Outcomes and factors associated with cryptococcal disease among cirrhotics: A study of the national inpatient sample 2005 to 2014

BACKGROUND

Cryptococcal disease (CD) confers a higher mortality in cirrhotic patients compared to non-cirrhotic patients. Factor association for CD in cirrhotic patients is poorly understood. Our aim was to determine the incidence, demographic, and comorbidities associated with CD among cirrhotic patients in the United States (US).

METHOD

Retrospective analysis of admissions of cirrhotic patients, with or without CD, using the National Inpatient Sample (NIS) database from 2005 to 2014. The number of admissions were reported in raw and weighted frequencies. The trends of CD among cirrhotic patients and overall CD were evaluated. Rao-Scott chi-square, t-tests, and multivariate logistic regressions were performed to evaluate variables and CD among cirrhotic patients.

RESULTS

There were 886,962 admissions for cirrhosis, and 164 of these with CD. By adjusted odds ratio (AOR), CD was more often associated with cirrhosis in Southern (2.95; 95 % CI 1.24, 7.02) and Western regions (4.45; 95 % CI 1.91, 10.37), Hispanic patients (1.80; 95 % CI 1.01, 3.20), and patients with chronic kidney disease (CKD) (3.13; 95 % CI 2.09, 4.69). Of note, CD in cirrhotic patients was associated with higher inpatient mortality (AOR of 3.89, 95 % CI 2.53, 5.99), longer length of stay (9.87 vs. 4.88 days), and a higher total charge ($76,880 vs. $ 37,227) when compared to cirrhotic patients without CD.

DISCUSSION

Patients with cirrhosis admitted with CD have a high inpatient mortality. The geographical location and CKD were important factors associated with CD among cirrhotic patients. Autoimmune liver diseases and immunosuppression did not appear to increase the risk of CD.

Approach to febrile neutropenia in patients undergoing treatments for hematologic malignancies

Febrile neutropenia (FN) is common among hematologic malignancy patients, including recipients of hematopoietic cell transplantation (HCT) and cellular therapies such as chimeric antigen receptor (CAR)-T-cell therapy. Prompt empiric antibiotic use has been the mainstay for decades but a "one-size-fits-all" approach is no longer broadly accepted, as treatment-related infectious risk are more understood. Growing antimicrobial resistance is an increasing clinical challenge. Evolving strategies on de-escalation of broad-spectrum antibiotics in FN without identified infection are areas of particular interest.

Identifying Effective Durations of Antibiotic Therapy for the Treatment of Carbapenem-resistant Enterobacterales Bloodstream Infections: A Multicenter Observational Study

In a propensity-score-weighted cohort of 183 adults with carbapenem-resistant Enterobacterales bacteremia at 24 US hospitals, patients receiving short courses of active therapy (7-10 days, median 9 days) experienced similar odds of recurrent bacteremia or death within 30 days as those receiving prolonged courses of active therapy (14-21 days, median 14 days).

Infectious complications among CD19 CAR-T cell therapy recipients: A single-center experience

BACKGROUND

CD19 chimeric antigen receptor (CAR)-T cell therapy has emerged as an effective treatment in those with refractory or relapsed lymphoma. CD19 CAR-T cell therapy can cause direct and indirect toxic adverse effects and increased risk for infection. Infectious complications and optimal antimicrobial prophylaxis strategies are an ongoing area of investigation.

METHODS

A single-center retrospective cohort study was conducted to review recipients of CD19 CAR-T cell therapy between April 2018 and December 2020. Patient characteristics and clinical outcomes were extracted from the electronic health records.

RESULTS

Infectious complications were identified in 18/50 (36%) recipients with 31 episodes of infection. The median time to infection was 225 days (range 0-614). Bacterial infections were most common with bloodstream infection followed by sinusitis and skin and soft tissue infection. Eight viral infections were identified, most being respiratory viral illnesses. Two fungal infections were identified: Pneumocystis jirovecii pneumonia (PJP) and disseminated fusariosis. Seventeen infections (54.8%) were classified as severe: leading to death, requiring hospitalization, need for empiric intravenous antibiotics, or significant alteration in hospital course. No characteristics were found to be statistically significant risks for infection, although a trend toward significance was seen in prior autologous stem cell transplant recipients (p = .12) and those with recurrent neutropenia (p = .14). Three patients (6%) died from infection.

CONCLUSION

Infections were common after CD19 CAR-T cell therapy and occurred beyond the first year. Further multicenter studies are needed to define infectious risks and optimize antimicrobial prophylaxis recommendations in recipients of CD19 CAR-T cell therapy.

Implementation of a Rapid Multiplex Polymerase Chain Reaction Pneumonia Panel and Subsequent Antibiotic De-escalation

Background

Net effects of implementation of a multiplex polymerase chain reaction (PCR) pneumonia panel (PNP) on antimicrobial stewardship are thus far unknown. This retrospective study evaluated the real-world impact of the PNP on time to antibiotic de-escalation in critically ill patients treated for pneumonia at an academic medical center.

Methods

This retrospective, quasi-experimental study included adult intensive care unit (ICU) patients with respiratory culture results from 1 May to 15 August 2019 (pre-PNP group) and adult ICU patients with PNP results from 1 May to 15 August 2020 (PNP group) at Nebraska Medical Center. Patients were excluded for the following reasons: any preceding positive coronavirus disease 2019 PCR test, lack of antibiotic receipt, or non-respiratory tract infection indications for antibiotics. The primary outcome was time to discontinuation of anti-methicillin-resistant Staphylococcus aureus (MRSA) therapy. Secondary outcomes included time to discontinuation of antipseudomonal therapy, frequency of early discontinuation for atypical coverage, and overall duration (in days) of antibiotic therapy for pneumonia.

Results

Sixty-six patients in the pre-PNP group and 58 in the PNP group were included. There were significant differences in patient characteristics between groups. The median time to anti-MRSA agent discontinuation was 49.1 hours in the pre-PNP and 41.8 hours in the PNP group (P = .28). The median time to discontinuation of antipseudomonal agents was 134.4 hours in the pre-PNP versus 98.1 hours in the PNP group (P = .47). Other outcomes were numerically but not significantly improved in our sample.

Conclusions

This early look at implementation of a multiplex PNP did not demonstrate a statistically significant difference in antibiotic use but lays the groundwork to further evaluate a significant real-world impact on antibiotic de-escalation in ICU patients treated for pneumonia.

Use of a beta-lactam graded challenge process for inpatients with self-reported penicillin allergies at an academic medical center

Background

The Antimicrobial Stewardship Program (ASP) at Nebraska Medicine collaborated with a board-certified allergist to develop a penicillin allergy guidance document for treating inpatients with self-reported allergy. This guidance contains an algorithm for evaluating and safely challenging penicillin-allergic patients with beta-lactams without inpatient allergy consults being available.

Methods

Following multi-disciplinary review, an order set for beta-lactam graded challenges (GC) was implemented in 2018. This contains recommended monitoring and detailed medication orders to challenge patients with various beta-lactam agents. Inpatient orders for GC from 3/2018-6/2022 were retrospectively reviewed to evaluate ordering characteristics, outcomes of the challenge, and whether documentation of the allergy history was updated. All beta-lactam challenges administered to inpatients were included, and descriptive statistics were performed.

Results

Overall, 157 GC were administered; 13 with oral amoxicillin and 144 with intravenous (IV) beta-lactams. Ceftriaxone accounted for the most challenges (43%). All oral challenges were recommended by an Infectious Diseases consult service, as were a majority of IV challenges (60%). Less than one in five were administered in an ICU (19%). Almost all (n = 150, 96%) were tolerated without any adverse event. There was one reaction (1%) of hives and six (4%) involving a rash, none of which had persistent effects. Allergy information was updated in the electronic health record after 92% of the challenges.

Conclusion

Both intravenous and oral beta-lactam graded challenges were implemented successfully in a hospital without a regular inpatient allergy consult service. They were well-tolerated, administered primarily in non-ICU settings, and were often ordered by non-specialist services. In patients with a self-reported penicillin allergy, these results demonstrate the utility and safety of a broadly adopted beta-lactam GC process.

The interplay of infectious diseases consultation and antimicrobial stewardship in candidemia outcomes: A retrospective cohort study from 2016 to 2019

OBJECTIVE

To evaluate the need for mandatory infectious diseases consultation (IDC) for candidemia in the setting of antimicrobial stewardship guidance.

DESIGN

Retrospective cohort study from January 2016 to December 2019.

SETTING

Academic quaternary-care referral center.

PATIENTS

All episodes of candidemia in adults (n = 92), excluding concurrent bacterial infection or death or hospice care within 48 hours.

METHODS

Primary outcome was all-cause 30-day mortality. Secondary outcomes included guideline-adherence and treatment choice. Guideline-adherence was assessed with the EQUAL Candida score.

RESULTS

Of 186 episodes of candidemia, 92 episodes in 88 patients were included. Central venous catheters (CVCs) were present in 66 episodes (71.7%) and were the most common infection source (N = 38, 41.3%). The most frequently isolated species was Candida glabrata (40 of 94, 42.6%). IDC was performed in 84 (91.3%) of 92 candidemia episodes. Mortality rates were 20.8% (16 of 77) in the IDC group versus 25% (2 of 8) in the no-IDC group (P = .67). Other comparisons were numerically different but not significant: repeat blood culture (98.8% vs 87.5%; P = .17), echocardiography (70.2% vs 50%; P = .26), CVC removal (91.7% vs 83.3%; P = .45), and initial echinocandin treatment (67.9% vs 50%; P = .44). IDC resulted in more ophthalmology examinations (67.9% vs 12.5%; P = .0035). All patients received antifungal therapy. Antimicrobial stewardship recommendations were performed in 19 episodes (20.7%). The median EQUAL Candida score with CVC was higher with IDC (16 vs 11; P = .001) but not in episodes without CVC (12 vs 11.5; P = .81).

CONCLUSIONS

In the setting of an active antimicrobial stewardship program and high consultation rates, mandatory IDC may not be warranted for candidemia.

Opportunities for Antimicrobial Stewardship Interventions Among Solid Organ Transplant Recipients

Although antimicrobial stewardship programs have excelled over the past decade, uptake and application of these programs to special populations such as solid organ transplant recipients have lagged. Here, we review the value of antimicrobial stewardship for transplant centers and highlight data supporting interventions that are ripe for adoption. In addition, we review the design of antimicrobial stewardship initiatives, targets for both syndromic and system-based interventions.

1298. Donor Call Simulation: A Novel Medical Education Tool to Evaluate Trainees’ Clinical Decision-Making in Transplant Infectious Disease

Background

Simulation is a useful education tool for high-stakes clinical skills and decision-making. Recommending whether to accept or reject an organ for transplantation based on infection risk is a critical core competency in Transplant Infectious Disease (ID), however there are no published data that learners have opportunities to practice this during training. We created a novel simulation to expose learners to this real-life clinical scenario and evaluated their clinical decision-making in these situations.

Methods

We created 6 simulations with common ID consult questions about whether to accept or reject an organ for transplant based on infection risk (Table 1). During learners’ Transplant ID rotations, faculty periodically texted or paged them with the simulation cases as though they were the transplant coordinator. Learners had 15 minutes to ask follow up questions before deciding to accept or reject the organ and explain their decision-making process in a survey. Learners completed a survey 1 month after the simulation experience to evaluate its effectiveness.

Results

Between October 2021 and April 2022, 16 learners from 7 medical centers participated in the simulation (Table 2) and 94% (15/16) completed the follow up survey. Eighty-seven percent (13/15) of ID learners reported that the simulation was effective in teaching them when to accept or reject organs and 80% (12/15) felt more prepared to make these decisions in practice. Most learners correctly identified acceptable organs for transplant during the simulations (Figure 1). Of the 100 clinical reasoning decisions made during the activity, 19% were discordant, where the learner correctly decided to accept or decline the organ but with incorrect or incomplete reasoning for this decision (Figure 2).

Conclusion

ID learners perceived our transplant ID simulation as an effective educational tool to learn when to accept or reject an organ for transplant. By evaluating the clinical reasoning behind these decisions our simulation provides ID educators with nuanced insight into their learners' thought process and allows for targeted coaching to correct deficits in reasoning.

Disclosures

Rebecca Kumar, MD, Gilead: Grant/Research Support|Regeneron: Grant/Research Support Jonathan Hand, MD, GlaxoSmithKline: Grant/Research Support|Janssen: Grant/Research Support|Pfizer: Grant/Research Support Roderick Go, DO, Aptose Biosciences: Stocks/Bonds|Bristol Meyers Squibb: Stocks/Bonds|Cytodyn Inc.: Stocks/Bonds|Scynexis: Grant/Research Support Erica J. Stohs, MD, MPH, bioMerieux: Grant/Research Support.

165. Biofire pneumonia panel use in severe pneumonia and antibiotic treatment in COVID-19 patients

Background

Hospitalized COVID-19 patients with severe pneumonia are commonly treated for secondary bacterial pneumonia. The Biofire pneumonia panel, a rapid molecular diagnostic tool with 18 bacterial, 8 viral and 7 resistance gene targets, was made available to critical care and infectious disease clinicians in May 2020 at our institution. We sought to describe its utilization and influence on antibiotic use in patients hospitalized with COVID-19 lower respiratory tract infection (LRTI).

Methods

Eligible patients with COVID-19 LRTI (positive PCR test and abnormal chest imaging) had sputum or bronchoalveolar lavage pneumonia panel (PNP) paired with a respiratory tract culture between May 4 and Dec. 8, 2020, were included. Demographics, comorbidities, clinical data including microbiologic testing, PNP indication(s), and antibiotic use after testing were abstracted through chart review. Descriptive statistics were utilized.

Results

Characteristics of 133 patients are provided in Table 1. Median age was 61 years, 93 (70%) were male, 93 (70%) were mechanically ventilated, and 68 (51%) died within 30 days on PNP testing. PNP results, including culture results are listed in Table 2. No target was identified in 63 (47%) patients. Staphylococcus aureus was the most common bacterial isolate identified (MSSA in 32 [24%], MRSA in 8 [6%]) with culture growth in 21 specimens. More than 1 target was identified in 29 patients (22%). Empiric antibiotics and subsequent modifications within 24h hours of pneumonia panel are provided in Table 3. Vancomycin and cefepime were most frequently prescribed. Antibiotic modifications were made in 71/133 patients. Cessation of the anti-MRSA agent occurred in 39/72 (54%) of eligible patients and the anti-Pseudomonal agent in 21/78 (27%).

Conclusion

The PNP is a useful tool to evaluate secondary bacterial pneumonia in critically ill COVID-19 patients and may assist clinicians and antimicrobial stewardship programs in expedited antibiotic discontinuation or de-escalation particularly where rates of secondary bacterial infection are low, such as COVID-19 LRTI.

Disclosures

Erica J. Stohs, MD, MPH, bioMerieux: Grant/Research Support Paul D. Fey, PhD, BioFire: Advisor/Consultant|BioFire: Grant/Research Support|Merck: Grant/Research Support Trevor C. Van Schooneveld, MD, bioMerieux: Advisor/Consultant|bioMerieux: Grant/Research Support|Insmed: Grant/Research Support|Merck: Grant/Research Support|Thermo-Fischer: Advisor/Consultant.

Beta-lactam allergies, surgical site infections, and prophylaxis in solid organ transplant recipients at a single center: A retrospective cohort study

BACKGROUND

Beta-lactam allergies (BLAs) are common in hospitalized patients, including transplant recipients. BLA is associated with decreased use of preferred surgical site infection (SSI) prophylaxis and increased SSIs, but this has not been studied in the transplant population.

METHODS

We reviewed adult heart, kidney, and liver transplant recipients between January 1, 2016 and December 31, 2019 to characterize reported BLA and collect SSI prophylaxis regimens at time of transplant. We compared the use of preferred SSI prophylaxis and SSI incidence based on reported BLA status. Post hoc we collected antibiotic days of therapy (DOT) (excluding pneumocystis prophylaxis) in the 30-day period posttransplant for patients without SSI. We utilized descriptive statistics for comparisons.

RESULTS

Of 691 patients included (116 heart, 400 kidney, and 175 liver transplant recipients), 118 (17%) reported BLA. Rash and hives were the two most reported BLA reactions (36% and 24%), categorized as potential T-cell mediated and IgE mediated, respectively. Preferred SSI prophylaxis was prescribed in 13 (11%) patients with BLA and 573 (92%) without BLA (p < .001). No difference could be detected in SSI incidence between BLA and non-BLA patients (4.2 vs. 4.3%, p = 1.0). Of 659 without SSI, 169 (25.6%) received antibiotics within 30 days of transplant; mean antibiotic DOT for BLA and non-BLA patients were 3.5 ± 8.0 versus 2.3 ± 5.8, p = .12.

CONCLUSION

BLA transplant recipients received nonpreferred SSI prophylaxis more frequently than non-BLA recipients, but there was no difference in 30-day SSIs between the groups. One-fourth of solid organ transplant recipients received systemic antibiotics within 30 days of transplant.

988. Is There Value of Infectious Diseases Consultation in Candidemia? A Single Center Retrospective Review From 2016-2019

Background

Candidemia is the second most common cause of healthcare-associated bloodstream infections in the US with mortality of approximately 25%. Studies demonstrate lower candidemia mortality with infectious diseases consultation (IDC). We evaluated effects of IDC on mortality and guideline-adherence at our institution to determine if mandatory IDC was warranted.

Methods

We retrospectively reviewed adults hospitalized with candidemia (≥ 1 blood culture positive for Candida) between 1/1/2016-12/31/2019. Exclusion criteria included age < 19 years, polymicrobial blood culture, or death or hospice within 48 hours. Primary outcome was all-cause 30-day mortality. Secondary outcomes included guideline-adherence and treatment choice. Guideline-adherence was assessed with a modified EQUAL Candida score (Table 1). Descriptive statistics were performed.

Table 1. Original vs Modified EQUAL Candida Score

Abbreviations. CVC: central venous catheter, BCx: blood culture

Results

Of 187 patients reviewed, 92 episodes of candidemia with 94 species of Candida were included. Patient characteristics are shown in Table 2. Central venous catheters (CVCs) were present in 66 (71.7%) patients and were the most common infection source (N=38 [41.3%]) followed by intra-abdominal (N=23 [25%]). The most isolated species were Candida glabrata (40/94 [42.6%]) and C. albicans/dublienensis (35/94 [37.2%]). 30-day mortality was 21.7%. IDC was performed in 84 (91.3%) cases. Outcomes are in Table 3. Mortality was not different between IDC vs no IDC (18 [21.4%] vs 2 [25%]); other comparisons were numerically different but not significant: repeat blood culture (98.8% vs 87.5%), echocardiography (70.2% vs 50%), CVC removal (91.7% vs 83.3%), and initial treatment echinocandin (67.9% vs 50%). All patients received antifungal therapy. IDC resulted in more ophthalmology consultations (77.4% vs 12.5%, p< 0.01). Mean modified EQUAL Candida score was higher with IDC (17.4 vs 13.9, p< 0.01).

Table 2. Patient Characteristics

Abbreviations. TPN: total parenteral nutrition, ICU: intensive care unit, AIDS: acquired immunodeficiency syndrome

Table 3. Outcomes

Abbreviations. NS: non-significant, CVC: central venous catheter

Conclusion

IDC was common in candidemic patients and not associated with significant differences in outcomes. Current antimicrobial stewardship and consultation practices at our center do not warrant mandated IDC for candidemia.

Disclosures

Trevor C. Van Schooneveld, MD, FACP, BioFire (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Insmed (Individual(s) Involved: Self): Scientific Research Study Investigator; Merck (Individual(s) Involved: Self): Scientific Research Study Investigator; Rebiotix (Individual(s) Involved: Self): Scientific Research Study Investigator

161. Flucytosine Utilization and Dosing Practices at an Academic Medical Center

Background

The typical dose of flucytosine is 25 mg/kg/dose every 6 hours for severe infections due to Candida and Cryptococcus. Many hospital protocols use ideal body weight (IBW) for initial dosing to achieve a goal peak serum concentration of 30-80 mcg/mL, but this is supported by very limited data. Our objective was to evaluate flucytosine dosing strategies, describe safety concerns, and explore financial benefits associated with using IBW.

Methods

All inpatient flucytosine orders for adults from 1/1/2015 through 10/31/2020 were retrospectively evaluated. Doses, weight used, flucytosine levels, adverse events, and potential cost savings associated with IBW dosing were characterized.

Results

During this period, 35 patients received flucytosine. The most common indications were cryptococcal meningitis (73%), pulmonary cryptococcosis (14%), and candidiasis (11%). Most patients were receiving concurrent liposomal amphotericin B (92%). Based on body mass index, most patients were overweight or obese (60%). Actual body weight was used for initial dosing in most cases (81%). Flucytosine peak monitoring was performed in 51% of cases. Initial peak levels were supratherapeutic in 10/19 cases (53%). Of those 10 patients, 70% were overweight/obese, and 60% would have received a lower initial dose if IBW had been used with dose rounding to the nearest 500mg capsule. Adverse events for all patients included new onset cytopenias, hepatic and renal dysfunction, occurring in 20%, 11%, and 60% respectively. Those with supratherapeutic levels had higher rates of new onset hepatic and renal dysfunction, 30% and 90% respectively. In 32% of cases, using IBW would have resulted in a lower daily dose, with an average dose reduction of 1888 mg, resulting in a mean cost savings per patient of &640/day using average wholesale price.

Conclusion

Most flucytosine orders were not dosed using IBW, which may have led to supratherapeutic levels. Using IBW for dosing in overweight patients may lead to reduced toxicity and potential cost savings. The default dosing weight for flucytosine in our electronic medical record will be set to IBW to encourage change.

Disclosures

Trevor C. Van Schooneveld, MD, FACP, BioFire (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Insmed (Individual(s) Involved: Self): Scientific Research Study Investigator; Merck (Individual(s) Involved: Self): Scientific Research Study Investigator; Rebiotix (Individual(s) Involved: Self): Scientific Research Study Investigator Bryan Alexander, PharmD, Astellas Pharma (Advisor or Review Panel member) Scott J. Bergman, PharmD, FCCP, FIDSA, BCPS, BCIDP, Merck & Co., Inc (Grant/Research Support) Scott J. Bergman, PharmD, FCCP, FIDSA, BCPS, BCIDP, Merck & Co., Inc (Individual(s) Involved: Self): Research Grant or Support

The limits of refusal: An ethical review of solid organ transplantation and vaccine hesitancy

Patients pursuing solid organ transplantation are encouraged to receive many vaccines on an accelerated timeline. Vaccination prior to transplantation offers the best chance of developing immunity and may expand the pool of donor organs that candidates can accept without needing posttransplant therapy. Furthermore, transplant recipients are at greater risk for acquiring vaccine-preventable illnesses or succumbing to severe sequelae of such illnesses. However, a rising rate of vaccine refusal has challenged transplant centers to address the phenomenon of vaccine hesitancy. Transplant centers may need to consider adopting a policy of denial of solid organ transplantation on the basis of vaccine refusal for non-medical reasons (i.e., philosophical or religious objections or personal beliefs that vaccines are unnecessary or unsafe). Arguments supporting such a policy are motivated by utility, stewardship, and beneficence. Arguments opposing such a policy emphasize justice and respect for persons, and seek to avoid worsening inequities or medical coercion. This paper examines these arguments and situates them within the special cases of pediatric transplantation, emergent transplantation, and living donation. Ultimately, a uniform national policy addressing vaccine refusal among transplant candidates is needed to resolve this ethical dilemma and establish a consistent, fair, and standard approach to vaccine refusal in transplantation.

884. Evaluation of Surgical Site Infections in Solid Organ Transplant Recipients with Beta-Lactam Allergies

Background

Beta-lactam allergies (BLA) are common, but the prevalence and impact on solid organ transplant (SOT) recipients is largely unknown. We assessed the prevalence of BLA labels in SOT recipients at the time of transplant and evaluated their influence on surgical site infection (SSI) prophylaxis and SSI incidence.

Methods

All patients undergoing first heart, kidney, liver SOT at our institution were retrospectively reviewed (1/1/2015-12/31/2019). Antibiotic allergies, surgical antibiotic prophylaxis, and SSIs were abstracted from the electronic medical record. Reported BLA reactions were classified as potentially IgE-mediated, delayed, or non-allergic based on documentation. SSIs were reported according to NHSN definitions, and the incidence of SSI was compared between patients with and without reported BLA. SSI prophylaxis regimens were compared to institutional guidelines. Basic descriptive statistics were performed.

Results

Out of a total cohort of 751 patients (122 heart, 435 kidney, 209 liver, 4 multi-organ), 129 (17%) reported at least one BLA, with 104 (15%) with reactions to penicillins, 26 (3%) to cephalosporins, and 1 (0.1%) to carbapenems. Commonly reported reactions were rash (38%), hives (25%), and “other” (21%); 28% of documented reactions were not documented or classified as non-allergic. SSI developed in 7 (6.1%) of heart, 10 (2.5%) of kidney, and 16 (9.4%) of liver transplant recipients. Excluding 44 patients already on antibiotics for treatment of systemic infection, guideline concordant beta-lactam antibiotic surgical prophylaxis was administered to 6 (5.2%) of BLA group vs 490 (85.8%) in the non-BLA group (p< 0.01); among the BLA group who did not receive a beta-lactam, 96 (83%) received a regimen concordant with institutional guidelines for penicillin allergy and 14 (12%) received guideline non-adherent regimens. Patients reporting BLA did not have a higher incidence of SSIs compared to those without BLA: 6 (4.8%) vs 27 (4.5%) respectively, p=0.86.

Conclusion

BLA prevalence in our SOT population was similar to previously reported rates, but many reported reactions were not allergic in nature. Pre-transplant allergy evaluation for patients with reported BLA may improve SSI antibiotic prophylaxis compliance.

Disclosures

All Authors: No reported disclosures

289. Impact of Clinician Specialty on the Use of Oral Antibiotic Therapy for Definitive Treatment of Uncomplicated Bloodstream Infections

Background

No established guidelines exist regarding the role of oral antibiotic therapy (OAT) to treat uncomplicated bloodstream infections (uBSIs) and practices may vary depending on clinician specialty and experience.

Methods

An IRB-exempt web-based survey was emailed to Nebraska Medicine clinicians caring for hospitalized patients, and widely disseminated using social media. The survey was open access and once disseminated on social media, it was impossible to ascertain the total number of individuals who received the survey. Chi-squared analysis for categorical data was conducted to evaluate the association between responses and demographic groups.

Results

Of 275 survey responses, 51% were via social media, and 94% originated in the United States. Two-thirds of respondents were physicians, 16% pharmacists, and infectious diseases clinicians (IDC) represented 71% of respondents. The syndromes where most were comfortable using OAT routinely for uBSI were urinary tract infection (92%), pneumonia (82%), pyelonephritis (82%), and skin/soft tissue infections (69%). IDC were more comfortable routinely using OAT to treat uBSIs associated with vertebral osteomyelitis and prosthetic joint infections than non-infectious diseases clinicians (NIDC), but NIDC were more likely to report comfort with routine use of OAT to treat uBSIs associated with meningitis and skin/soft tissue infections. IDC were more likely to report comfort with routine use of OAT for uBSIs due to Enterobacteriaceae and gram-positive anaerobes, while NIDC were more likely to be comfortable with routinely using OAT to treat uBSIs associated with S. aureus, coagulase-negative staphylococci and gram-positive bacilli. In one clinical vignette of S. aureus uBSI due to debrided abscess, 11% of IDC would be comfortable using OAT vs 28% of NIDC; IDC were more likely to report routinely repeating blood cultures (99% vs 83%, p&lt; 0.05).

Figure 1: Clinician comfort using oral antibiotic therapy to treat uncomplicated bacteremia due to specific syndromes

Conclusion

Considerable variation in comfort using OAT for uBSIs among IDC vs NIDC exists, highlighting opportunities for IDC to continue to demonstrate their value in clinical practice. Understanding the reasons for variability may be helpful in creating best practice guidelines to standardize decision making.

Disclosures

All Authors: No reported disclosures

Reported β-Lactam and Other Antibiotic Allergies in Solid Organ and Hematopoietic Cell Transplant Recipients

BACKGROUND

Patients with reported β-lactam antibiotic allergies (BLAs) are more likely to receive broad-spectrum antibiotics and experience adverse outcomes. Data describing antibiotic allergies among solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients are limited.

METHODS

We reviewed records of adult SOT or allogeneic HCT recipients from 1 January 2013 to 31 December 2017 to characterize reported antibiotic allergies at time of transplantation. Inpatient antibiotic use was examined for 100 days posttransplant. Incidence rate ratios (IRRs) comparing antibiotic use in BLA and non-BLA groups were calculated using multivariable negative binomial models for 2 metrics: days of therapy (DOT) per 1000 inpatient days and percentage of antibiotic exposure-days.

RESULTS

Among 2153 SOT (65%) and HCT (35%) recipients, 634 (29%) reported any antibiotic allergy and 347 (16%) reported BLAs. Inpatient antibiotics were administered to 2020 (94%) patients during the first 100 days posttransplantation; average antibiotic exposure was 41% of inpatient-days (interquartile range, 16.7%-62.5%). BLA patients had significantly higher DOT for vancomycin (IRR, 1.4 [95% confidence interval {CI}, 1.2-1.7]; P < .001), clindamycin (IRR, 7.6 [95% CI, 2.2-32.4]; P = .001), and aztreonam in HCT (IRR, 9.7 [95% CI, 3.3-35.0]; P < .001), and fluoroquinolones in SOT (IRR, 2.9 [95% CI, 2.1-4.0]; P < .001); these findings were consistent when using percentage of antibiotic exposure-days.

CONCLUSIONS

Transplant recipients are frequently exposed to antibiotics and have a high prevalence of reported antibiotic allergies. Reported BLA was associated with greater use of β-lactam antibiotic alternatives. Pretransplant antibiotic allergy evaluation may optimize antibiotic use in this population.

2668. Β Lactam and Other Antibiotic Allergies in Patients Undergoing Solid-Organ and Hematopoietic Cell Transplantation

Background

Patients with reported β-lactam antibiotic allergies (BLA) are more likely to receive broad-spectrum antibiotics and experience adverse outcomes. There are limited data on the burden of β-lactam and other antibiotic allergies among solid-organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients.

Methods

We reviewed records of first-time adult SOT or allogeneic HCT recipients from January 1, 2013 to December 31, 2017 to characterize allergy labels at the time of transplant. Days of hospitalization and inpatient antibiotic use for pre-specified antimicrobials were collected for the first 100 days post-transplant, and incidence rate ratios (IRR) comparing BLA to non-BLA group were calculated using negative binomial models adjusted for transplant type, age, and diagnosis of cystic fibrosis as appropriate. If the adjusted estimates were significantly different for SOT and HCT recipients, separate models were presented.

Results

Among 2153 SOT (65%) and HCT (35%) recipients, 634 (29%) reported any antibiotic allergy and 347 (16%) reported BLAs (Figure 1). Of 634 patients with allergy labels, the most common were penicillins (40%), sulfa (29%), and cephalosporins (17%); 31% reported allergies to ≥2 classes of antibiotics. The most commonly reported reaction to β-lactams was rash (42%), followed by unknown (18%) and hives (17%). In a multivariable model (Table 1), patients with reported BLAs had significantly higher use of vancomycin (IRR 1.35 [95% CI 1.13, 1.60], P < 0.001) and significantly lower use of ampicillin-sulbactam (IRR 0.13 [0.05, 0.39], P < 0.001) and piperacillin–tazobactam (IRR 0.39 [0.25, 0.62], P < 0.001) compared with those without BLAs. For some antibiotics, the effect of BLA varied by SOT/HCT (Table 2). No significant differences in Clostridioides difficile infection or inpatient days were noted.

Conclusion

Transplant recipients have a high burden of reported antibiotic allergies, in particular BLAs. A BLA label was significantly associated with altered antibiotic prescribing in the early post-transplant period. Pre-transplant allergy evaluation may be helpful in directing antibiotic use following transplant as part of a comprehensive antibiotic stewardship program.

Disclosures

All authors: No reported disclosures.

1001. Feasibility and Outcomes of a Pre-Transplant Antibiotic Allergy Evaluation Program for Allogeneic Hematopoietic Cell Transplant (HCT) Candidates

Background

Antibiotic allergies impact the management of hematopoietic cell transplant (HCT) patients who are often prescribed antibiotics for infection prophylaxis and treatment. We evaluated the feasibility and outcomes of an antibiotic allergy evaluation program prior to allogeneic HCT.

Methods

In August 2017, we implemented a program to expedite allergy clinic referrals for adult allogeneic HCT candidates who reported an antibiotic allergy at their initial pre-transplant evaluation visit (PTEV). Allergy labels and clinical data including outcomes of allergy evaluation were prospectively collected for patients with PTEVs between 8/10/17 and November 15/18. The use of selected antibiotics was collected in the 100 days following HCT among patients with a reported β-lactam allergy (BLA). Choice of prophylactic agent for Pneumocystis jiroveci among patients with reported sulfa allergies was assessed among HCT recipients after engraftment.

Results

Of 276 allogeneic HCT candidates, 109 (39.5%) reported >= 1 antibiotic allergy (Table 1). Of the 109, 69 (63%) were referred for allergy evaluation; 83% (57/69) of those referred were evaluated at a median of 14 days after PTEV, and a median of 18 days before transplant. Among evaluated patients, 45 (79%) had >= 1 antibiotic allergy de-labeled including 74% (28/38) of those with BLA (Figure 1). Of the 10 patients whose BLAs could not be delabeled, 1 had a possible immediate IgE-mediated reaction, 5 had a delayed type IV hypersensitivity, and 4 had other reactions or required additional testing. Post-transplant antibiotic use among evaluated vs. nonevaluated patients reporting BLA is shown in Figure 2. Among 31 patients with reported sulfa allergies who underwent HCT, those who were evaluated received TMP-SMX rather than alternative prophylaxis more often (48%; 11/23) than those who were not evaluated (25%; 2/8). 10 (43%) of 23 evaluated patients were delabeled; 7 of 10 delabeled patients received TMP-SMX.

Conclusion

Antibiotic allergies are frequently reported among HCT candidates. Pre-transplant antibiotic allergy evaluation was feasible, led to de-labeling of the majority of reported allergies, and may alter antibiotic prescribing and increase the use of preferred agents following transplant.

Disclosures

All authors: No reported disclosures.

1066. Antimicrobial Stewardship Program: Audit and Feedback for Continued Improvement

Background

Audit and feedback is a foundational approach used by antimicrobial stewardship programs (ASP) and has been our primary method for ASP intervention for over 7 years. We sought to evaluate and improve our ASP methods as well as identify barriers to effective antimicrobial management.

Methods

We distributed an online survey at our institution, to clinicians (prescribers and pharmacists). Results compared their perceptions of the ASP and barriers to antimicrobial stewardship. Descriptive statistics include counts and percentages for categorical variables. Fisher’s exact test was performed to describe the comparison groups for each survey response. We reviewed survey comments and categorized according to themes.

Results

We distributed the survey to 459 clinicians over 4 months with 110 surveys completed for a response rate of 24%. Prescribers comprised 77.3% of respondents. 74.5% of clinicians reported that antibiotic overuse is a problem at our institution. Prescribers were more likely to agree that conflicting priorities to core measures was a barrier to stewardship as well as disagree with current guidelines (P < 0.05) compared with pharmacists. Figure 1 demonstrates other barriers. Prescribers found ASP more helpful than pharmacists in antimicrobial dose adjustments (P < 0.05). Figure 2 demonstrates other scenarios where ASP provided input with varying degrees of perceived helpfulness. Pharmacists used the ASP website more than prescribers (P < 0.05). Text message and phone call were preferred methods of contact with prescribers favoring messages and pharmacists favoring phone calls. Clinicians infrequently used order-sets; Figure 3 demonstrates reasons for lack of use. 17.2% of participants commented about the ASP; of these, 42% were positive and 32% contained suggestions to improve communication and education. Comments are summarized in Figure 4.

Conclusion

Overall, clinicians agree that antimicrobial overuse is a concern at our institution. ASP is generally well received; however, after 7 years of operation, this survey shows that continued improvement is needed, notably in communication, education, and EMR order-sets. Results will be used to refine methods of effective communication and information delivery to nurture an effective relationship.

Disclosures

All authors: No reported disclosures.

2666. De-escalation of Broad-Spectrum Antibiotics in Hematopoietic Stem Cell Transplant Patients During Initial Episode of Febrile Neutropenia

Background

Febrile neutropenia (FN) is a common and serious complication in patients undergoing hematopoietic stem cell transplant (HSCT). Typically, broad-spectrum antibiotics (BSA) are promptly initiated with controversy on timing of de-escalation. ECIL 2013 guidelines suggest de-escalation after 72 hours if the patient is infection free and afebrile for at least 48 hours. Conversely, the 2011 IDSA recommends continuing BSA in patients who defervesce until absolute neutrophil count (ANC) recovery. In 2014, our center’s practice changed to early de-escalation and we sought to compare outcomes between the two practices.

Methods

We retrospectively analyzed patients who underwent a HSCT in 2013 and 2017 with an episode of FN and negative infectious work up. The standard care group (SCG) were continued on BSA until ANC recovery. The early de-escalation group (EDG) de-escalated to fluoroquinolone prophylaxis at least 24 hours prior to ANC recovery after the patient was fever free for 48 hours. The primary end-point was duration of BSA. Secondary endpoints included 30-day mortality, re-hospitalization and length of stay (LOS) from FN. Median values were compared with the Mann–Whitney test.

Results

Among 229 HSCT patients, 155 (68%) developed FN post-transplant and of those 97 (63%) were without infection (13 EDG and 84 SCG). Initial FN duration of BSA was less in the EDG (3.09 days vs. 4.69 days, P = 0.069). Total antibiotic free days to 30 day follow-up were similar (EDG 24.08 vs SCG 25.19, P = 0.81). Duration of neutropenia was less in the SCG with 7.99 days compared with 11.69 days in the EDG (P = 0.007), but duration of initial fever was less in the EDG (2.55 days vs. 3.33 days, P = 0.023). 30 day mortality was 0% in both groups. Rates of re-hospitalization within 30 days were approximately the same (7.1% vs. 7.6%). LOS from FN was not significantly different with 6.68 days in SCG and 7.75 days in EDG (P = 0.140). More new bacterial infections were identified within 30 days of FN in the SCG than the EDG (10.7% vs. 7.6%).

Conclusion

Early BSA de-escalation resulted in no significant difference in LOS from FN and fewer days of BSA with 30-day mortality and re-hospitalization rates similar. This data suggest de-escalating BSA prior to ANC recovery is likely safe and leads to less BSA exposure, but more multi-center data are needed.

Disclosures

All authors: No reported disclosures.

1023. Isavuconazonium Use at an Academic Transplant Center

Background

Isavuconazonium is an appealing anti-fungal due to its broad spectrum of activity, predictable pharmacokinetics, oral bioavailability, and lack of QTc prolongation, but real-world experience with it is limited. At our academic medical center, isavuconazonium is restricted to the infectious diseases (ID) service for treatment of invasive fungal infections, including endemic mycoses due to high prevalence, and is recommended for patients intolerant of first-line agents. The purpose of this study was to describe isavuconazonium use at our institution and assess adherence to its formulary guidelines.

Methods

Inpatients with an order for isavuconazonium between June 2016 and November 2018 were analyzed via retrospective chart review. Prescribing team, indication, and rationale for use were evaluated.

Results

There were 97 inpatient encounters with an isavuconazonium order among 57 patients. Of those, 30 were solid-organ transplants and 9 had bone marrow transplants. Indications for isavuconazonium were: histoplasmosis 25%, high-risk fungal prophylaxis 21%, invasive aspergillosis 9%, candidiasis 2%, and other 44% (Table 1). Preceding anti-fungal therapy included: voriconazole 49%, posaconazole 12%, fluconazole 9%, micafungin 7%, amphotericin B 5%, itraconazole 4%, and none 35%. The rationale for the use of isavuconazonium is described in Table 2. ID consultation occurred in 79% of patients. Those without a consult had an indication of prophylaxis or were continuation of therapy started outpatient or at an outside hospital (OSH).

Conclusion

Histoplasmosis was the most common infection treated with isavuconazonium, despite limited data for that indication. Further investigation of the clinical course for these patients is warranted. Reasons for use most commonly centered on concern for QTc prolongation, clinical failure, and drug interactions. Over one-third of patients received no anti-fungal therapy prior to initiation. Adherence to required ID consultation was high. Patients on isavuconazonium for prophylaxis or as continuation therapy without a consult may still benefit from ID review to assess the appropriateness of therapy.

Disclosures

All authors: No reported disclosures.