Context Matters: Social Psychological Factors That Underlie Academic Performance across Seven Institutions

To enhance equity and diversity in undergraduate biology, recent research in biology education focuses on best practices that reduce learning barriers for all students and improve academic performance. However, the majority of current research into student experiences in introductory biology takes place at large, predominantly White institutions. To foster contextual knowledge in biology education research, we harnessed data from a large research coordination network to examine the extent of academic performance gaps based on demographic status across institutional contexts and how two psychological factors, test anxiety and ethnicity stigma consciousness, may mediate performance in introductory biology. We used data from seven institutions across three institution types: 2-year community colleges, 4-year inclusive institutions (based on admissions selectivity; hereafter, inclusive), and 4-year selective institutions (hereafter, selective). In our sample, we did not observe binary gender gaps across institutional contexts, but found that performance gaps based on underrepresented minority status were evident at inclusive and selective 4-year institutions, but not at community colleges. Differences in social psychological factors and their impacts on academic performance varied substantially across institutional contexts. Our findings demonstrate that institutional context can play an important role in the mechanisms underlying performance gaps.

58. Evaluation of a Disease State Stewardship Intervention for Urinary Tract Infections at an Academic Medical Center

Background

Urinary tract infections (UTIs) are often misdiagnosed and mismanaged. Disease state stewardship initiatives targeting UTIs may have a significant impact on the overuse of antimicrobials (ABX). The purpose of our study is to evaluate the effectiveness of a UTI focused disease state stewardship intervention.

Methods

This retrospective study was conducted at a tertiary care academic medical center. Patients > 18 years of age with a collected urinalysis (UA) and receiving ABX for a UTI were included. Retrospective review of UTI management from 9–11/2017 was performed and used as the baseline. In the post-intervention period, 9–11/2018, the UTI management guideline had been published and service lines educated. A prospective audit and feedback (PAAF) initiative was started 6/2019, whereby the antimicrobial stewardship team performed daily reviews of patients on ABX for UTIs. Patients reviewed 9–11/2019 were included in the PAAF cohort. Exclusion criteria included: pregnancy, undergoing a urologic procedure, treatment of a concomitant infection, receiving therapy based on outside recommendations, or left AMA/expired during treatment. The primary outcome of this study was to evaluate overall guideline adherence.

Results

600 patients (200 in each group) were included, with 419 (69.8%) female and an overall median age of 61.4 years. Altered mental status (24.8%) and dysuria (21.5%) were the two main diagnostic testing indications. Treatment of asymptomatic presentations decreased between the three periods, 74.0% vs 48.5% vs 36.0%. Appropriate ordering of UA (33.5% vs 55.0% vs 68.5%, p< 0.001) and urine cultures (29.0% vs 57.1% vs 64.8%, p< 0.001) improved following guideline implementation and PAAF. Interventions by the stewardship team were made in 21% of patients during PAAF, namely therapy discontinuation (78.6%). Overall guideline adherence significantly improved over time, 13.0% vs 27.0% vs 36.5%, p< 0.001.

Conclusion

UTI disease state intervention was associated with a reduction in the treatment of asymptomatic presentations, increase in appropriate diagnostic ordering, and improvement in overall guideline adherence. PAAF can be a powerful stewardship strategy for promoting consistency in UTI treatment and decreasing unnecessary ABX use.

Disclosures

All Authors: No reported disclosures

1982. A Diagnostic Stewardship Intervention for Clostridioides difficile: Impact of Stool Toxin Testing on Treatment of Adult Inpatients

Background

Testing for Clostridioides difficile infection has been the subject of recent debate. Guidelines from the Infectious Diseases Society of America now support the addition of a stool toxin test to a positive nucleic acid amplification test (NAAT) as part of a multi-step testing algorithm. In November 2017, the University of Kentucky HealthCare system added stool toxin testing to any specimen positive for C. difficile by NAAT. This change was accompanied by face to face education with provider groups and clinical decision support in the form of interpretive verbiage added to the results that are reported into the electronic record. The objective of this study was to assess whether this diagnostic stewardship intervention made an impact on C. difficile treatment

Methods

We performed a retrospective review of adult patients admitted to UK HealthCare from November 1, 2017 through October 31, 2018 who tested positive by NAAT but negative by stool toxin test to determine whether or not they were treated. We also assessed treatment by service line to see whether there were treatment differences among these groups. A cost analysis was also performed.

Results

A total of 300 adult inpatients were positive for C. difficile by NAAT during the study period with 71% (213 patients) having a negative stool toxin test. Of those, 58% (123) were never started on C. difficile therapy and an additional 14% (30) had their therapy stopped after 48 hours. Only 28% (60) of these patients received a full course of therapy. Hospital medicine had the highest rate of non-treatment at 82%. Conversely, our solid-organ and bone marrow transplant services had the lowest rate of non-treatment at 31%. Overall, this approach was associated with an estimated 1470 oral vancomycin days avoided (5,880 doses) and a cost savings of $6,278.

Conclusion

The addition of stool toxin testing to NAAT combined with education and clinical decision support lead to a dramatic reduction of treatment for NAAT positive but toxin-negative patients. This form of diagnostic stewardship had a significant impact on therapy decisions and can be a powerful antimicrobial stewardship approach to decrease unnecessary treatment of C. difficile colonization.

Disclosures

All authors: No reported disclosures.

149. Short vs. Long Course of Antibiotics for Uncomplicated Gram-Negative Bacteremia

Background

Bloodstream infections (BSI) continue to be a major cause of morbidity and mortality in the United States; thus, the correct choice of antibiotics for an appropriate duration is imperative. However, there are limited recommendations on adequate duration of treatment of bacteremia caused by Gram-negative organisms. Therefore, treating an infection for an adequate duration to prevent complications while preventing adverse effects from unnecessary antibiotic exposure remains a balancing act. This study aims to compare clinical outcomes between patients treated with a short (7–10 days) vs. long (11–20 days) course of antibiotics for uncomplicated gram-negative bacteremia.

Methods

This single-center retrospective cohort study evaluated adult patients admitted between January 2007 to October 2018 with a blood culture positive for gram-negative bacteria. Data came from the University of Kentucky Microbiological Laboratory and Center for Clinical and Translational Science (CCTS) Data Bank. Patients included must have received appropriate antibiotics for at least 7 days. Appropriate antibiotics were defined as those to which the organism is susceptible with day one of therapy as the first day of appropriate antibiotic therapy. Patients were excluded if they were treated with aminoglycoside monotherapy, had polymicrobial bacteremia, or if treated for longer than 20 days of therapy.

Results

A total of 466 patients were identified (208 in the short-course group and 258 in the long course group). Gender and ethnicity were similar across both groups. The patients in the long course group had more ICU admissions compared with the short-course group (52.7% vs. 43.3%, P = 0.0426), tended to be older (57 ± 16.7 vs. 53 ± 15.9 years, P = 0.0119), had a higher Charlson Comorbidity Index (5.7 ± 3.6 vs. 4.6 ± 3.6, P = 0.0009) and remained admitted to the hospital longer (23.2 ± 25.6 vs. 15.8 ± 17.5 days, P = 0.0002). However, patients treated with a long course had no difference in 30-day mortality compared with the short-course group (3.9% vs. 3.4%, P = 0.7701).

Conclusion

Patients with an uncomplicated gram-negative BSI treated with a short course (7–10 days) of antibiotics do not appear to have a significant difference in 30-day mortality compared with those patients treated with a long course (11–20 days).

Disclosures

All authors: No reported disclosures.

2436. Use of Piperacillin/Tazobactam vs. Cefepime or Carbapenem for Infections Due to Serratia, Citrobacter, or Enterobacter

Background

Methods

Results

Conclusion

Disclosures

1026. Trends in Infective Endocarditis During the Substance Use Disorder Epidemic at an Academic Medical Center

Background

In many areas of the United States, substance use disorders (SUD) have increased dramatically over the past decade. Overdose deaths have increased as well, and Kentucky ranks among the nation’s leaders in deaths per 100,000 population. Infective endocarditis (IE) is a well-known complication of intravenous drug use, contributing to significant morbidity and mortality, but few studies have evaluated the effect of the current SUD epidemic on rates and demographics of IE. We sought to examine the trends in IE and IE with SUD at our institution.

Methods

We collected data from patients admitted to a large academic medical center in Kentucky between January 1, 2013 and December 31, 2016. Patients were classified according to the International Classification of Diseases, Tenth Revision. Patients were considered to have IE if they received codes I33 or I38. Patients were considered to have an SUD if they received codes F11.10, F15.10, F14.10, F19.10, or Z86.59. Data were collected through the TriNetX database (TriNetX, Cambridge, MA).

Results

There were 2,100 cases of IE during the study period. The mean (SD) age was 53 years (21). Of those, 440 also had an SUD. The mean (SD) age of these patients was 41 years (11). Patients in both the IE and IE/SUD categories were primarily male (54% and 55%) and white (94% and 94%). The number of cases of IE increased from 190 in 2013 to 430 in 2016 (R² = 0.9877). The number of IE cases diagnosed as having an SUD increased from 30 (16% of all IE cases) in 2013 to 130 (30% of all IE cases) in 2016 (R² = 0.7352 for the trend). This increase in cases corresponds to a 333% increase in the number of cases of IE with SUD.

Conclusion

Between 2014 and 2016, opioid overdose deaths in Kentucky rose from 24.7 to 33.5 per 100,000 population, a 35.6% increase. During a similar timeframe, the number of IE cases associated with SUD at our institution rose 333%. While it is possible that increased coding of substance use disorders factored into this dramatic increase, it appears that the number of IE cases associated with SUD is rising at a disproportionately rapid rate.

Disclosures

All authors: No reported disclosures.

1878. Expanding Kentucky’s “One and Done” Tradition: Lipoglycopeptide Administration in the Emergency Department at a Tertiary, Academic Medical Center

Background

Acute bacterial skin and skin structure infection (ABSSSI) incidence continues to rise, accounting for around 3.5 million emergency department (ED) visits per year in the United States. Dalbavancin and oritavancin are lipoglycopeptides with long half-lives allowing for single dose treatment options for eligible patients presenting with ABSSSIs in the ED, avoiding an inpatient admission. The objective of this study was to investigate the financial outcomes of utilizing these agents in the ED.

Methods

This was a single-center, retrospective study in adult patients with ABSSSIs that received a lipoglycopeptide in the ED at an academic medical center from April 2016 to February 2018. A multidisciplinary institutional guideline was developed and implemented in April 2016. Data were documented in the electronic medical record and/or REDCap™ database. A comparator group was identified by utilizing similar ICD-10 codes for patients that were admitted for ABSSSI. Variable direct cost-avoidance was examined to explore the financial implication of lipoglycopeptide treatment in this population.

Results

The average length of stay in the comparator group who were admitted for ABSSSIs during the predefined time period was 4.3 days. Because patients receiving a lipoglycopeptide did not require admission for intravenous antibiotics, 94.6 patient-days were avoided increasing the capacity by 14.1 patients. Overall, 22 patients received either dalbavancin (n = 18) or oritavancin (n = 4). The age was 40.8 ± 13.2 years for the study group with 55% male. The age of the comparator group was 40.5 ± 19.7 years. All patients were discharged home from the ED without being admitted. Two patients were readmitted for treatment failure requiring IV antibiotics. Despite 2 of 22 patients receiving a lipoglycopeptide without insurance, the variable direct cost avoidance was $4,560 per case, or $1,060 per day.

Conclusion

The use of lipoglycopeptides offers patient convenience and financial benefits, warranting its consideration for use in the ED at tertiary academic medical centers.

Disclosures

All authors: No reported disclosures.

529. Overdiagnosis of Clostridioides difficile with a Multiplex PCR Panel

Background

While advantageous by casting a wider diagnostic net, multiplex panels can be problematic if the pretest probability is low. A significant increase in reported Clostridioides difficile infections (CDI) was noted at our institution following introduction of a multiplex comprehensive GI (CGI) panel which includes an analyte for C. difficile. Owing to these concerns, the C. difficile analyte result was suppressed when reporting and providers were advised to order a standalone C. difficile PCR (CDPCR) test if CDI was a concern. The objective of this study was to investigate concerns of false positive C. difficile results from the CGI panel.

Methods

C. difficile diagnostic practices were prospectively evaluated from April to August 2017. Patient charts were reviewed in response to a positive C. difficile analyte on the CGI panel. CDPCR results were reviewed if ordered. If not ordered, chart review and discussion with the provider was conducted to investigate clinical suspicion for CDI. The results were analyzed to examine the performance of the C. difficile analyte on the CGI panel.

Results

Overall, a total of 1,611 CGI panels were performed with C. difficile being detected in 156 specimens. Of these positive results, a subanalysis was performed on 123 positive specimens for whom complete data was available. A CDPCR was performed in 80 (65%) of these specimens. Among those, only 44 (55%) were CDPCR positive and 22 (28%) were CDPCR negative (likely a false-positive CGI result), and 14 (17%) were rejected because of specimen consistency. For the remaining 43 C. difficile-positive CGI panel specimens that did not have an accompanying CDPCR, seven were in children below 2 years of age. Direct provider discussion occurred in the remaining 36 cases. Providers declined CDPCR testing in 24 of those cases due to a lack of clinical concern.

Conclusion

The use of the CGI panel for C. difficile led to over diagnosis of CDI. This could have significant consequences for clinical care and the reporting of hospital acquired infections.

Disclosures

All authors: No reported disclosures.

1311. Incorporating an “Escape Room” Game Design in Infectious Diseases Instruction

Background

As health professions education evolves toward active learning environments, interest in using games as an educational tool is increasing. One contemporary commercial game that has design potential for learning activities is an “escape” or “breakout” room. Escape rooms are live-action games where teams of players work to achieve a common goal in a set amount of time. Limited literature is available assessing this type of gaming format for education design. This study investigated the design and implementation of an escape room learning activity in a third-year pharmacy infectious disease elective course at the University of Kentucky College of Pharmacy.

Methods

During a Gram-positive antimicrobial resistance module, third-year pharmacy students participated in both patient case-based instruction and an escape room learning activity. Three IRB-approved surveys were distributed electronically to students; the first was completed prior to class and functioned as a standard teaching tool to assess mastery of content based on pre-assigned reading and previous coursework. Two surveys were completed after the session to assess knowledge and perceptions gained during each learning activity. Students answered multiple-choice knowledge-based questions and then responded to five statements using a Likert scale from 1 to 7 (1 = Not at all, 4 = Somewhat, and 7 = Very much) to indicate perceptions of each instructional activity.

Results

Nineteen students participated in the study. The mean correct scores for knowledge-based assessment were 90.5% in the pre-class survey, 82.1% in the post-case survey, and 90.5% in the post-escape room survey. There was an overall positive perception of both learning activities based on results of the survey questions. The escape room learning activity was preferred by 18 of 19 students (94.7%), but only 11 of 19 (57.9%) indicated they learned better from the escape room.

Conclusion

This study illustrates an escape room designed to meet lecture learning objectives is a feasible active learning technique. While students demonstrated knowledge gained from the activity and indicated positive perceptions, this approach warrants further evaluation.

Disclosures

All authors: No reported disclosures.