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Background It is unclear based on published literature whether shorter courses of antibiotic treatment may be appropriate for urinary tract infections (UTI) in patients with SCI/D given their complex baseline clinical status. Methods This retrospective cohort study was conducted at the VA San Diego Healthcare System (VASDHS), which has a dedicated SCI/D unit. Adults with SCI/D were identified for inclusion if they had received antibiotics for a positive urine culture in conjunction with UTI symptoms from 1/2018-12/2020. Individual UTI events were excluded if associated with potential sources of harbored infection, anatomic abnormalities increasing risk of bacteriuria, non-bacterial pathogens, concurrent infections prolonging antibiotic treatment, or antibiotic courses managed outside of VASDHS. Treatment groups comprised UTI events treated with no more than 7 days of antibiotics (group 1) versus more than 7 days (group 2). Study endpoints were recurrence or new incidence of UTI within 30 and 90 days after completion of antibiotic treatment and onset of C. difficile infection or death within 30 or 90 days, respectively, after treatment completion. Statistical tests included Chi-square, Mann-Whitney U, and logistic regression. Results One-hundred and seven patients with 241 unique UTI events were included in this study, with 79 events in group 1 and 162 events in group 2. Baseline characteristics were similar across both groups, aside from a higher incidence of hospital admission and more severe SCI/D based on the American Spinal Cord Injury Association (ASIA) impairment scale in group 2. Efficacy outcomes are described in Table 1. No deaths occurred within 90 days of treatment completion, and C. difficile infection occurred in 1 patient in group 2 after 3 days of antibiotic therapy. Duration of antibiotic therapy was not predictive of treatment failure within 30 days of antibiotic completion. Factors predictive of treatment with longer courses of antibiotic therapy included hospital admission and more severe ASIA impairment scale score. Table 1. Incidence of UTI after antibiotic completion Conclusion The findings of this study suggest that for some patients with SCI/D, UTI treatment lasting 7 days or fewer may be effective compared to longer courses of antibiotics and could be beneficial in reducing collateral damage from antibiotic use. Disclosures All Authors: No reported disclosures

Background Antibiotic dosing optimization is a key principle of antimicrobial stewardship. This study evaluated the impact of an extended infusion piperacillin/tazobactam dosing protocol on clinical outcomes in acutely ill veterans treated for infections at VA San Diego. Methods This retrospective cohort study looked at veterans admitted to the medical-surgical unit who were treated with piperacillin/tazobactam for at least 48 hours. The control group included patients who received treatment between 12/14/2017 to 7/22/2018, and the “protocol” or after protocol implementation group included patients who received treatment between 7/23/2018 to 2/28/2019. Excluded from the study were veterans with microbiological cultures showing intermediate sensitivity or resistance to piperacillin/tazobactam, those who experienced interruption in therapy, or those who required dialysis. Primary clinical outcomes included in-hospital mortality rate, 30-day mortality rate, hospital length of stay (LOS), and 30-day readmission rates. Rates of adverse effects such as elevated liver enzymes, thrombocytopenia, acute kidney impairment (AKI), and Clostridium difficile infection were also collected. χ 2, Fisher’s exact, and Mann-Whitney U tests were used for statistical analysis. Results 260 veterans were included in the final analysis: 96% male, mean age 65 years, mean BMI 29, 84 met SIRS criteria for sepsis, and 55% received at least 48 hours of concomitant vancomycin. Groups had similar outcomes for median LOS, in-hospital mortality, and 30-day mortality. The incidence of AKI was significantly lower in the protocol group (39.2% vs. 56.9%, p=0.004), in veterans on concomitant vancomycin (42.3% vs. 63.2%, p=0.011), and in veterans with obesity (36.4% vs. 70.8%, p=0.001). Rates of liver enzyme elevation, thrombocytopenia, and C. difficile infection were lower in the protocol group though these were not significant. Conclusion There was a significantly lower rate of AKI with EI dosing which supports enhanced patient safety. This may be the preferred method of administration for obese patients and/or those receiving vancomycin concurrently. This is the first study to demonstrate that EI piperacillin/tazobactam dosing significantly reduces rates of AKI in patients on concomitant vancomycin. Disclosures All Authors: No reported disclosures

Background Bacterial prostatitis (BP) is notoriously difficult to treat. Few antibiotics penetrate the prostate well, and antibiotic resistance can further restrict options. A small body of recent literature suggests fosfomycin, a bactericidal antibiotic that can treat multidrug resistant (MDR) organisms and has little cross-resistance, may both effectively penetrate the prostate and treat BP. This study sought to add to the limited literature on the efficacy and safety of fosfomycin for BP. Methods Patients treated for BP with fosfomycin between November 2009 and May 2019 at the San Diego VAMC were retrospectively examined. Patients were excluded if they died within 6 months of completion of fosfomycin or if fosfomycin was used for less than half of the treatment course. If fosfomycin was used to treat a urinary tract infection (UTI), an infectious disease physician determined if the UTI may have been undiagnosed BP. Outcomes were clinical and microbiological cure at 6 months and adverse events to fosfomycin reported during the trial period. Results The study included 29 patient cases. All but one had chronic BP. Most initially presented outpatient (66%). Almost all had prior occurrences of BP treated with antibiotics (90%). The most common pathogen was E. coli (73%), and 87% of all pathogens were MDR. The most common fosfomycin dosing regimen was 3g PO q48h (66%), with 3g PO q24h as the next most common (21%). Less than half of patient cases received fosfomycin courses > 28 days (38%), while the remaining received courses < 14 days (62%). At 6 months, 48% achieved clinical cure and 44% achieved microbiological cure. When comparing those who received courses > 28 days vs. courses < 14 days, clinical cure was achieved in 55% vs. 44% and microbiological cure in 56% vs. 39%, respectively. Adverse events were reported in 6 unique patients (27%), mostly diarrhea with one instance of nausea. Conclusion Fosfomycin may be a safe and effective alternative for the treatment of chronic BP. Treatment courses longer than 4 weeks may be more effective than courses shorter than 2 weeks with a similar rate of adverse events. This study also highlights inpatients as a relevant BP population and a need for provider education on identifying BP and prescribing optimal durations of therapy. Disclosures All Authors: No reported disclosures

Background VISN 22 is comprised of eight VA hospitals serving Southern California, Arizona, and New Mexico. The VISN 22 Antimicrobial Stewardship Workgroup formed in November 2018 with the purpose of sharing strong practices and program strategies. We compared antibiogram compilation strategies and antimicrobial susceptibilities and correlated antimicrobial susceptibilities for Pseudomonas aeruginosa and Escherichia coli with inpatient and outpatient antibiotic use. Methods 2018 antibiograms were collected from each hospital. Antibiotic utilization rates (antibiotic days per 1000 patient-days present) were extracted from VA Corporate Data Warehouse data. Pearson correlation coefficients were calculated between 2018 utilization of specific agents and P. aeruginosa and E. coli susceptibilities to those agents at each facility. Results Antibiograms varied according to authorship (microbiology and/or infectious diseases), reporting frequency, rules regarding isolate reporting, and location and specimen specificity (Table 1). Facilities reported at least 90% susceptibility to a median of 3 antibiotics (range 1 to 5) for P. aeruginosa and 5 antibiotics (range 1 to 7) for E. coli. The strongest negative correlations between antimicrobial use and susceptibility were observed for meropenem/imipenem (-0.43) and piperacillin–tazobactam (-0.41) with P. aeruginosa and piperacillin–tazobactam (-0.23) and fluoroquinolones (-0.21) with E. coli. A moderate negative correlation was observed between outpatient fluoroquinolone prescriptions per 1000 patients and E. coli susceptibility (-0.24). Conclusion Antibiogram composition is variable across VISN 22; not all reporting is consistent with CLSI recommendations. There was a modest correlation between some categories of antimicrobial use and resistance in P. aeruginosa and E. coli. Sharing antibiogram and antibiotic utilization data are helpful in developing antimicrobial stewardship strategies especially as we examine those hospitals with lower rates of resistance and antibiotic use. Disclosures All authors: No reported disclosures.