Combination eravacycline therapy for ventilator-associated pneumonia due to carbapenem-resistant Acinetobacter baumannii in patients with COVID-19: A case series

BACKGROUND

Carbapenem-resistant Acinetobacter baumannii (CRAB) pneumonia is associated with poor clinical outcomes and increased mortality. Clinical data regarding the optimal treatment of CRAB is limited, and combination therapy is often preferred. Eravacycline has demonstrated in-vitro activity against A. baumannii and has been considered for the treatment of pulmonary infections caused by CRAB.

OBJECTIVE

The objective of this case series was to describe clinical outcomes associated with eravacycline when utilized as part of a combination regimen for the treatment of CRAB pneumonia at a county hospital.

METHODS

A retrospective chart review was conducted from April 1, 2020, to October 1, 2020, which included hospitalized patients ≥18 years of age, diagnosed with coronavirus disease 2019 (COVID-19), with a sputum culture positive for CRAB, and receipt of at least one dose of eravacycline. The primary outcome studied was clinical resolution of CRAB pneumonia. A key secondary outcome was microbiological resolution.

RESULTS

A total of 24 patients received combination eravacycline therapy for a median of 10.5 days. Overall, 17 (71%) patients demonstrated clinical resolution of CRAB pneumonia. Repeat sputum cultures post-treatment were collected in 17 (71%) patients, of which 12 (71%) achieved microbiological resolution. No adverse events attributable to eravacycline were identified.

CONCLUSION

With limited viable salvage treatment options, combination eravacycline therapy showed favorable microbiological and clinical outcomes in patients with CRAB pneumonia. In light of this, eravacycline could be considered as a potential treatment option when designing CRAB pneumonia salvage therapy regimens.

Safety and Efficacy of Ceftriaxone in the Treatment of Methicillin-Susceptible Staphylococcus aureus Bloodstream Infections: A Noninferiority Retrospective Cohort Study

BACKGROUND

Antistaphylococcal penicillins and cefazolin are the treatments of choice for methicillin-susceptible Staphylococcus aureus (MSSA) infections, requiring multiple doses daily. At Parkland, eligible uninsured patients with MSSA bloodstream infections (BSI) receive self-administered outpatient parenteral antimicrobial therapy (S-OPAT). Ceftriaxone was used in a cohort of S-OPAT patients for ease of once-daily dosing.

OBJECTIVE

A retrospective study was conducted to evaluate clinical outcomes for patients discharged with ceftriaxone versus cefazolin to treat MSSA BSI.

METHODS

A retrospective cohort noninferiority study design was used to assess treatment efficacy of ceftriaxone versus cefazolin among Parkland S-OPAT patients treated from April 2012 to March 2020. Demographic, clinical, and treatment-related adverse events data were collected. Clinical outcomes included treatment failure as defined by repeat positive blood culture or retreatment within 6 months, all-cause 30-day readmission rates, and central line-associated bloodstream infection (CLABSI) rates.

RESULTS

Of 368 S-OPAT patients with MSSA BSI, 286 (77.7%) received cefazolin, and 82 (22.3%) received ceftriaxone. Demographics and comorbidities were similar for both groups. There were no treatment failures in the ceftriaxone group compared with 4 (1%) in the cefazolin group (P = 0.58). No difference in 30-day readmission rate between groups was found. The CLABSI rates were lower in ceftriaxone group (2%) compared with cefazolin (11%; P = 0.02). Limitations include retrospective cohort design.

CONCLUSIONS

Ceftriaxone was found to be noninferior to cefazolin in this study. Our findings suggest that ceftriaxone is a safe and effective treatment of MSSA BSI secondary to osteoarticular or skin and soft tissue infections when used in the S-OPAT setting.

POSTER ABSTRACT

OFID on 2018 Nov; 5(Suppl 1): S316: doi: 10.1093/ofid/ofy210.894.

Evaluation of Dalbavancin Use on Clinical Outcomes, Cost-Savings, and Adherence at a Large Safety Net Hospital

Dalbavancin is a second-generation lipoglycopeptide antibiotic with activity against Gram-positive organisms. Dalbavancin is Food and Drug Administration (FDA)-approved for acute bacterial skin and soft tissue infections (ABSSTIs). There is a lack of substantial data on dalbavancin in more invasive infections, particularly in high-risk populations (patients with intravenous drug use and unstable living conditions). In this retrospective observational study, we reviewed all patients that received at least one dose of dalbavancin in an inpatient or outpatient setting at Parkland Hospital from February of 2019 to August of 2021. The demographics, type of infection, and rationale for dalbavancin were collected at the baseline. Clinical failure was measured by an avoidance of emergency department (ED) visits or hospital readmission at 30, 60, and 90 days. A separate analysis was conducted to estimate hospital, rehabilitation, or nursing facility days saved based on the projected length of treatment. 40 patients were included, and the majority were uninsured (85%), experiencing homelessness (60%), or had intravenous drug use (IDU) (57.5%). Indications for use included ABSSTIs (45%), bloodstream infection (67.5%), osteomyelitis (40%), infective endocarditis (10%), and septic arthritis (10%). Clinical failure was observed in 5 of the 40 patients (12.5%). Nonadherence to medical recommendations, a lack of source control, and ongoing IDU increased the risk of failure. Dalbavancin saved a total of 566 days of inpatient, rehabilitation, and nursing facility stays. Dalbavancin is a reasonable alternative to the standard of care in an at-risk population, offering decreased lengths of stays and cost savings. The uses of second-generation lipoglycopeptides are desirable alternatives to traditional outpatient parenteral antibiotic therapies for patients who otherwise would not qualify or for patients who desire less hospital contact in light of the COVID-19 pandemic. IMPORTANCE This study contributes additional experience to the literature of dalbavancin use in off-label indications, particularly for patients who do not qualify for outpatient parenteral antimicrobial therapy. The majority of the patient population were people who inject drugs and the uninsured. There is difficulty in tracking outcomes in this patient population, given their outpatient follow-up rates; however, we were able to track emergency room visits and readmissions throughout the majority of the local metroplex. The clinical use of dalbavancin at our institution also increased in the midst of the COVID-19 pandemic in an effort to preserve hospital resources and limit health care exposure. In addition, we are able to provide institution-specific cost-saving data with the use of dalbavancin.

2177. Institutional Prevalence of Drug-Resistant Pathogens in Community-Acquired Pneumonia

Background

Community-acquired pneumonia (CAP) is a leading cause of hospitalizations and plays a major role in mortality. The previous Infectious Diseases Society of America (IDSA) definition of healthcare-associated pneumonia (HCAP) was found to be neither sensitive nor specific for identifying drug-resistant pathogens including methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PsA) as a cause of CAP, and use is no longer supported by current guidelines. The 2019 IDSA guidelines for CAP management emphasizes the need for clinician understanding of local epidemiology data to guide selection of appropriate treatment. The primary objective of this study was to determine the prevalence of MRSA and PsA CAP at our institution.

Methods

This was a retrospective observational study of patients admitted to our 870-bed public hospital with a CAP or HCAP diagnosis within 48 hours of admission between March 2016 and March 2021. The primary outcome of prevalence of CAP caused by MRSA or PsA was determined by comparing the number of blood and adequate sputum cultures with MRSA or PsA to total reviewed cases. Secondary outcomes included the percentage of initial antibiotic regimens involving a broad-spectrum agent, percentage of initial broad-spectrum regimens de-escalated within 72 hours if indicated, and duration of CAP antibiotic treatment.

Results

A total of 220 patients were included. MRSA or PsA was isolated in 1.36% of adequate sputum cultures collected (n=3/35) and in no collected blood cultures (n=0/208). The local prevalence of CAP caused by MRSA or PsA among the analyzed sample was 1.36% (n=3/220) (Table 1). MRSA nares screening tests were completed in 10% of cases, 4.5% of which were positive (n=1/22). Secondary end point results are presented in Table 2.Table 1.

655. Combination Eravacycline Therapy for Carbapenem-Resistant Acinetobacter baumannii Pneumonia

Background

Acinetobacter baumannii typically causes infections in debilitated, hospitalized patients and is difficult to treat due to multiple virulence factors and the presence of intrinsic and acquired antibiotic resistance mechanisms leading to frequent isolation of multi-drug resistant (MDR) phenotypes. Due to problematic pharmacokinetics and/or dose-limiting toxicities of salvage agents, combination therapy with aminoglycosides, ampicillin/sulbactam, polymyxins, minocycline, or tigecycline, is often used. Eravacycline has demonstrated greater in-vitro potency against A. baumannii compared to other tetracycline derivatives making it potentially the more appealing option. However, its utility is hindered by a lack of data supporting pharmacodynamic targets and adequate dosing strategies for CRAB. The goal of this case series was to describe our experience with the use of combination eravacycline therapy for the treatment of CRAB pneumonia.

Methods

This case series included all patients ≥ 18 years of age, diagnosed with SARS-CoV-2, ≥ 1 sputum culture positive for CRAB and a clinical diagnosis of new bacterial pneumonia, who received at least one dose of eravacycline between April 1st and October 1st, 2020. The primary outcome was clinical resolution of CRAB pneumonia. Secondary outcomes evaluated microbiological resolution, need for extended durations of therapy, and frequency of re-starting CRAB therapy within 48 hours of completion.

Results

In total, 25 patients were included in this case series. The median duration of combination therapy was 10 days. Most patients (96%) received eravacycline + ampicillin/sulbactam, with 7 of those patients also receiving inhaled colistin (Table 2). In total, 17 (68%) patients achieved clinical resolution of CRAB pneumonia. Post-treatment sputum cultures were collected in 18 patients, of which 13 (72%) achieved microbiological resolution. One patient received > 14 days of therapy and no patients re-initiated therapy within 48 hours of eravacycline completion. Table 1:Baseline CharacteristicsTable 2:Study Outcomes

Conclusion

In this small case series, eravacycline showed favorable clinical outcomes in patients with CRAB pneumonia. In light of limited treatment options, this agent can be considered for CRAB pneumonia salvage therapy.

Disclosures

All Authors: No reported disclosures.

737. Oral Antibiotic Stepdown Therapy for Uncomplicated Streptococcal

Background

Streptococcus species are known pathogens in bloodstream infections (BSIs). Traditionally, BSIs are managed with intravenous (IV) antibiotics, however there is growing literature supporting oral (PO) antibiotics in BSIs as well as other invasive infections. Advantages to PO therapies include shortened hospital stay, reduced treatment costs, and avoidance of line-related complications. Currently, there is a paucity of data supporting the use of PO antibiotics in streptococcal BSIs.

Methods

This retrospective cohort study evaluated patients with streptococcal bacteremia between September 2019 to September 2021. Patients 18 and older were included if they had at least one positive blood culture for any Streptococcus species and excluded if BSI was polymicrobial, or treatment was for complicated BSI, identified by receipt of targeted therapy for ≥ 16 days, or source being endocarditis, osteomyelitis, or meningitis. Clinical outcomes were compared between patients who completed treatment with IV antibiotics verses those who completed with an PO stepdown regimen. The primary endpoint was clinical failure, which was a composite endpoint defined as BSI recurrence with the same pathogen and infection-related readmission within 30 days from completion of antibiotics.

Results

A total of 158 patients were included, with 77 (49%) receiving a full course of IV antibiotics and 81 (51%) receiving an PO antibiotic stepdown regimen. Clinical failure was not different between the IV antibiotics group versus the PO stepdown group, respectively (16% vs. 15%, odds ratio [OR] = 0.94; 95% confidence interval [CI], 0.40 to 2.25). No differences were observed in 30-day all-cause mortality. Patients that received PO antibiotic stepdown therapy had a significantly shorter hospital length of stay by 6 days (6 versus 12 days, p< 0.01).

Conclusion

Our results suggest that clinical cure with an PO stepdown regimen for uncomplicated streptococcal BSIs is comparable to IV antibiotics. The benefit of comparable efficacy in the setting of reduced length of stay and avoidance of central line placement for outpatient IV antibiotics should be considered when making treatment plans for patients with uncomplicated streptococcal BSIs.

Disclosures

All Authors: No reported disclosures.

Therapeutic Options for Coronavirus Disease 2019 (COVID-19): Where Are We Now?

PURPOSE OF REVIEW

Rapidly evolving treatment paradigms of coronavirus disease 2019 (COVID-19) introduce challenges for clinicians to keep up with the pace of published literature and to critically appraise the voluminous data produced. This review summarizes the clinical evidence from key studies examining the place of therapy of recommended drugs and management strategies for COVID-19.

RECENT FINDINGS

The global magnitude and duration of the pandemic have resulted in a flurry of interventional treatment trials evaluating both novel and repurposed drugs targeting various aspects of the viral life cycle. Additionally, clinical observations have documented various stages or phases of COVID-19 and underscored the importance of timing for the efficacy of studied therapies. Since the start of the COVID-19 pandemic, many observational, retrospective, and randomized controlled studies have been conducted to guide management of COVID-19 using drug therapies and other management strategies. Large, randomized, or adaptive platform trials have proven the most informative to guide recommended treatments to-date. Antimicrobial stewardship programs can play a pivotal role in ensuring appropriate use of COVID-19 therapies based on evolving clinical data and limiting unnecessary antibiotics given low rates of co-infection.

SUMMARY

Given the rapidly evolving medical literature and treatment paradigms, it is recommended to reference continuously updated, curated guidelines from national and international sources. While the drugs and management strategies mentioned in this review represent the current state of recommendations, many therapies are still under investigation to further define optimal COVID-19 treatment.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11908-021-00769-8.

Improved Antibiotic Prescribing Practices for Respiratory Infections Through Use of Computerized Order Sets and Educational Sessions in Pediatric Clinics

Background

Computerized clinical decision support systems (CDSS) have shown promising effectiveness in improving outpatient antibiotic prescribing.

Methods

We developed an intervention in the form of EPIC (Verona, WI, USA) order sets comprised of outpatient treatment pathways for 3 pediatric bacterial acute respiratory infections (ARIs) coupled with educational sessions. Four pediatric clinics were randomized into intervention and control arms over pre- and postimplementation study periods. In the intervention clinics, education was provided in between the 2 study periods and EPIC order sets became available at the beginning of the postimplementation period. The primary end point was the percentage of first-line antibiotic prescribing, and the secondary end points included antibiotic duration and antibiotic prescription modification within 14 days.

Results

A total of 2690 antibiotic prescriptions were included. During the pre-implementation phase, there was no difference in first-line antibiotic prescribing (74.9% vs 77.7%; P = .211) or antibiotic duration (9.69 ± 0.96 days vs 9.63 ± 1.07 days; P > .999) between the study arms. Following implementation, the intervention clinics had a higher percentage of first-line antibiotic prescribing (83.1% vs 77.7%; P = .024) and shorter antibiotic duration (9.28 ± 1.56 days vs 9.79 ± 0.75 days; P < .001) compared with the control clinics. The percentage of modified antibiotics was small in all clinics (1.1%-1.6%) and did not differ before and after the intervention (for all statistical comparisons, P ≤ .354).

Conclusions

A computerized CDSS involving treatment pathways in the form of order sets coupled with educational sessions was associated with a higher percentage of first-line antibiotic prescribing and shorter antibiotic duration for the outpatient treatment of pediatric bacterial ARIs.

Decreased Outpatient Fluoroquinolone Prescribing Using a Multimodal Antimicrobial Stewardship Initiative

Background

Fluoroquinolones are antibiotics prescribed in the outpatient setting, though they have serious side effects. This study evaluates the impact of stewardship interventions on total and inappropriate prescribing of fluoroquinolones in outpatient settings in a large county hospital and health system.

Methods

In an effort to decrease inappropriate outpatient fluoroquinolone usage, a multimodal antimicrobial stewardship initiative was implemented in November 2016. Education regarding the risks, benefits, and appropriate uses of fluoroquinolones was provided to providers in different outpatient settings, Food and Drug Administration warnings were added to all oral fluoroquinolone orders, an outpatient order set for cystitis treatment was created, and fluoroquinolone susceptibilities were suppressed when appropriate. Charts from October 2016, 2017, and 2018 were retrospectively reviewed if the patient encounter occurred in primary care clinics, emergency departments, or urgent care centers within Parkland Health & Hospital System and a fluoroquinolone was prescribed. Inappropriate use was defined as a fluoroquinolone prescription for cystitis, bronchitis, or sinusitis in a patient without a history of Pseudomonas aeruginosa or multidrug-resistant organisms and without drug allergies that precluded use of other oral antibiotics.

Results

Total fluoroquinolone prescriptions per 1000 patient visits decreased significantly by 39% (P < .01), and inappropriate fluoroquinolone use decreased from 53% to 34% (P < .01). More than 90% of inappropriate fluoroquinolone prescriptions were given for cystitis, while bronchitis and sinusitis accounted for only 4.4% and 1.6% of inappropriate indications, respectively.

Conclusion

A multimodal stewardship initiative appears to effectively reduce both total and inappropriate outpatient fluoroquinolone prescriptions.