Left Ventricular Assist Device: Review of Antimicrobial Prophylaxis Strategies and Incidence of Infections at a Tertiary Care Center 12-Year Experience

Background

Left ventricular assist devices (LVAD) have an associated infection rate of 13%-80% postimplant. An optimal strategy for surgical infection prophylaxis (SIP) at the time of implantation has not been well defined. We aimed to evaluate the different LVAD implantation antibiotic prophylaxis regimens as well as the incidence of LVAD infection at our institution.

Methods

We performed a single-center, retrospective study of patients who underwent LVAD implantation between February 2007 and June 2019. The primary outcome was the incidence of LVAD infection (LVADI), within 3 months and 1 year of placement, between patients who received expanded or narrow-spectrum regimens for SIP. We assessed outcomes using Kaplan-Meier, time-to-first event. We used a noninferiority analysis, which was established if the narrow-spectrum event rate was no more than 5% greater than the expanded-spectrum event rate.

Results

We included 399 patients, 305 (76.4%) patients received narrow-spectrum SIP, whereas the remaining 94 (23.6%) patients received the expanded-spectrum regimen. Statistical noninferiority of the narrow spectrum to the multiple drug regimen was demonstrated at both time points, and statistical superiority of the narrow-spectrum group across 12-month follow up was further evident (P = .037).

Conclusions

We report evidence supporting noninferiority, or even superiority, of the narrow-spectrum over expanded-spectrum antimicrobial prophylaxis strategy with respect to LVADI. These findings support data-driven antimicrobial prophylaxis strategies.

Infectious disease physician characteristics and prescription of meropenem in the hospital

Objective

Physician characteristics may be correlated with medical treatment decisions and patient outcomes. This study examined the correlations between characteristics of infectious disease (ID) physicians and the use of the restricted antimicrobial meropenem.

Design

This was a retrospective cohort study following 27 attending ID physicians for 5 years at a large academic medical center.

Methods

All inpatient ID clinical encounters between 2013 and 2018 were assessed for physician and patient characteristics, including patient Charlson Comorbidity Index, patient sex, ID service seeing the patient, physician career stage, physician training location, and physician sex. Adjusted and unadjusted odds ratios were calculated for the receipt of meropenem on the same day as an ID clinical note.

Results

Between 2013 and 2018, meropenem was administered on the same day as 9046 (11.1%) of 81,787 inpatient ID encounters. After adjustment for patient and practice-specific factors, physician career stage was associated with administration of meropenem. Patients seen by mid-career and late-career ID physicians were more likely to receive meropenem than those seen by early-career physicians (aOR 1.22 95% confidence interval [CI 1.13-1.31 and aOR 1.17 95% CI 1.10-1.25, respectively).

Conclusions

ID provider characteristics may help target future antimicrobial stewardship program interventions.

1637. Improving Transitions of Care in the Division of Infectious Diseases

Background

Patients dismissed from the hospital on oral or intravenous antibiotics frequently need follow-up appointments with the Division of Infectious Diseases (ID). Follow-up appointments may be inappropriately scheduled with respect to timing and indication. Suboptimal transitions of care may lead to increased no-shows and ultimately poor patient outcomes.

Methods

The baseline sample included 102 patients seen by the inpatient ID services at Mayo Clinic’s Rochester Methodist and Saint Mary’s Hospitals between January 1, 2017 and June 30, 2017. Defects in transitions of care were categorized as those pertaining to sign-off templates, sign-off labels, follow-up priority, and timing. The current transfer of care system from our institution is outlined in Figure 1.

Results

Out of 102 patients, 75 (74%) had at least one defect identified. Root cause analysis revealed multiple factors contributing to this performance gap (Figure 2). Patients often have variable health literacy and social or financial difficulties. There are often multiple ID providers with inadequate time to properly orchestrate follow-up. There are undefined checkpoints and triaging in the department’s scheduling policies. Interventions involved reformatting the ID sign-off template and clarifying the roles of providers in the transitions-of-care process. Analysis after 6 months of implementation revealed improvement of communication among teams, decline in improper sign off by 13% and decrease in antibiotic prescription errors by 2%.

Conclusion

This study demonstrates that well-designed sign-off templates can help with effective communication of the final treatment plan among providers and possibly improve patient outcomes. The target goal is to reduce the number of improper sign-offs by 50% within 1 year.

Disclosures

All authors: No reported disclosures.

421. Babesiosis: Retrospective Review of 38 Cases from Upper Midwest

Background

Babesiosis is a tick-borne illness caused by protozoal infection of the genus Babesia. Clinical presentation varies widely from asymptomatic to rapidly fatal infection and diagnosis requires a high index of clinical suspicion. It is an emerging health risk and clinicians need to be aware of its different clinical manifestations.

Methods

We retrospectively collected and analyzed data from 38 patients with babesiosis from 1990 to 2015.

Results

Mean age of patients was 63 years. 68% of patients required hospitalization with 21% requiring intensive care unit (ICU) stay. Mean length of illness before diagnosis was 15.6 days and symptoms comprised of malaise (82%), subjective fever (71%), chills (55%), anorexia (29%), arthralgia (29%), and nausea (16%). Only 47% of the patients recalled tick bites. Mean hemoglobin in the outpatients was 12.4 g/dL compared with 9.8 g/dL in the hospitalized patients (P < 0.01). Among hospitalized patients, mean hemoglobin for ICU admissions was 7.5 g/dL vs. 10.9 g/dL (P < 0.01) for those without ICU stay. Mean parasitemia was 10.1% in those requiring ICU compared with 1.4% in those admitted to the medical floor (P < 0.01). 28.9% had Lyme disease, and 10.5% had anaplasma coinfection. Co-morbidities included diabetes mellitus (n = 3), asplenia (n = 5), and immunosuppression (n = 3). Diagnosis was made with PCR and peripheral smear in 50% of patient whereas 50% were diagnosed with PCR alone. In 27% of patients with positive PCR, peripheral smear was negative. All patients with asplenia required hospitalization with 3/5 requiring ICU with initial parasitemia ranging from 2.5 to 28% and duration of parasitemia ranging from 10 to 142 days. Initial treatment comprised of clindamycin plus quinine in 31% of patients whereas combination of atovaquone and azithromycin was used in 69% of patients. Median duration of treatment was 10 days. Overall three patients underwent exchange transfusion with parasitemias ranging from 12.3 to 28.5%. None of the patients died during hospitalization.

Conclusion

Less than half of the patients with babesiosis recall tick bites. There is usually a delay in diagnosis of up to 2 weeks due to nonspecific nature of symptoms. In more than one-fourth of patients with babesiosis peripheral smear may be falsely negative. Hemoglobin and percentage parasitemia seemed to correlate with severity of illness.

Disclosures

All authors: No reported disclosures.

1243. Comparative Analysis of Antimicrobial-related Adverse Events in the Outpatient Treatment of Staphylococcal Infections

Background

Limited data exist to evaluate safety-related outcomes in Outpatient Parenteral Antimicrobial Therapy (OPAT) patients treated with antimicrobial agents for Gram-positive infections.

Methods

This retrospective, single-center study enrolled Mayo Clinic OPAT patients between 2013 and 2017. The primary objective of the study compared rates of therapy modification due to drug-related toxicity for staphylococcal infections treated with ceftriaxone, cefazolin, nafcillin, oxacillin, vancomycin, daptomycin, ceftaroline, linezolid, or ertapenem. Secondary objectives included determination of the frequency and type of adverse drug events (ADEs) attributed to OPAT and rate of readmission due to ADEs attributed to OPAT.

Results

One hundred seventy-two patients were identified (cefazolin n = 54, ceftriaxone n = 49, vancomycin n = 30, daptomycin n = 16, nafcillin n = 9, ertapenem n = 6, ceftaroline n = 4, oxacillin n = 3, linezolid n = 1). The overall treatment completion rates were high (153/172, 89.0%). Patients completed an average of 35.3 days (7 to 95) of therapy with their original antibiotic. Fourteen patients required change to a different antibiotic due to antimicrobial toxicity (ceftriaxone=5; vancomycin=2; cefazolin = 2; daptomycin = 2; ceftaroline = 1; nafcillin = 1; oxacillin = 1) and five patients experienced treatment failure required an additional agent (ceftriaxone = 2; nafcillin = 2; linezolid = 1). Adverse drug events (ADEs) were the most common reason for antimicrobial adjustment (14/19, 73.7%). The most common ADEs were hypokalemia (28/172, 16.3%) and diarrhea (25/172, 14.5%). There were only two cases of Clostridium difficile. Thirty-day readmissions due to antimicrobial therapy were low with 11 patients.

Conclusion

OPAT with Gram-positive agents used for staphylococcal infections is effective, but antimicrobial modifications still occur. Clinicians should be aware of the risk of ADEs and readmissions in OPAT patients. A multidisciplinary approach may enhance management of ADEs and possibly preventing readmissions

Disclosures

All authors: No reported disclosures.