davis, PharmD, Nothing to disclose Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

98. Outcomes of Clinical Decision Support for Outpatient Management of Clostridioides difficile Infection

Background

Our antimicrobial stewardship program identified high rates of suboptimal metronidazole prescribing for Clostridioides difficile infection (CDI) within ambulatory clinics. An outpatient best practice advisory (BPA) was implemented to notify prescribers “Vancomycin or fidaxomicin are preferred over metronidazole for C.difficile infection” when metronidazole was prescribed to a patient with CDI.

Methods

We conducted an IRB approved quasi-experiment before and after implementation of the BPA on June 3, 2020. Inclusion: Adult patients diagnosed with and treated for a first episode of symptomatic CDI at an ambulatory clinic between 11/1/2019 and 11/30/2020. Exclusion: fulminant CDI. Primary endpoint: guideline-concordant CDI therapy, defined as oral vancomycin or fidaxomicin. Oral metronidazole was considered guideline-concordant if prescribed due to cost barrier. Secondary endpoints: reasons for alternative CDI therapy, patient outcomes, prescriber response to the BPA. Descriptive and bivariate analyses were completed.

Results

189 patients were included in the study, 92 before and 97 after the BPA. Median age: 59 years, 31% male, 75% Caucasian, 30% with CDI-related comorbidities, 35% with healthcare exposure, 65% with antibiotic exposure, 44% with gastric acid suppression therapy within 90 days of CDI diagnosis. The BPA was accepted 23 out of 26 times and optimized the therapy of 16 patients in six months. Guideline-concordant therapy increased after implementation of the BPA (72% vs. 91%, p=0.001) (Figure 1). Vancomycin prescribing increased and metronidazole prescribing decreased after the BPA (Figure 2). Reasons for alternative CDI therapy included medication cost, lack of insurance coverage, and non-CDI infection. There was no difference in clinical response or unplanned encounter within 14 days after treatment initiation. Fewer patients after the BPA had CDI recurrence within 14-56 days of the initial episode (27% vs. 7%, p< 0.001).

Figure 1. Guideline-concordant CDI therapy

Figure 2. Specific CDI therapy

Conclusion

Clinical decision support increased prescribing of guideline-concordant CDI therapy in the outpatient setting. A targeted BPA is an effective stewardship intervention and may be especially useful in settings with limited antimicrobial stewardship resources.

Disclosures

Susan L. Davis, PharmD, Nothing to disclose Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

62. Secondary Prophylaxis in Clostridioides difficile Infections: a Closer Look at Outcomes

Background

Clostridioides difficile infection (CDI) is an urgent public threat and carries a 25% chance of recurrence (rCDI). Data on safety and efficacy of oral vancomycin prophylaxis (OVP) in reducing rCDI is limited. We implemented a best practice advisory (BPA) to alert the prescriber and antibiotic stewardship (ASP) team for patients with CDI in the previous 60 days being initiated on systemic antimicrobials. The alert states “Don’t use antibiotics in patients with recent CDI without convincing evidence of need. Antibiotics pose a high risk of recurrence”. ASP team would recommended OVP if antibiotics are continued. This study evaluated the impact of the BPA alert on OVP prescribing and patient outcomes.

Methods

IRB approved, retrospective, observational cohort study comparing patients who received OVP to no OVP. Inclusion: adults with history of laboratory confirmed CDI, ≥ 14 days post-CDI treatment completion, BPA from 3/7/19 – 3/31/20, receiving non-CDI systemic antimicrobials, and without history of bezlotoxumab infusion. Data were reported using descriptive statistics and bivariate analysis. Primary endpoint: rCDI within 2-8 weeks post-OVP completion. Secondary endpoints: vancomycin-resistant Enterococcus spp (VRE) in clinical culture post-OVP and 1-year mortality.

Results

70 patients included: 32 (46%) no-OVP and 38 (54%) OVP. Baseline characteristics, previous CDI treatment, and outcomes were similar (Table 1). Index CDI was severe in the OVP group (18, 47% vs. 9, 28%). Median Charlson comorbidity index: 7 (3 – 9) no-OVP and 7 (5 – 9) OVP. OVP regimens, 125 mg by mouth: once daily 4 (10%), twice daily 22 (58%), and every 6 hours 12 (32%). Median prophylaxis duration: 10 days (6 – 13). rCDI occurred in 3 (9%) no-OVP and 2 (5%) OVP (P = 0.654). Mortality: 10 (31%) no-OVP and 16 (42%) OVP (P = 0.458).

Table 1. Patient Characteristics and Endpoints

Conclusion

OVP was utilized in approximately half of patients who required non-CDI antibiotics. Efficacy interpretation is limited by inconsistent dosing regimens and significant comorbid illness in the cohort. Future work will focus on further optimizing the BPA and standardizing the OVP regimen.

Disclosures

Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder) Susan L. Davis, PharmD, Nothing to disclose

56. High Frequencies of Adverse Drug Events with Intravenous vs Oral High-Dose Trimethoprim-Sulfamethoxazole: An Opportunity for Antibiotic Stewardship

Background

Trimethoprim-sulfamethoxazole (TMP-SMX) is a high-bioavailability antibiotic associated with potentially serious adverse drug events (ADE). The objective of this study was to evaluate the safety of intravenous (IV) and oral (PO) high-dose TMP-SMX.

Methods

IRB-approved retrospective cohort of hospitalized patients from January 2016 to November 2020. Inclusion: ≥ 18 years old and > 72 hours of renally adjusted high-dose TMP-SMX defined as ≥ 5 mg/kg/day of TMP. Exclusion: prophylaxis. Endpoints during treatment: hyponatremia with sodium < 135 mmol/L, hyperkalemia with potassium > 5 mmol/L, serum creatinine increase of ≥ 0.3 mg/dL or 1.5-1.9 times from baseline, and fluid overload on physical exam. Descriptive and bivariate statistics were performed.

Results

Each group included 50 patients (Table 1). Intensive care unit patients comprised 82% IV TMP-SMX compared to 32% PO. Most common infection: respiratory tract 86% IV and 68.1% PO. Most common organisms were Stenotrophomonas maltophilia (52% IV and 18% PO) and Pneumocystis jiroveci (16.3% IV and 62% PO). Median (IQR) days of inpatient therapy: 6 (5-7.5) PO vs. 7.5 (6-11.3) IV. Median (IQR) days of total duration: 9 (6-21.5) PO vs. 12 (7.8-14) IV (p=0.93). IV group: 88% of patients received >1 liter of D5W daily. Median (IQR) liters of D5W daily was 1 (1-1.5). 56% had a diuretic added, and 38% had a diuretic dose increase. Majority of patients (78%) on IV were taking other oral medications. 100% patients experienced any adverse event with IV vs. 70% with PO (unAdjOR 2.43; 95% CI 1.89-3.13). Most common ADE in both groups: hyponatremia, hyperkalemia, and elevated creatinine. Hyponatremia: 92% with IV and 32% with PO (unAdjOR 24.44; 95% CI 7.50-79.68). Edema on physical exam, an ADE specific to IV TMP-SMX, was the third most common side effect in the IV group. Relative changes from baseline in sodium, potassium, and creatinine from those who experienced hyponatremia, hyperkalemia and elevated creatinine were listed in Table 2.

Table 1. Baseline and Clinical Characteristics

Table 2. Adverse Effects

Conclusion

Patients on IV TMP-SMX therapy were more likely to experience an ADE compared to PO, likely driven by the high volume of free water. Most patients on IV TMP-SMX were on other PO medications, suggesting a missed stewardship opportunity for IV to PO conversion to reduce patient harm.

Disclosures

Susan L. Davis, PharmD, Nothing to disclose Michael P. Veve, Pharm.D., Cumberland (Grant/Research Support)Paratek Pharmaceuticals (Research Grant or Support) Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

497. Moderate Versus High Dose Corticosteroids in Adult Patients with Severe COVID-19: Less Is More

Background

The early administration of corticosteroids (CS) in patients with severe COVID-19 (hospitalized with need for supplemental oxygen) has been the only therapy to improve survival. However, the optimal dosing of CS remains unclear. Beginning March 2020 methylprednisolone (MP) in a dose of 40mg twice daily (high dose CS - HDC) was adopted at our institution. Based on emerging trials, this dose of MP was reduced to 16mg twice daily (moderate dose CS – MDC) in November 2020. The study aims to evaluate the outcome difference in patients receiving HDC versus MDC.

Methods

This pre-post quasi-experimental study was done at Henry Ford Hospital, an 877-bed tertiary care hospital in Detroit, Michigan. Consecutive patients in the HDC group from September 1, 2020 to November 15, 2020 were compared to the MDC group from November 30, 2020 to January 20, 2021. Only hospitalized patients with severe COVID-19 were included. The primary outcome was 28-day mortality. Secondary outcomes included progression to mechanical ventilation, length of hospital stay, discharge on supplemental oxygen and CS-associated adverse events. Patient demographics were evaluated using descriptive statistics. Bivariate and multivariable logistic regression analysis was planned to test the association between primary outcome and exposure.

Results

470 patients were evaluated, 218 and 252 in the HDC and MDC groups respectively. Clinical characteristics and severity of illness on admission were comparable in both groups (Table 1). Among comorbidities - lung disease, cardiovascular disease and hypertension were higher in MDC. Antibiotic and tocilizumab use were lower in MDC. Significantly more patients in MDC group received oral CS. There was no difference in mortality between HDC and MDC through bivariate and multivariate analysis (14.7% and 13.5%, p &lt; 0.712, adjusted OR 0.913 [0.514-1.619]) (Table 2,3). Median length of hospital stay was 5 and 6 days in HDC and MDC respectively (p &lt; 0.001). There was no difference in CS-associated adverse events.

Conclusion

The survival in severe COVID-19 patients treated with MDC is comparable to HDC. Oral corticosteroids are an equally effective option.

Disclosures

Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

592. Antimicrobial Utilization in Solid Organ Transplant Recipients 12-Months Post-Transplantation

Background

Antimicrobials are widely used in solid organ transplant recipients (SOTr). Yet, antimicrobial utilization in the transplant (TP) population is not well characterized. National Healthcare Safety Network antimicrobial use (NHSN-AU) does not provide data specific to SOTr. This study sought to describe inpatient antibiotic use among SOTr up to 1-year post-TP.

Methods

A cross-sectional study was performed of all SOTr who received a TP between January 2015 to December 2016. Demographics, TP type, antibiotic use variables, hospital days, and Clostridioides difficile infection (CDI) are described. Inpatient antibiotic administration was measured for 365 days starting from date of TP surgery. Automated data generated for NHSN-AU reporting was utilized, and SOTr data was abstracted by cross-matching with the transplant database. Transplant-patient days was used as the denominator for metrics. Variables included duration of therapy (DOT), DOT/1000 patient days, antimicrobial free days (inpatient days no antimicrobials were administered), and NHSN-AU reporting targets of anti-methicillin resistant S. aureus (MRSA), broad spectrum, and high-risk CDI agents. Data was analyzed using descriptive statistics via Microsoft Excel®.

Results

A total of 530 SOTr were analyzed. Baseline characteristics are shown in Table 1. Median age was 61, male gender 64%, median Charlson Comorbidity Index was 5. Kidney TP (43%), liver TP (32%), lung (9%) and heart (8%) were most common TP types. Among these four TP types: Lung TP had the highest median DOT (13 days), DOT/1000 patient days (6.6) and ratio of DOT/total patient (1.9) (Table 2). Liver TP had the most antimicrobial free days (34%). Proportionally, anti-MRSA agents use was highest in thoracic TP (lung/heart), broad-spectrum agent use was common in all but kidney TPs, and high-risk CDI agents use was highest among kidney TP (Table 3). A total of 34 SOTr had CDI, 76% in kidney/liver TPs.

Conclusion

Our study provides preliminary and important data of inpatient antibiotic utilization specifically in SOTr, generated using automated NHSN-AU data cross-matched to transplant database. These metrics can be utilized to promote antimicrobial stewardship efforts directed to specific TP types.

Disclosures

Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

688. Incidence and Risk Factors for Prosthetic Valve Endocarditis Following TAVR: 2015-2019

Background

Transcatheter aortic valve replacement (TAVR) is increasingly used for lower risk patients. Incidence of TAVR endocarditis ranges from 0.2% to 3.3%. The purpose of this study was to determine local incidence and risk factors of prosthetic valve infective endocarditis (PVIE) in a contemporary cohort.

Methods

IRB approved retrospective, nested case-control study evaluated the 1-year incidence and risk factors for PVIE among TAVR recipients from 2015 to 2019. Inclusion: ≥ 18 years, TAVR procedure at Henry Ford Health System. Exclusion: repeat TAVR. PVIE cases were matched with controls who did not experience PVIE. PVIE defined as diagnosis documentation in the electronic medical record.

Figure 1. Study Design

Results

23/1266 patients were identified as cases corresponding to a 1-year incidence of 1.82%. The median time to PVIE was 127 days and 35% occurred within 60 days. The most frequently isolated organisms were streptococci (26%), MRSA (13%), and MSSA (13%). Baseline demographics and comorbidities for 23 PVIE cases and 161 controls are displayed in Table 1. Significant risk factors for PVIE in bivariate analysis included STS-PROM (Society of Thoracic Surgeons Predicted Risk of Mortality), median: 4.1 controls and 6.4 cases (p = 0.012). Age, BMI, and comorbidities were not significantly different. Diabetes was notably more frequent among cases (36% vs 48%, p = 0.274). Patients with PVIE had more post-op RBC transfusions (5% vs 21.7% p = 0.003), ECG changes (23% vs 43.5%, p = 0.035), heart block (15.5% vs 34.8%, p = 0.038), longer length of stay (2 days, range 1 to 4 vs 4 to 11, p = 0.004), and thirty-day readmission (10.6% vs 52.2%, p &lt; 0.001). Results displayed in Table 2.

Table 1. Patient Characteristics and Risk Factor Analysis

Conclusion

The results from this study give insight to the local incidence, microbiology, and risk of PVIE following TAVR. Future directions include a larger evaluation of modifiable risks such as diabetes management and examining the heart block patients who received permanent pacemaker implants.

Disclosures

Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder) Janet F. Wyman, DNP, CNS-BC, FACC, Edwards Lifesciences (Consultant) Dee Dee Wang, MD, Edwards LifeSciences (Consultant) Brian O'Neill, MD, Edwards Lifesciences (Consultant)

Long-term outcomes in patients presenting with optic neuritis: Analyses of the MSBase registry

BACKGROUND

Short-term outcomes of optic neuritis (ON) have been well characterized. Limited data exists on longer-term visual outcomes in patients who present with ON. The large MSBase registry allows for characterization of long-term visual outcomes after ON.

METHODS

Via the MSBase Registry, data on patients from 41 centers was collected during routine clinical and research visits. Physical and visual disability were measured using the expanded disability status scale (EDSS) and the visual function score (VFS). Inclusion criteria for this analysis included age ≥ 18 years, clinically isolated syndrome (CIS), ON-onset, baseline visit within 6 months of onset, and at least one follow-up visit. Survival analysis was used to evaluate the association of disease-modifying treatment with time to conversion to clinically definite MS or sustained EDSS/VFS progression.

RESULTS

Data from 60,933 patients were obtained from the MSBase registry in July 2019. Of these, 1317 patients met inclusion criteria; 935 were treated at some point in disease course, while 382 were never treated. At baseline, mean age was 32.3 ± 8.8 years, 74% were female, median EDSS was 2 (IQR 1-2), and median VFS was 1 (IQR 0-2). Median follow-up time was 5.2 years (IQR 2.4-9.3). Treatment was associated with reduced risk and delayed conversion to clinically definite MS (HR = 0.70, p < 0.001), sustained EDSS progression (HR = 0.46, p < 0.0001) and sustained VFS (HR = 0.41, p < 0.001) progression.

CONCLUSIONS

In the MSBase cohort, treatment after ON was associated with better visual and neurological outcomes compared to no treatment. These results support early treatment for patients presenting with ON as the first manifestation of MS.

APOSTEL 2.0 Recommendations for Reporting Quantitative Optical Coherence Tomography Studies

OBJECTIVE

To update the consensus recommendations for reporting of quantitative optical coherence tomography (OCT) study results, thus revising the previously published Advised Protocol for OCT Study Terminology and Elements (APOSTEL) recommendations.

METHODS

To identify studies reporting quantitative OCT results, we performed a PubMed search for the terms "quantitative" and "optical coherence tomography" from 2015 to 2017. Corresponding authors of the identified publications were invited to provide feedback on the initial APOSTEL recommendations via online surveys following the principle of a modified Delphi method. The results were evaluated and discussed by a panel of experts and changes to the initial recommendations were proposed. A final survey was recirculated among the corresponding authors to obtain a majority vote on the proposed changes.

RESULTS

A total of 116 authors participated in the surveys, resulting in 15 suggestions, of which 12 were finally accepted and incorporated into an updated 9-point checklist. We harmonized the nomenclature of the outer retinal layers, added the exact area of measurement to the description of volume scans, and suggested reporting device-specific features. We advised to address potential bias in manual segmentation or manual correction of segmentation errors. References to specific reporting guidelines and room light conditions were removed. The participants' consensus with the recommendations increased from 80% for the previous APOSTEL version to greater than 90%.

CONCLUSIONS

The modified Delphi method resulted in an expert-led guideline (evidence Class III; Grading of Recommendations, Assessment, Development and Evaluations [GRADE] criteria) concerning study protocol, acquisition device, acquisition settings, scanning protocol, funduscopic imaging, postacquisition data selection, postacquisition analysis, nomenclature and abbreviations, and statistical approach. It will be essential to update these recommendations to new research and practices regularly.

Optimizing preoperative antibiotics in patients with β-lactam allergies: A role for pharmacy

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

Patients with a reported β-lactam allergy (BLA) are often given alternative perioperative antibiotic prophylaxis, increasing risk of surgical site infections (SSIs), acute kidney injury (AKI), and Clostridioides difficile infection (CDI). The purpose of this study was to implement and evaluate a pharmacist-led BLA clarification interview service in the preoperative setting.

Methods

A pharmacist performed BLA clarification telephone interviews before elective procedures from November 2018 to March 2019. On the basis of allergy history and a decision algorithm, first-line preoperative antibiotics, alternative antibiotics, or allergy testing referral was recommended. The pharmacist intervention (PI) group was compared to a standard of care (SOC) group who underwent surgery from November 2017 to March 2018.

Results

Eighty-seven patients were included, with 50 (57%) and 37 (43%) in the SOC and PI groups, respectively. The most common surgeries included orthopedic surgery in 41 patients (47%) and neurosurgery in 17 patients (20%). In the PI group, all BLA labels were updated after interview. Twenty-three patients were referred for allergy testing, 12 of the 23 (52%) completed BLA testing, and penicillin allergies were removed for 9 of the 12 patients. Overall, 28 of the 37 (76%) pharmacy antibiotic recommendations were accepted. Cefazolin use significantly increased from 28% to 65% after the intervention (P = 0.001). SSI occurred in 5 (10%) patients in the SOC group and no patients in the PI group (P = 0.051). All of these SSIs were associated with alternative antibiotics. Incidence of AKI and CDI was similar between the groups. No allergic reactions occurred in either group.

Conclusion

Implementation of a pharmacy-driven BLA reconciliation significantly increased β-lactam preoperative use without negative safety outcomes.

11. Missed Vaccine Opportunities During the COVID-19 Pandemic

Background

The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults over the age of 65 to reduce S. pneumoniae pneumonia. Our institution follows a standing order for nurses to vaccinate adults who meet the Advisory Committee on Immunization Practices (ACIP) criteria. During the COVID-19 pandemic surge, the pneumococcal vaccine and influenza vaccine nurse-driven protocol was determined to be non-essential on 3/23, and 4/2 respectively. Our study aims to characterize missed vaccine opportunities among patients hospitalized with COVID-19 during this surge.

Methods

A retrospective cross-sectional study of PCR-positive COVID-19 patients admitted to an inner-city hospital and discharged alive between the dates of 3/23 and 4/21/2020. Patients under the age of 65 were excluded. Data collected included patient age, gender, race, length of stay, co-morbidities that would indicate a vaccine opportunity, prior vaccinations, and whether there was a vaccine opportunity for PPSV23 and influenza defined by ACIP indications. Vaccine history was evaluated using the electronic medical record (EMR) and Michigan Care Improvement Registry. If there was a vaccine opportunity, we documented whether a vaccine was given before hospital discharge. Total numbers of vaccines given for time periods in 2019 and 2020 were collected from EMR for comparison.

Results

100 patients over the age of 65 were included. The average age was 72.8 years, and most patients (66%) were of African American race. The mean length of stay was five days. 52 patients were identified as having an opportunity to receive PPSV23, and 0 patients received the vaccine. 67.3% had more than one indication for PPSV23. 37 patients were eligible to receive influenza vaccine, and 0 received the vaccine. Results are summarized in table 1. Figures 1 and 2 display the number of pneumococcal and influenza vaccines given per EMR, respectively.

Figure 1

Figure 2

Table 1

Conclusion

Due to prioritization of potential staffing shortages and clustering nursing care, an opportunity to vaccinate patients with pneumococcal and influenza vaccines was missed. It is important for health care providers to be aware of this potential opportunity for vaccination of high-risk patients in order to promote primary prevention in future waves of pandemics.

Disclosures

All Authors: No reported disclosures

391. Outcomes of Empiric Antimicrobial Therapy in COVID-19 Positive Patients

Background

The COVID-19 pandemic has revealed new challenges for antimicrobial stewardship. Optimal medical treatment is not completely understood at this time. The epidemiology and outcomes of bacterial co-infections are not well-established; however, empiric antibiotic (abx) use is anecdotally common. The purpose of this study is to characterize empiric antimicrobial drug selection and timing in COVID-19 and evaluate the impact on patient outcomes.

Methods

Cross-sectional cohort study for COVID-19 positive inpatients from March 1, 2020 to June 1, 2020 at an academic medical center and 4 community hospitals. Inclusion: patients with a documented positive COVID-19 PCR nasopharyngeal swab. Exclusion: patients less than 18 years; deceased or transitioned to hospice within 24 hours of admission. Primary endpoint: empiric abx drug, initiation, duration and indication. Additional data collected: severity of illness, co-infection diagnosis, microbiology, and adverse drug effects (ADE). Clinical outcomes included time to recovery by COVID-19 ordinal outcome, clinical status at day 15, and readmission.

Results

400 patients were included with 27% from the ICU. COVID symptom category included mild (23.8%), moderate (53%), severe (15%), and critical (8.3%). 322 (80.5%) received abx at any time during hospital stay, 301 (93.5%) started within 1 day of admission. Most common documented indication community-acquired pneumonia (69%). Identified 43 (10.8%) microbiologically confirmed co-infections, including 5 MRSA and 7 Pseudomonas. Median duration of initial abx 4 days. 54/322 (16.8%) had abx restarted after discontinuation. Median days to recovery without abx was 10 days (7 – 14) and 14 days (9 – 20) with abx. Patient characteristics and outcomes described in table 1. 74 abx related ADE were identified: gastrointestinal 37 and renal 22.

Conclusion

It’s difficult to distinguish bacterial and Covid-19 in coinfections in patients ill enough to be hospitalized. Longer courses of empiric abx therapy were prevalent as the severity of illness increased. However, the low frequency of microbiologically confirmed bacterial co-infections results in potentially unnecessary abx exposure. This exposure increases risk of abx ADE and may not improve clinical outcome.

Disclosures

All Authors: No reported disclosures

209. Antibiotic Utilization During the COVID-19 Surge in Detroit

Background

Antibiotic overutilization during the COVID-19 pandemic has been reported, despite relatively infrequent bacterial co-infection. We explored antibiotic utilization before, during and after the COVID-19 surge in Michigan.

Methods

Cross-sectional study at an 877-bed hospital in Detroit, Michigan from January 2019 through May 2020. Measures: Count of COVID-19 hospital admissions by day. Monthly antibiotic utilization for formulary agents used to treat pneumonia were measured using monthly days of therapy (DOT) per 1000 patient days present and the National Health Care Safety Network Standardized Antimicrobial Administration Ratio (SAAR). Descriptive analysis was utilized.

Results

The first COVID-19 case was detected March 11, 2020 and peaked in early April (Figure 1). Antibiotic utilization is demonstrated in Figure 2. The COVID-19 peak was associated with increased use of multiple antibiotics; notably, DOT per 1000 days present for ceftriaxone, cefepime and doxycycline were 85.43, 79.42 and 71.56, respectively in April. The institutional all-antibacterial SAAR was significantly reduced in May at 0.96, p=0.0022, after the COVID-19 surge.

Figure 1

Figure 2

Conclusion

We observed increased utilization of multiple antibiotics during the COVID-19 surge, and reduction in the all-antibacterial SAAR after the surge. More robust information is needed to promote optimal antibiotic use for patients with COVID-19 infections.

Disclosures

All Authors: No reported disclosures

182. Missed Opportunities to Discontinue Unnecessary Vancomycin During Pharmacist Therapeutic Monitoring

Background

Unnecessary and prolonged IV vancomycin exposure increases risk of adverse drug events, notably nephrotoxicity, which may result in prolonged hospital length of stay. The purpose of this study is to identify areas of improvement in antimicrobial stewardship for vancomycin appropriateness by clinical pharmacists at the time of therapeutic drug monitoring (TDM).

Methods

Retrospective, observational cohort study at an academic medical center and a community hospital. Inclusion: patient over 18 years, received at least three days of IV vancomycin where the clinical pharmacy TDM service assessed for appropriate continuation for hospital admission between June 19, 2019 and June 30, 2019. Exclusion: vancomycin prophylaxis or administered by routes other than IV. Primary outcome was to determine the frequency and clinical components of inappropriate vancomycin continuation at the time of TDM. Inappropriate vancomycin continuation was defined as cultures positive for methicillin-susceptible Staphylococcus aureus (MRSA), vancomycin-resistant bacteria, and non-purulent skin and soft tissue infection (SSTI) in the absence of vasopressors. Data was reported using descriptive statistics and measures of central tendency.

Results

167 patients met inclusion criteria with 38.3% from the ICU. SSTIs were most common indication 39 (23.4%) cases, followed by pneumonia and blood with 34 (20.4%) cases each. At time of vancomycin TDM assessment, vancomycin continuation was appropriate 59.3% of the time. Mean of 4.22 ± 2.69 days of appropriate vancomycin use, 2.18 ± 2.47 days of inappropriate use, and total duration 5.42 ± 2.94. 16.4% patients developed an AKI. Majority of missed opportunities were attributed to non-purulent SSTI (28.2%) and missed MRSA nares swabs in 21% pneumonia cases (table 1).

Conclusion

Vancomycin is used extensively for empiric treatment of presumed infections. Appropriate de-escalation of vancomycin therapy is important to decrease the incidence of adverse effects, decreasing hospital length of stay, and reduce development of resistance. According to the mean duration of inappropriate therapy, there are opportunities for pharmacy and antibiotic stewardship involvement at the time of TDM to optimize patient care (table 1).

Missed opportunities for vancomycin de-escalation

Disclosures

All Authors: No reported disclosures

182. Appropriateness of Treatment Duration for S. aureus Bacteremia (SAB)

Background

An algorithm-based guide to optimal treatment duration in staphylococcus bacteremia demonstrated a non-inferior rate of clinical success compared with standard of care. The purpose of this descriptive study was to assess appropriateness of staphylococcus bacteremia duration of therapy according to the SAB treatment algorithm.

Methods

IRB approved, retrospective cohort describing antibiotic use in S. aureus bacteremia across a health system from January to March 2019. Patients were included if they had at least one blood culture with S. aureus. Exclusion criteria included transfer from outside hospital, concurrent osteomyelitis diagnosis, and death within 72 hours of positive culture. The primary outcome was the appropriate duration of antibiotics for uncomplicated SAB. Secondary outcomes included clinical failure, antibiotic adverse effects, 90-day mortality, and hospital length of stay.

Results

A total of 59 patients were included. The median age was 66 years old and 22 patients (37.3%) were female. Diagnosis: uncomplicated SAB 28 (47.5%) and complicated SAB 31 (52.5%); MRSA 32 (%) and MSSA 27 (%). Infectious Diseases Consultation 56 (94.9%). 4 patients died before treatment duration was determined. Breakdown of treatment durations and clinical failures are listed in Tables 1. Appropriate duration occurred in 9 (32.1%) of patients with SAB. Overall, 14 patients experiences antibiotic adverse effects, 11 which occurred in antibiotic use for ≥4 weeks, 4 occurred in patients with uncomplicated SAB treated for ≥4 weeks. Breakdown of adverse effects: acute kidney injury 9, myositis 1, rash 1, nausea/vomiting 1, anaphylaxis 1, hypersensitivity pneumonitis 1.

Conclusion

Excess treatment duration for uncomplicated SAB was common (16%), in this study, inconsistent with best practice recommendations. 79% of adverse effects occurred in patients who received a ≥4 week course. The results of this study suggest more efforts are needed to implement contemporary evidence-based treatment duration algorithms for uncomplicated SAB to minimize unnecessary antibiotic harm.

Disclosures

All authors: No reported disclosures.

772. Access Denied: Impact of Insurance Denials for High-Cost Outpatient Parenteral Antimicrobial Therapy

Background

Outpatient parenteral antimicrobial therapy (OPAT) allows patients to receive prolonged antimicrobial therapy while reducing the length of hospitalization and healthcare costs. In the United States, most public and private insurance companies require prior authorization (PA) for OPAT. The impact of OPAT PA delays is not known. This study aimed to characterize discharge barriers and authorization delays associated with high-cost OPAT antibiotics.

Methods

IRB-approved study of adult patients discharged with high-cost OPAT antibiotics from January to December 2017. Antibiotics were included based on the frequency of OPAT use and average sales price (ASP) greater than $100 per day, including: daptomycin, ceftaroline, ertapenem, and the novel β-lactam β-lactam inhibitor combinations. Patients with an OPAT authorization delay >24 hours were compared with patients without an OPAT authorization delay. Primary endpoint: total direct hospital costs, starting from the start of treatment with the OPAT antibiotic, from the institutional perspective using Healthcare Cost and Utilization Project and Center for Medicare and Medicaid Services 2019 ASP Drug Pricing data. Secondary outcomes: discharge delay and 30-day readmission or mortality.

Results

Two-hundred patients included: 151 (76%) no OPAT delay vs. 49 (25%) OPAT delay. The use of antibiotics was similar between groups, except ertapenem was more common in the no OPAT delay group: 60 (43%) vs. 15 (25%), P = 0.022. Patients with no OPAT delay were more commonly discharged with home infusion and less commonly to a facility: 75 (53%) vs. 19 (32%), P = 0.007, and 52 (37%) vs. 37 (63%), P = 0.001, respectively. Discharge delays were more common in patients with OPAT delays: 21 (15%) vs. 31 (53%), P < 0.001. The median total direct hospital costs were higher in patients with OPAT delays: $7,770 (3,031–13,974) vs. $19,576 vs. (10,056–37,038), P < 0.001. Table 1 compares the total direct hospital costs of patients with and without an authorization delay.

Conclusion

OPAT with high-cost antibiotics requires significant care coordination. Authorization delays for these antibiotics are common and may contribute to a delay in discharge. OPAT transitions of care represent an important opportunity for Infectious Diseases providers to improve care and address access barriers.

Disclosures

All authors: No reported disclosures.

1989. Impact of Pharmacist-Led β-Lactam Allergy Clarification Interview on Optimizing Preoperative Antibiotic Prophylaxis

Background

Patients with reported β-lactam allergies (BLA) are often given alternative perioperative antibiotic prophylaxis, increasing risk of surgical site infections (SSI), acute kidney injury (AKI), and Clostridioides difficile infection (CDI). The purpose of this study was to implement and evaluate a pharmacist-led BLA clarification interview in the preoperative setting.

Methods

This single-center, IRB-approved, quasi-experimental study compared surgical patients with a BLA between November 2017 and March 2018 (pre-intervention) vs. November 2018 and March2019. From November 2018 to March 2019, a pharmacist performed BLA clarification phone interviews for patients scheduled for a surgical procedure. Based on the allergy history and decision algorithm, first-line antibiotics, alternative antibiotics, or an allergy testing referral were recommended and documented in the EHR. The allergy label was updated as well. The primary outcome was the use of β-lactams preoperatively. Secondary outcomes included 30-day SSI and CDI, AKI, allergic reactions, allergy labels updated or removed, time to incision, and vancomycin doses administered.

Results

87 patients were included in the study; 50 (57%) and 37 (43%) in the pre- and post-group, respectively. Most common surgeries: orthopedic 41 (47%), neurosurgery 17 (20%). In the post-group, all EHR BLA labels were updated after interview. 23 patients were referred for allergy testing, 12 (52%) completed BLA testing, and 7 BLA allergies were removed. 76% of pharmacy antibiotic recommendations were accepted (figure). Cefazolin use significantly increased from 28% to 65% post-intervention, P = 0.001; vancomycin use also increased from 19 (38%) to 22 (59%), P = 0.047. Time to incision decreased by a median of 8 minutes (P = 0.484). SSI occurred in 5 (10%) patients in the pre-group only, P = 0.051. All of these were associated with alternative antibiotics. Incidence of AKI and CDI were similar between the groups (P > 0.05). No allergic reactions occurred in either group.

Conclusion

Clarifying reported BLA in the perioperative setting significantly increased β-lactam preoperative use without negative clinical sequelae.

Disclosures

All authors: No reported disclosures.

2030. Impact of an Antimicrobial Stewardship Program on Carbapenem Susceptibility in a National Hospital in Bhutan

Background

The overuse of broad-spectrum antibiotics drives antimicrobial resistance (AMR), and the prevalence of highly-resistant Gram-negative infections is increasing across the world, especially in low- and middle-income countries (LMIC). Carbapenem resistance is of particular concern since these are often the last line agents. Antimicrobial restriction is an antimicrobial stewardship intervention (AMS) that aims to reduce the use of broad-spectrum antibiotics to preserve antimicrobial susceptibility.

Methods

This is retrospective, observational study of antibiotic consumption and prevalence of antibiotic resistance of bacterial isolates from inpatients at Jigme Dorji Wangchuck National Referral Hospital, a 350-bed multi-specialty hospital in Thimphu, Bhutan. Antibiotic consumption and antimicrobial susceptibility were monitored from January 2015 to December 2017 by the pharmacy department and the microbiology lab, respectively. Antibiotic consumption was measured using defined daily doses (DDD) and expressed as DDDs per 1,000 persons per day. The antibiotic susceptibility was determined using the Clinical Laboratory Standards Institute (CLSI) guideline. A hospital AMS program with multidisciplinary team and good hospital managerial/ leadership support were initiated in 2016 and interventions included antimicrobial restrictions, educations, guidelines for use, post prescription review, de-escalation, audit and feedback.

Results

From 2015 to 2016, the DDDs of carbapenems and piperacillin–tazobactam (PTZ) increased while ceftriaxone decreased (Figure 1). After the AMS program was implemented in 2016, the annual DDDs of carbapenems decreased while PTZ and ceftriaxone increased. Antimicrobial susceptibility of Klebsiella pneumoniae and Escheriachia coli blood isolates to carbapenems and ceftriaxone increased from 2016 to 2017: 50/61 (82%) vs. 45/49 (92%) and 24/91 (26%) vs. 31/92 (34%), respectively.

Conclusion

Implementing an AMS program that restricted the use of carbapenems resulted in a decrease in carbapenem use and increased antimicrobial susceptibility for carbapenems and ceftriaxone. AMS interventions can be successful to decrease carbapenem-resistance in LMIC.

759. High-Dose Daptomycin Is Well Tolerated via 2-Minute Infusion

Background

Intravenous (IV) base solution shortages pose issues in the administration of IV antimicrobials and necessitate alternative administration strategies. Safety data supports 2-minute infusions of IV daptomycin up to the labeled dose of 6 mg/kg. The purpose of this study was to evaluate the safety of administering high-dose daptomycin (HDD) (>6 mg/kg) as a 2 minute IV infusion compared with traditional 30-minute infusion.

Methods

IRB-approved, retrospective cohort in a five-hospital health system admitted 9/1/17–9/1/18. Inclusion criteria: Patients receiving HDD as either a rapid 2 minute IV push (IVP) or a traditional 30-minute infusion (IVI) while inpatient. Exclusion criteria: <2 doses of HDD, pregnant, age <18, concomitant medication associated with infusion reactions (e.g., amphotericin B or monoclonal antibody). Primary outcome: proportion of patients with infusion-related reactions (IRR) after daptomycin administration. Infusion-related reactions were assessed using the Naranjo algorithm and adjudicated by 2 reviewers blinded to administration strategy. Bivariate statistical tests were used to compare patient characteristics and outcomes between groups. Data were reported using descriptive statistics and measures of central tendency.

Results

300 patients included: IVP n = 200, IVI n = 100, representing a total of 1697 administrations. Median age IVP 61 (49, 71), IVI 63 (52, 74). Median BMI IVP 28 (23, 35), IVI 27 (23, 32). Median daptomycin dose IVP 700 (550, 900), IVI 700 (600, 900) with mg/kg doses of 8.2 (7.9, 10) and 8.3 (8, 10), respectively. Administration site was similar in both groups with the most common central venous catheters. Potential IRR occurred in 4% of the IVP arm and 1% of IVI arm, P = 0.28. After adjudication, IRR occurred in 1% of both treatment groups. Descriptions of IRR are in Table 1 and only 1 patient in the IVI arm required discontinuation. CPK elevations: 3% of entire cohort.

Conclusion

Administering HDD as an IVP was not associated with increased risk of IRR compared with IVI. This administration may be advantageous during fluid shortages and in outpatient administration.

Disclosures

All authors: No reported disclosures.

1884. Assessment of Potential Antimicrobial-Related Harms in Hospitalized Adults With Common Infections

Background

Methods

Results

Conclusion

Disclosures

238. Sharing Unit-Specific Stewardship Metrics With Front-line Providers to Improve Antibiotic Prescribing

Background

Methods

Results

Conclusion

Disclosures

2043. T2-Candida (T2MR) vs. Β-D-Glucan (BDG) for Preemptive Antifungal Stewardship in the Intensive Care Unit (ICU)

Background

Timely empiric antifungal therapy is essential in the management of candidemia but must be weighed with the risks of overuse. The purpose of this study was to compare preemptive antifungal therapy and outcomes following a negative T2MR or BDG test result among ICU patients.

Methods

IRB-approved, quasi-experiment in a four hospital system, May 2014–October 2017. T2MR implemented November 2015. Inclusion: preemptive anidulafungin (AFG), negative blood culture(s) and either a negative BDG by system guideline interpretation or T2MR. Exclusions: transplant, neutropenia, or another documented indication for antifungals. Primary endpoint: days of preemptive AFG. Secondary outcomes: ICU and hospital length of stay, incidence of invasive candidiaisis after discontinuation of preemptive therapy, reinitiation of antifungal therapy in the index admission, and inpatient mortality. Early discontinuation defined as single dose only.

Results

A total of 179 patients included: BDG n = 79, T2MR n = 100. Median age: BDG 63 (50, 71); T2MR 59 (50, 70). Baseline SOFA score: 8 (6,11) BDG; 12 (8,15) T2MR. Candida score ≥ 3: 43 and 41%, respectively. Preemptive AFG: 2 (1,5) days BDG and 1 (1,2) days T2MR (P < 0.001). Subsequent proven candidemia: 2 (2.5%) BDG; 1 (1%) T2MR. Antifungal reinitiated: 13 (17%) BDG; 12 (12%) T2MR. Mortality: 35 (44%) BDG, 59 (59%) T2MR, P = 0.07. AFG was discontinued early in 91 (51%) patients. T2MR was the only characteristic associated with early D/C (Table 1).

Conclusion

T2MR testing facilitates use of early preemptive echinocandin therapy in ICU patients and minimizes unnecessary prolonged therapy when compared with use of BDG.

Disclosures

G. Alangaden, T2 Biosystems: Speaker’s Bureau, Educational grant and Speaker honorarium.

Safety and efficacy of outpatient parenteral antibiotic therapy in an academic infectious disease clinic

WHAT IS KNOWN AND OBJECTIVE

Outpatient parenteral therapy (OPAT) has become a safe and effective modality for patients requiring intravenous or prolonged antimicrobial therapy since the 1970s. It is being increasingly utilized in various settings; however, studies evaluating the safety and efficacy of clinic-based OPAT are limited. Since 2012, patients being considered for OPAT have required an infectious disease (ID) consultation at our institution. Candidates receiving once-daily antimicrobials who were ineligible for home infusion or nursing home placement as determined by their insurance companies and those who preferred the clinic over nursing home or home infusion were referred to the ID clinic. This study assessed the safety and outcome of patients receiving OPAT in an academic inner-city ID clinic in Detroit, Michigan.

METHODS

This was a retrospective cross-sectional study of electronic medical records of patients, identified through clinic records, who received at least 2 days of OPAT from December 2012 to December 2015. Demographics, types of infections, antimicrobial regimen used, adverse events and outcome were evaluated.

RESULTS

A total of 122 cases were identified during the study period. Mean age was 62 years with 55% male; 102 (84%) of 122 patients had peripherally inserted central catheter (PICC). Fifty-five per cent of patients participated in the clinic-based OPAT programme for insurance reasons, and 43% preferred the clinic over nursing home or home infusion. The most common infections were bone and joint (36%), followed by skin and soft tissue (18%) and urinary tract infections (12%). Ertapenem (44%) and daptomycin (41%) alone or in combination were used most frequently with 40% of patients receiving at least 4 weeks of treatment. Thirteen patients (11%) experienced one or more adverse drug events on daptomycin and/or ertapenem; of these, nine (69%) patients were receiving daptomycin monotherapy. Gastrointestinal symptoms (29%), cramping and myalgias (29%) and asymptomatic creatine phosphokinase (CPK) elevation (24%) were the most common adverse events. Three (3%) of 102 patients had PICC-related complications. Fourteen (88%) of 16 patients with adverse events or PICC-related complications required changing or stopping antibiotics; two (2%) had infection-related readmission. Conversely, 113 (93%) of 122 patients who completed treatment were considered cured and none had treatment failure at the end of 30 days of treatment. No patients died as a result of treatment or infection-related complications.

WHAT IS NEW AND CONCLUSION

Outpatient parenteral therapy in our academic ID clinic was a safe and effective alternative to home infusion or skilled nursing facilities for patients requiring long-term antibiotics with few adverse events and complications.

An Open Access future? Report from the eurocancercoms project

In March 2011, as part of the background research to the FP7 Eurocancercoms project, the European Association for Cancer Research (EACR) conducted an online survey of its members working in Europe to discover their experiences of and attitudes to the issues surrounding academic publishing and Open Access. This paper presents the results from this survey and compares them to the results from a much larger survey on the same topic from the Study of Open Access Publishing (SOAP). The responses from both surveys show very positive attitudes to the Open Access publishing route; perhaps the most challenging statistic from the EACR survey is that 88% of respondents believe that publicly funded research should be made available to be read and used without access barriersAs a conclusion and invitation to further discussion, this paper also contributes to the debate around subscription and Open Access publishing, supporting the case for accelerating the progress towards Open Access publishing of cancer research articles as a particularly supportive way of assisting all researchers to make unhindered progress with their work.

Is the Internet useful for clinical practice?

BACKGROUND

Internet use in dentistry is increasing. The authors surveyed dentists to determine how they are using the Internet to support patient care and how useful they perceive the Internet to be.

MATERIALS AND METHODS

The authors sent a 25-question survey to 455 subscribers to the Internet Dental Forum, an Internet discussion list. Participants completed the survey through a Web page or by e-mail during an 18-day period in December 1998. The survey included questions about when they began using the Internet and their motivations for doing so, their positive and negative experiences, where they use the Internet and why, their use of information resources--including electronic information resources--and demographics.

RESULTS

The authors received 314 surveys from 438 participants, a 72 percent response rate. Participants reported demographic characteristics similar to national averages and were highly computer-literate. Most considered the Internet essential for their practice and had increased their Internet use for professional reasons over time. Ninety-seven percent of respondents used the Internet at home, and 68 percent used it in the office. Only 5 percent used the Internet in the treatment area. The primary reason cited by participants for using the Internet was to keep up in general, followed by to answer patient-specific questions and to provide patient education. Reduction of professional isolation was one of the most frequently cited advantages of using the Internet.

CONCLUSIONS

The authors found that some dentists use the Internet to support clinical practice and that it helped dentists adopt new techniques for patient treatment and obtain information on new materials or products.

CLINICAL IMPLICATIONS

The Internet appears to support clinical practice mostly indirectly, by helping users keep up in general, rather than by answering specific clinical questions.

Evidence that the high incidence of treatment failures in Indian kala-azar is due to the emergence of antimony-resistant strains of Leishmania donovani

The possibility that the high frequency of treatment failures in Indian kala-azar might be due to infection with antimony-resistant strains of Leishmania donovani has not been experimentally addressed. L. donovani isolates were obtained from splenic aspiration smears of 24 patients in Bihar, India, who either did not respond (15) or did respond (9) to 1 or more full courses of treatment with sodium antimony gluconate (SAG). A strong correlation (P<.001) between clinical response and SAG sensitivity in vitro was observed only when strains were assayed as intracellular amastigotes: responsive isolates ED50=2.4+/-2.6, ED90=6.4+/-7.8 microgram SAG/mL; unresponsive isolates ED50=7.4+/-3.7 microgram SAG/mL, ED90=29.1+/-11.1 SAG/mL. No correlation with clinical response was found by use of extracellular promastigotes (ED50=48+/-22 vs. 52+/-29 microgram/mL). The emergence of antimony-resistant L. donovani strains appears to be a cause of treatment failures in India.

Photoelastic stress patterns produced by implant-retained overdentures

STATEMENT OF PROBLEM

When 2 implants are used to support a removable overdenture, optimal stress distribution to minimize forces to the implants is desired.

PURPOSE

This study used photoelastic analysis to compare the stress patterns generated around implants with 2 retention mechanisms.

MATERIAL AND METHODS

Two root form implants were anchored in a photoelastic mandible and a removable overdenture was fabricated. The denture was lined with a resilient layer of impression material to simulate oral mucosa. Attachment of the denture to the implants was varied by using ball/O-ring and bar-clip attachments. Vertical and oblique occlusal forces from 10 to 200 lb were applied unilaterally to the right and left first molars. Resultant stress distributions in the photoelastic mandible were photographed and evaluated.

RESULTS

With vertical forces, the ball/O-ring attachment transferred minimal stress to both implants. Vertical forces applied to the bar-clip overdenture created immediate stress patterns of greater magnitude and concentration on both implants. A posterior oblique load resulted in similar stress patterns to both systems with slightly greater stress to the bar-clip overdenture.

CONCLUSIONS

Within the limits of this study, ball/O-ring attachments transferred less stress to implants than the bar-clip attachments when the photoelastic model was subjected to a posterior vertical load.

Typhlitis in a patient with acute lymphoblastic leukemia prior to the administration of chemotherapy

PATIENTS AND METHODS

A 3-year-old girl with acute lymphoblastic leukemia developed typhlitis immediately after diagnosis and before the institution of chemotherapy.

PURPOSE

Typhlitis is a necrotizing colitis that develops in immunodeficient patients with severe neutropenia. Most patients are leukemic children who are receiving or have received chemotherapy. Typhlitis in the absence of chemotherapy is rare. We report a fatal case of typhlitis in an untreated leukemic patient.

RESULTS

This case emphasizes the multifactorial pathogenesis of typhlitis, which may occur in the absence of chemotherapy.

CONCLUSIONS

Typhlitis should always be considered as a potential cause of acute sepsis and abdominal pain in a leukemic patient.

Carbohydrate utilization in exercising muscle in subtotally nephrectomized rabbits

Subtotally nephrectomized rabbits were compared with sham-operated controls. The isolated soleus muscle of one leg was exercised using controlled stimulus parameters at 1 Hz until the contraction tension (amplitude) was reduced by one half. The muscle was then quickly frozen in liquid nitrogen and analyzed for lactate, pyruvate, glycogen, alanine, glutamine and alpha-ketoglutarate. The resting leg was used as a control and similarly frozen and analyzed. The difference between resting and exercised muscle lactate and pyruvate concentration was significantly greater in experimental animals while muscle alanine and alpha-ketoglutarate concentrations were lower in the experimental animals. There was no difference in the time required to reach one half of the muscle contraction amplitude between experimental and control animals. Blood lactate levels rose in the experimental animals to a greater degree than in control animals, similar to that seen in human subjects with renal failure.

The effect of concurrent manual activity on the dichotic listening performance of boys with learning disabilities

Three groups of learning-disabled children, defined according to their Wechsler Intelligence Scale for Children (WISC) profiles, and one normal control group, were given both a standard dichotic listening task and a dichotic listening task performed concurrently with a manual tapping task. Learning-disabled children who showed no disparity in their verbal and performance subscale scores on the WISC demonstrated a right ear preference under standard testing and when tapping with the left hand, but not the right, which was nearly the same pattern as that obtained by the control group. Learning-disabled children whose verbal WISC score was at least 15 point lower than their performance demonstrated a right-ear preference only when tapping with their left hand. Finally, learning-disabled children who had high verbal, low performance WISC profiles showed no ear preference under any conditions. These results were interpreted as indicating that these three types of learning-disabled children are differentially lateralized and differentially affected by the facilitory-inhibitory effects of concurrent hemispheric activities.