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Background The first COVID-19-positive patient was identified in Ireland on 29 February 2020 (Department of Health, Government of Ireland; https://www.gov.ie/en/pressrelease/2f75fd-statement-from-the-national-public-healthemergency-team-sat-29-feb/). Healthcare worker (HCW) quarantining became a core intervention for those identified as ‘close contacts’ to reduce onward transmission within the workplace to patients and colleagues. Whether a quarantining strategy could be justified at a time when there was an increased demand for the services of HCWs remained unknown. Aims To establish whether quarantining staff away from a healthcare setting during a pandemic is justified. Methods This retrospective study examined close contacts of COVID-19-positive index cases (both residents and HCWs) in a community hospital over a 4-week period from 1 to 28 April 2020. Close contacts were identified in accordance with national guidelines. Zones of the hospital were examined to determine the number of COVID-positive index cases and their close contacts. A cumulative result for the hospital was recorded. Results While outcomes varied over time, per zone and per HCW category, the overall conversion rate from close contact to an index case was 30%. Conclusions This study vindicates the policy of quarantining close contact HCWs from their workplaces as they pose a significant threat to both their patients and fellow workers.

Introduction In response to the Covid19 pandemic a community Hospital was transformed in to a Community Frailty Unit (CFU). The aims were to meet the needs of patients living with frailty including medical instability and end of life care outside the acute setting, to improve patient flow and to improve integration of acute and community frailty services. Method Existing community teams were integrated with an acute based multidisciplinary team including a frailty practitioner and pharmacist. Supported by programme managers they rapidly transformed (within 3 weeks) processes to align these with the acute site including paperwork, assessments, use of a flow board, board rounds and discharge to assess. Technology was used to organise transfers via the NHS Digital approved App Pando. Point of care testing and oxygen concentrators were put in place. Results Median and mean length of stay (LOS) in the acute site reduced by 59% (14.5 to 6 days) and 56% (18 to 8 days) respectively. Median and mean LOS in the community site reduced by 38% (16 to 10 days) and 39% (18 to 11 days) respectively. Readmissions fell from 10% to 2%. 85% of staff rated the following better or much better: the capability of the service to manage every aspect of the patient’s care; integration; co-ordination of transfers. 83% of staff rated patient experience better or much better and 79% rated discharge co-ordination better or much better. At 85% bed occupancy at a cost of £67 k/bed/year this released 5,525 bed days and 16.9 beds with a return on investment of £1,132,300. Conclusion It is possible to rapidly integrate community and acute services and to establish acute frailty unit care in a community setting. A CFU can lead to improved integration, patient flow, patient and staff experience at reduced system wide cost.

Background: Respiratory syncytial virus (RSV) is a leading cause of pediatric death, with >99% of mortality occurring in low- and lower middle-income countries. At least half of RSV-related deaths are estimated to occur in the community, but clinical characteristics of this group of children remain poorly characterized. Methods: The RSV Global Online Mortality Database (RSV GOLD), a global registry of under-5 children who have died with RSV-related illness, describes clinical characteristics of children dying of RSV through global data sharing. RSV GOLD acts as a collaborative platform for global deaths, including community mortality studies described in this supplement. We aimed to compare the age distribution of infant deaths, Bill and Melinda Gates Foundation, BMGF: OPP1148988.8; Johnson and Johnson, J&J; Merck; Roche; AbbVie, This publication is based on research funded in part by the Bill & Melinda Gates Foundation (grant number OPP1148988.8). ES reports grants from Bill and Melinda Gates Foundation, during the conduct of the study; grants, personal fees and non-financial support from Astra Zeneca Inc, grants, personal fees and non-financial support from Merck & Co., grants, personal fees and non-financial support from Regeneron Inc, grants, personal fees and non-financial support from Pfizer Inc, personal fees, non-financial support and other from Abbvie Inc, personal fees from Alere Inc, grants, personal fees and non-financial support from Roche Inc, other from GSK Inc, grants from Johnson and Johnson, grants and nonfinancial support from Novavax Inc, outside the submitted work; FP reports grants and personal fees from JANSSEN, grants and personal fees from NOVAVAX, INC, personal fees from BAVARIAN NORDIC A/S, personal fees from PFIZER, personal fees from SANOFI, personal fees from REGENERON, personal fees from MERCK, outside the submitted work.

Background According to the Centers for Disease Control and Prevention, patients admitted to the hospital are commonly discharged on antibiotic therapy with prolonged courses of therapy, which contributes to excessive antibiotic exposure and adverse events. The purpose of this study was to evaluate total antibiotic duration of therapy at hospital discharge at Indiana University Health Arnett, White Memorial, and Frankfort hospitals. Methods A multicenter, retrospective electronic health record review was conducted from 1 January to 30 June 2019. Patients were included if they were at least 18 years of age, began antibiotic therapy while admitted, and continued antibiotic therapy at hospital discharge for 1 of the following indications: skin/soft tissue infection (SSTI), urinary tract infection (UTI), community-acquired pneumonia (CAP), or acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The number of days of therapy (DOT) of each inpatient and outpatient antibiotic prescribed was collected to calculate the total DOT, which was utilized to determine the appropriateness of the duration of therapy. Results Of the 547 patients included, 233 patients (42.6%) had CAP, 120 (21.9%) had UTI, 101 (18.5%) had SSTI, and 93 (17%) had AECOPD. The median duration of antibiotic therapy across all indications was 9 days (interquartile range [IQR], 7–11). Median duration for CAP was 9 days (IQR, 7–10), AECOPD was 7 days (IQR, 5–9), UTI was 8 days (IQR, 6–10), and SSTI was 12 days (IQR, 10–14). Conclusions Excess antimicrobial duration at hospital discharge represents an unmet need of antimicrobial stewardship programs., We reviewed the total duration of antibiotic therapy in 547 patients at the time of hospital discharge. When combining inpatient and outpatient days of therapy, antibiotic duration for common types of infection is excessive compared with recommendations from clinical practice guidelines.

Background We implemented a preprocedural severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening initiative designed to sustain health care during a time when the extent of SARS-CoV-2 infection was unknown. Methods This was a prospective study of patients undergoing procedures at 3 academic hospitals in Pittsburgh, Pennsylvania (April 21–June 11), and 19 community hospitals across Middle/Western Pennsylvania and Southwestern New York (May 1–June 11). Patients at academic hospitals underwent symptom screening ≤7 days preprocedure, then SARS-CoV-2 nasopharyngeal polymerase chain reaction (PCR) testing 1–4 days preprocedure. A subset also underwent day-of-procedure testing. Community hospital patients underwent testing per local protocols. We report SARS-CoV-2 PCR positivity rates, impact, and barriers to testing encountered through June 11. PCR positivity rates of optional preprocedural SARS-CoV-2 testing for 2 consecutive periods following the screening initiative are also reported. Results Of 5881 eligible academic hospital patients, 2415 (41.1%) were tested (April 21–June 11). Lack of interest, distance, self-isolation, and nursing home/incarceration status were barriers. There were 11 PCR-positive patients (10 asymptomatic) among 10 539 patients tested (0.10%; 95% CI, 0.05%–0.19%): 3/2415 (0.12%; 95% CI, 0.02%–0.36%) and 8/8124 (0.10%; 95% CI, 0.04%–0.19%) at academic and community hospitals, respectively. Procedures were performed as scheduled in 40% (4/10) of asymptomatic PCR-positive patients. Positivity increased during subsequent coronavirus disease 2019 (COVID-19) surges: 54/34 948 (0.15%; 95% CI, 0.12%–0.20%) and 101/24 741 (0.41%; 95% CI, 0.33%–0.50%) PCR-positive patients from June 12–September 10 and September 11–December 15, respectively (P Conclusions Implementing preprocedural PCR testing was complex and revealed low infection rates (0.24% overall), which increased during COVID-19 surges. Additional studies are needed to define the COVID-19 prevalence threshold at which universal preprocedural screening is warranted.

Background Novel coronavirus disease 2019 (COVID-19) poses a challenge to infection control within hospital systems. Asymptomatic children and their caretakers carry the risk of silently spreading infection in pediatric emergency departments and hospital units. Our current knowledge is evolving, and infection control measures are frequently changing depending on new emerging data. Methods We conducted a point-prevalence study to assess SARS-CoV-2 Real-Time Polymerase Chain Reaction (SARS-CoV-2 RT-PCR) results of hospitalized children, their asymptomatic caretakers, and caretaker-child test concordance at a major community hospital in New York City. We screened Children and caretakers with temperature measurements and the presence of COVID-19 symptoms before pediatric emergency department evaluation. Children requiring hospitalization and their caretakers had nasopharyngeal swabs for SARS-CoV-2 RT-PCR. The paired results are used to identify the infection control level at the appropriate pediatric unit. Results Forty consecutive asymptomatic caretaker-child pairs had SARS-CoV-2 RT-PCR testing between May 28th to June 22nd, 2020. The rate of asymptomatic COVID-19 was 2.5% in hospitalized children and 7.5% in caretakers. The caretaker-child SARS-CoV-2 RT-PCR test concordance was evident in 95% of the cohort. Conclusion This cohort had a low asymptomatic SARS-CoV-2 PCR positive rate in children and their caretakers with a high concordance rate of paired test results. It suggests that children’s SARS-CoV-2 PCR test result will likely correspond to their accompanying caretaker at healthcare facilities where admission screening is performed.

Background Patients presenting to the emergency department who require inpatient care are either admitted to our tertiary care inpatient units or transferred directly to a community hospital. When patients appropriate for community care cannot be transferred due to a lack of community beds and instead remain in a tertiary care bed, there are palpable downstream effects on patient flow. A pre-study audit confirmed that, once admitted, transfers from the inpatient unit to a community bed are rare. This project aimed to improve access to tertiary care beds by increasing inpatient transfers to community hospitals. Objectives The project aimed to transfer 25% of all eligible patients from the Paediatric Medicine inpatient units to community hospitals over a 4-month period by identifying eligible patients and streamlining the transfer process. Design/Methods An Ishikawa diagram with input from inpatient physicians and nurses and community hospital colleagues identified 4 modifiable barriers. A process map was created along with a simplified transfer process. Medical teams and nurse leaders were provided with the charts of contact numbers, geographic locations and levels of care for community hospitals. Intake nurses tracked eligible patients. Encrypted text messages were sent to inpatient physicians on their mobile devices every morning reminding them to assess specific patients for transfer. The outcomes of all identified patients including process and balancing measures were tracked. Results Multiple PDSA cycles focused on improving the success of identifying eligible patients at multiple points in the process. The study’s outcome measure was the rate of successful inpatient transfers for all eligible patients. From November 2018 to March 2019, 120 patients were identified as eligible for transfer at the time of admission: 45 (37.5%) were discharged within 24 hours, 42 (35%) were not considered clinically appropriate for transfer by the attending physician and 33 were considered appropriate for transfer. Twenty-four were approached for transfer (72.7%); 9 were not approached for non-clinical reasons. Six (18.2%) refused transfer and 10 (30%) were successfully transferred. These rates were sustained over the study period. Conclusion A streamlined transfer process can improve patient flow, optimize utilization of tertiary care beds and provide care closer to home. A more robust method of tracking patients that could flag patients and send physicians electronic reminders is needed. Most importantly, optimal use of tertiary care beds requires a culture shift to ensure every patient is considered for transfer to the community when medically appropriate.

Background Airway intubation is a high-risk procedure, especially in the paediatric population. Training ED healthcare providers is challenging because it is rare. Success and adverse events (AEs) could be due to patients’ illness, the health professional intubating, and hospital factors. Objectives Describe paediatric intubations in an adult community-based hospital, with primary outcomes being first-pass success and AEs. The secondary objective is to determine what factors are association with intubation success and related AEs. Design/Methods Retrospective chart review of patients < 18 years intubated in the ED between Jan 1, 2006 and Mar 31, 2017 (demographics, intubation details, physiologic outcomes). Analysis: descriptive and comparative statistics (intubations with vs. without AEs), p Results n=121 intubations occurred in the ED over the 10-year period. Mean (standard deviation) age 6.9 (6.8) years. First pass success occurred in n=76 (62.8%), and 33 (27.3%) second pass success. There was n=22 (18.2) minor AEs, n=3 (2.5) major AEs. There were no significant differences between profession intubating and first pass success (p=0.384), or AEs (p=0.472), Table 1. Indications for intubation included respiratory and/or oxygenation failure n=54 (44.6%), airway protection n=51 (42.2%), airway obstruction n=4 (3.3%), cardiopulmonary arrest n=2 (1.7%) [n=9 missing]. Use of specialized equipment was used in n=19 of the intubations, n=12 on first attempt, 8 second attempt, 4 third attempt. No accidental extubations occurred, but the ETT was repositioned in n=33 (27%) after first intubation. Conclusion Pediatric intubation in an adult community-based hospital is rare. Success rate of intubation on first attempt is low with minor AEs. There was no significant difference between the type of health professional intubating. These results will inform the development of tools and education for paediatric advanced airway management in adult community-based hospitals, and enhance patient outcomes in the ED.

Background: Studies have shown that poorly-controlled hyperglycemia worsens the outcomes in patients with COVID-19 (C-19) and C-19 may damage pancreatic islets via ACE2 receptors causing acute hyperglycemia. The major population we serve at Kingsbrook Jewish Medical Center (KJMC) are underprivileged with many of them having multiple comorbidities. Methods: This is a retrospective study wherein patients, admitted from February 2020 to April 2020 with hyperglycemia, were selected and divided into 2 groups based on presence or absence of C-19. Data include demographics, comorbidities, blood glucose level, serum osmolality, serum bicarbonate, anion gap, acute kidney injury (AKI), serum creatinine, ICU admission, length of stay (LOS) and mortality. Data were analyzed using descriptive study and T-test. Results: 100 patients were included in the C-19 group (CG) and 88 patients were included in the Non C-19 group (NCG). Major comorbidities were similar in both groups including HTN, DM, CKD followed by ESRD. Mean age of patients (years) was 65.68 in CG and 61.17 in NCG. 61% were male in CG and 53.41% were male in NCG. 16% and 9% developed DKA and HHS in CG, and 13.64% and 6.82% developed DKA and HHS in NCG respectively. 15% in CG had combined DKA & HHS and 3.41% had same in NCG. Mean blood glucose level (mg/dl) was 541.6 in CG and 460.0 in NCG (p=0.03). Mean serum osmolality (mOsm/kg) was 335.7 (SD±41.01) in CG and 317.1 (SD±30.54) in NCG (p=0.01). Mean serum bicarbonate (mEq/L) was 17.73 (SD±6.31) in CG and 21.46 (SD±5.94) in NCG (p

Background Telemedicine (TM) has emerged as a viable solution to extend infectious disease (ID) expertise to communities without access to this specialty.1 TM allows clinicians in rural settings to connect with specialists at distant sites and provide the best care for their patients, often eliminating the need for hospital transfers. Here, we describe the experience from one of the longest standing inpatient Tele-ID consult services using live audio-video (AV) visits with the assistance of a telepresenter. Methods Longitudinal data were collected from a 126-bed rural hospital in Pennsylvania that had no access to ID consultation before 2014. Live AV consults during business hours began in 2014 and telephonic physician to physician consults were made available 24/7. All ID consult data were extracted from the hospital electronic health record between 2014 to 2019. Key outcomes assessed included the number of consult encounters, total hospital length of stay (LOS), discharges to home, transfer to tertiary care centers, and readmission rates at 30 days. Results Most consulted patients were Caucasians, and females with an average age of 64.7 years (Table 1). The number of unique consult encounters increased annually from 111 in 2014 to 469 in 2019 (Table 1). The Charlson Comorbidity Score and Elixhauser Comorbidity Index also increased each year beginning in 2016 (Table 1). By contrast, LOS decreased each year as did the 30-day readmission rate (Table 2). Most patients were not transferred (average 89.4% over 6 years) to tertiary care centers and more than half were discharged to home each year (Table 2). Conclusion This longitudinal 6-year observation study of an inpatient TM ID service at a rural hospital showed remarkable annual growth in consult encounters (total growth >400%). Despite increasing patient acuity, overall hospital LOS decreased over time (10.2 to 8.2 days). Patient transfers to tertiary care centers remained low (average 10.5% over 6 years) as did 30-day readmissions (average 16.3% over 6 years). The majority of patients were discharged to home (average 61.3% over 6 years). These findings show that a rural inpatient TM ID consult service can expand over time and is an effective alternative for hospitals without access to ID expertise. Disclosures John Mellors, MD, Abound Bio (Shareholder)Accelevir Diagnostics (Consultant)Co-Crystal Pharmaceuticals (Shareholder)Gilead (Consultant, Grant/Research Support)Merck (Consultant) Rima Abdel-Massih, MD, Infectious Disease Connect (Shareholder, Other Financial or Material Support, Chief Medical Officer)

Background The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections has led to 105690 cases and 7647 deaths in Massachusetts as of June 16. Methods The study was conducted at Saint Vincent Hospital, an academic health medical center in Worcester, Massachusetts. The institutional review board approved this case series as minimal-risk research using data collected for routine clinical practice and waived the requirement for informed consent. All consecutive patients who were sufficiently medically ill to require hospital admission with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample were included. Results A total of 109 consecutive patients with COVID 19 were admitted between March 15 and May 31. Sixty one percent were men, the mean age of the cohort was 67. Forty one patients (37%) were transferred from nursing homes. Twenty seven patients died (24%) and the majority of the dead patients were men (62%). Fifty one patients (46%) required admission to the medical intensive care unit and 34 necessitated mechanical ventilation, twenty two patients on mechanical ventilation died (63%). The most common co-morbidities were essential hypertension (65%), obesity (60%), diabetes (33%), chronic kidney disease (22%), morbid obesity (11%), congestive heart failure (16%) and COPD (14%). Five patients required hemodialysis. Fifty five patients received hydroxychloroquine, 24 received tocilizumab, 20 received convalescent plasma and 16 received remdesivir. COVID 19 appeared in China in late 2019 and was declared a pandemic by the World Health Organization on March 11, 2020. Our study showed a high mortality in patients requiring mechanical ventilation (43%) as opposed to those who did not (5.7%). Hypertension, diabetes and obesity were highly prevalent in this aging population. Our cohort was too small to explore the impact of treatment with remdesivir, tocilizumab or convalescent plasma. Conclusion In this cohort obesity, diabetes and essential hypertension are risk factors associated with high mortality. Patients admitted to the intensive care unit who need mechanical ventilation have a mortality approaching 50 %. Disclosures All Authors: No reported disclosures

Background Asymptomatic bacteriuria is a common finding in hospitalized patients. This is defined as bacteriuria of ≥105 colony-forming units (cfu) per mL without any genitourinary signs or symptoms. Treatment for such leads to increased antimicrobial resistance and is especially common in the inpatient setting. One study showed a lack of appropriate clinical indication to order a urinalysis in more than half of the patients. In order to expedite a patient’s care, it is common to order a urinalysis and urine culture together and await the results. One study evaluated the impact of changing the order set in inpatients and yielded a 45% reduction in the urine cultures ordered and cost savings as high as $103,845. Reflex testing is used to facilitate effective and efficient patients care while remaining compliant with state and federal regulations in the ordering of lab test. Methods Starting October 25, 2019, the electronic medical record order set was changed so there were only 2 options from the previous 9 options. The modified options included a “Urine analysis with reflex culture” and “Urine analysis with microscopy.” The reflex was not encouraged to be used for those who were pregnant, neutropenic, or had any evidence of immunocompromise. Results Following the implementation of this initiative in October 2019, there was a decrease in overall urine culture cost. From Jan 2019 to September 2019, the cost ranged between $13428.96 to $15157.44/month in the Emergency Department. On the inpatient side, it ranged between $5141.12 to $6559.36/month. After revision of the new order set, the ED cost had dropped to as low as $5672.96/month and $3811.52/month for inpatients. This is a cost reduction of approximately $9484.48 and $2747.84 for the ED and inpatient, respectively.The total number of cultures also reduced from an average of 326/month in the ED to 193/month. The inpatient number of cultures dropped from an average of 130/month to 102/month. Conclusion Modifying the process of urine culture ordering has significantly cut down cost for both the hospital and patient. With clear education and modification of the electronic medical record, such interventions can dramatically improve the unnecessary testing for UTI’s. Disclosures All Authors: No reported disclosures

Background Facilities with robust antimicrobial stewardship programs often have infectious disease (ID) pharmacists with devoted time to complete antimicrobial stewardship initiatives. Smaller facilities with limited resources or lacking ID pharmacists, may encounter challenges meeting antimicrobial stewardship regulatory requirements. The goal of this study is to assess the impact of a staff pharmacist-driven prospective audit and feedback program in a small community hospital. Methods A pre- and post-intervention study was performed to assess the primary outcome of days of therapy per 1,000 patient days (DOT) for targeted antimicrobials (ciprofloxacin, levofloxacin, piperacillin/tazobactam, cefepime, ceftazidime). Secondary outcomes were antibiotic expenditures and rates of Clostridioides difficile infection (CDI). Results Significant decreases in DOT were observed for piperacillin/tazobactam (29.88 vs. 9.25; p < 0.001), ciprofloxacin (23.22 vs. 9.97; p < 0.001), levofloxacin (11.2 vs. 5.07; p < 0.001) and overall antipseudomonal DOT (62.91 vs. 51.67; p < 0.001). There was no difference in ceftazidime DOT (8.75 vs. 6.47; p= 0.083) and an increase in cefepime DOT (20.47 vs. 34.35; p < 0.001). A trend towards decreased rates of CDI was seen (4.9/10,000 patient days vs. 2.64/10,000 patient days; p= 0.931). There were significant decreases in antibiotic expenditures for piperacillin/tazobactam ($52,498 vs. $10,937; p < 0.001), levofloxacin ($2,168 vs. $672; p < 0.001), ciprofloxacin ($6,700 vs. $1,954; p < 0.001). Lower expenditures for ceftazidime were seen ($9,952 vs. $7,457; p= 0.29). Cefepime expenditures increased ($25,638 vs. $40,097; p= 0.001). An overall decrease in the expenditure for the targeted antibiotics was seen ($95,715 vs. $62,837; p < 0.001). Conclusion Implementation of a staff pharmacist-driven prospective authorization and feedback program led to a significant decrease in DOT and antibiotic expenditures for several targeted antibiotics and a trend towards decreased rates of CDI. Despite increased DOT and expenditures for cefepime, there was an overall decrease amongst the targeted antibiotics. With proper implementation, staff pharmacists can significantly benefit antimicrobial stewardship initiatives. Disclosures All Authors: No reported disclosures

Background Elevated D-dimer level is frequently seen in patients with COVID-19 and is associated with worse clinical outcomes. The potential benefit of systemic anticoagulation in COVID-19 has been suggested, but data lack on when to initiate anticoagulation. We aimed to identify a cut-off value of D-dimer at which anticoagulation may provide mortality benefit in COVID-19. Methods A retrospective review was conducted for a cohort of patients hospitalized with COVID-19 at a 262-bed community hospital in a Washington D.C. suburb. Patients hospitalized between April 1, 2020, and April 30, 2020, with laboratory-confirmed COVID-19 were included if d-dimer levels were checked during hospitalization. Demographics, laboratory results, and hospital courses were reviewed. Logistic regression was used to examine the association between anticoagulation and in-hospital mortality, controlling for the d-dimer value. The association was examined in subgroups with different d-dimer cut-offs. Multivariable logistic regression models were developed to assess if the association between anticoagulation and mortality remains after adjusting for other mortality risk factors. Results 101 patients were included in the study and 32 (31.7%) died during hospitalization. The average age was 61.2 ± 14.8 years old and 50.5% were males. Older age, male sex, hypertension, and peak d-dimer level were associated with mortality in univariable analysis (p< 0.05). For patients with peak d-dimer level >3mcg/mL, anticoagulation use was associated with lower mortality after controlling for the d-dimer level (OR 0.25, 95% CI 0.06–0.97 p=0.045). This association weakened after adjusting for age, sex, and hypertension. (OR 0.33, 95% CI 0.07–1.46, p=0.143). For patients with peak d-dimer level >5 mcg/mL, anticoagulation use was associated with lower mortality after controlling for the d-dimer level (OR 0.11, 95% CI 0.02–0.68, p=0.017) and this association remained significant after adjusting for age, sex, and hypertension (OR 0.11, 95% CI 0.01–0.86, p=0.035). Conclusion In hospitalized COVID-19 patients with a d-dimer level higher than 5 mcg/mL, anticoagulation use was independently associated with lower mortality. Disclosures All Authors: No reported disclosures

Background Community-acquired pneumonia (CAP) is responsible for ~1 million emergency department (ED) visits yearly and the leading cause of infection-related deaths. Given that increasing antibiotic resistance rates complicate appropriate empiric antibiotic selection, clinicians may benefit from tools to help identify patients at risk for drug-resistant pathogens (DRPs). Limitations of traditional tools, such as healthcare-associated pneumonia criteria (HCAP), have led to development of novel scoring tools such as the drug resistance in pneumonia (DRIP) score. Webb et al. showed the DRIP score was more predictive of CAP caused by DRPs than HCAP criteria. The objective of this study was to validate the DRIP score in a local population of hospitalized patients at an academic and a community medical center. Methods Patients who presented to the ED between May 2017 and May 2019 were included in this retrospective review. Patients were included if they were ≥ 18 years diagnosed with CAP by radiographic evidence with respiratory culture positivity and susceptibility results. Exclusion criteria were: presence of non-bacterial non-respiratory pathogens, patients with cystic fibrosis, lung transplant or systemic co-infections. The primary outcome was validation of the DRIP score by comparing the sensitivity, specificity, negative and positive predictive values (NPV/PPV) to the derivation and validation study by Webb et al. Secondary outcomes were the percentage of CAP cases with DRPs and the predictability of DRP using the DRIP score versus HCAP criteria. Results A total of 164 patients were included; 60.4% were male with a median age of 70 years. The primary outcome shown in Table 1 demonstrated similar sensitivity, specificity, NPV, and PPV of the DRIP score to those in the study by Webb et al. Staphylococcus aureus (32.9%) and Streptococcus pneumoniae (27.4%) were the most commonly isolated pathogens and CAP due to DRPs occurred in 30.5% of patients. The DRIP score also demonstrated improved performance in predicting DRPs in CAP compared to the HCAP Criteria as shown in Table 2. Table 1. DRIP Score Validation Table 2. Predictability of the DRIP score vs. HCAP criteria Conclusion Our results further validate the DRIP score derived by Webb et al. in predicting DRPs in CAP. These results encourage a local prospective evaluation of the DRIP score as an antimicrobial stewardship tool. Disclosures All Authors: No reported disclosures

Background High-flow nasal cannula (HFNC) is a form of noninvasive respiratory support used for paediatric acute respiratory illnesses. Past HFNC research has focused on its use in bronchiolitis and in intensive care units, but little is reported on its use in the community hospital setting. We aimed to investigate the paediatric population using HFNC, any adverse events, and risk factors for deterioration. Methods A retrospective chart review was performed on patients admitted to a community paediatric ward. Inclusion criteria were patients between 1 day and 17 years of age, admitted between September 2013 and April 2016, and treated with HFNC for at least 4 hours. Results A total of 85 children met inclusion criteria. The average age of patients in our study was 3.41 years with 39% of patients >2 years of age. 46% of patients had an admitting diagnosis of bronchiolitis, 33% pneumonia, and 16% with asthma. Transfer rate to tertiary care centre paediatric intensive care unit was 18%. Patients transferred required greater FIO2 (odds ratio [OR] 1.04, P=0.018, confidence interval [CI] 1.007 to 1.082), and were 3.2 times more likely to be positive for respiratory syncytial virus (RSV) (P=0.081, CI 0.868–11.739). There were no adverse events attributed to HFNC in the population. Conclusion HFNC is being utilized in the community hospital setting for children of varied age and types of respiratory illnesses. Children requiring higher FIO2 are at risk of respiratory deterioration which may identify them earlier for transfer to tertiary care. Further research into the safety and efficacy of HFNC for different paediatric illnesses in the community is needed.

Background Peripheral venous catheters (PVCs) are common in hospitals, but the literature surrounding PVC-associated bacteremia is lacking. We describe incidence rates, risk factors, and outcomes related to PVC-associated Staphylococcus aureus bacteremia (SAB), a common cause of hospital-onset (HO) SAB. Methods This is a retrospective case–control study conducted at a 537-bed teaching community hospital during 2015–2016. Cases were adult inpatients with HO SAB with infectious diseases documentation of the PVC as the only source of bacteremia. Cases were matched 1:2 with controls on approximate PVC insertion date, age, mortality prediction score, and insurance type. Odds ratios (ORs) were estimated using conditional logistic regression. PVC utilization was estimated by a point-prevalence survey from July 2017. Results Of 205 SAB episodes, 160 were community-onset and 45 were HO; 16 (36%) HO cases were PVC-associated. Cases (n = 16) were more likely than controls (n = 32) to have a PVC placed in the antecubital area (odds ratio [OR], 11.9; 95% confidence interval [CI], 1.5–95.7; P = .02) and PVC duration ≥4 days (OR, 4.0; 95% CI, 1.1–15.2; P = .04). The point prevalence of at least 1 PVC in adult inpatients was 86%, and the incidence density of HO PVC–associated SAB was 0.15 per 1000 PVC-days. The mean length of stay for cases was 13.2 days. All cases successfully completed parenteral antibiotics with a mean treatment length of 23.6 days. Conclusions PVC-associated SAB is a common cause of HO SAB that results in significant morbidity. PVC placement in the antecubital area and line duration should be minimized to reduce HO SAB.

Background At the time of this writing, there is no FDA approved medication for the treatment of COVID-19. One medication currently under investigation for COVID-19 treatment is tocilizumab, an interleukin-6 (IL-6) inhibitor. It has been shown there are increased levels of cytokines including IL-6 in severe COVID-19 hospitalized patients attributed to cytokine release syndrome (CRS). Therefore, inhibition of IL-6 receptors may lead to a reduction in cytokines and prevent progression of CRS. The purpose of this retrospective study is to utilize a case-matched design to investigate clinical outcomes associated with the use of tocilizumab in severe COVID-19 hospitalized patients. Methods This was a retrospective, multi-center, case-matched series matched 1:1 on age, BMI, and days since symptom onset. Inclusion criteria included ≥ 18 years of age, laboratory confirmed positive SARS-CoV-2 result, admitted to a community hospital from March 1st – May 8th, 2020, and received tocilizumab while admitted. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, total mechanical ventilation days, mechanical ventilation mortality, and incidence of secondary bacterial or fungal infections. Results The following results are presented as tocilizumab vs control respectively. The primary outcome of in-hospital mortality for tocilizumab (n=26) vs control (n=26) was 10 (38%) vs 11 (42%) patients, p=0.777. The median hospital length of stay for tocilizumab vs control was 14 vs 11 days, p=0.275. The median days of mechanical ventilation for tocilizumab (n=21) vs control (n=15) was 8 vs 7 days, p=0.139, and the mechanical ventilation mortality was 10 (48%) vs 9 (60%) patients, p=0.463. In the tocilizumab group, for those expired (n=10) vs alive (n=16), 10 (100%) vs 7 (50%) patients respectively had a peak ferritin > 600 ng/mL, and 6 (60%) vs 8 (50%) patients had a peak D-dimer > 2,000 ng/mL. The incidence of secondary bacterial or fungal infections within 7 days of tocilizumab administration occurred in 5 (19%) patients. Conclusion These findings suggest that tocilizumab may be a beneficial treatment modality for severe COVID-19 patients. Larger, prospective, placebo-controlled trials are needed to further validate results. Disclosures Christian Cheatham, PharmD, BCIDP, Antimicrobial Resistance Solutions (Shareholder)

Background Penicillin (PCN) allergy is a serious adverse reaction that prevents use of first line therapy. 10% of the population reports a PCN allergy, however less than 1% is truly allergic. Elimination of false allergies significantly impacts patient’s lives and decreases antimicrobial resistance and cost. Penicillin Skin Testing (PST) is a tool to support antimicrobial stewardship (ASP) and to optimize allergy de-labeling. The goal of this pilot study was to implement a pharmacy-nurse driven PST service in the outpatient pre-surgical clinic in a community hospital and to assess the impact of PST on the usage of vancomycin as the pre-op prophylaxis agent. Methods In May 2019 a single-center, prospective pilot in the outpatient clinic for pre-surgical adult patients with a documented PCN allergy was approved. Patients were identified via a PCN allergy report, generated from the electronic medical record and interviewed by the ASP pharmacist to identify the type of reaction. The study excluded patients if they were unable to give informed consent, if they took anti-histamines within 72 hours of the test, or if the allergy is clinically insignificant. The nurse administered the test and the ASP pharmacist read the results, documented them in the system, and counseled patients. Results A total of 155 patients with PCN allergy qualified for PST and only one patient had a true allergy. 154 patients had a negative test and their allergy was deleted in their electronic health system. In addition, those patients received cefazolin as the antibiotic of choice before their surgery which is narrower spectrum and has less side effects compared to vancomycin. Furthermore, all patients were counseled and acknowledged the impact of the results. After performing PST there was an overall 39% decrease in vancomycin DOT/1000 in the surgical population (2018 May-Dec Average DOT/1000 patient Days=3.75 vs 2019 May-Dec Average DOT/1000 patient Days=2.3. (p < 0.005)) Conclusion The PST service offers an efficient method to collect a detailed PCN allergy history and de-label patients accordingly. PST helps reduce the pre-surgical prophylaxis use of broad spectrum agents and allergy testing significantly increases patient satisfaction Disclosures All Authors: No reported disclosures

Background Carbapenem-resistant gram-negative organisms are a continuously mounting threat, underscoring the need for effective antimicrobial stewardship interventions to improve the use of carbapenems. We sought to implement several multidisciplinary antimicrobial stewardship interventions beginning in January 2019 in an effort to reduce unnecessary meropenem use and the incidence of carbapenem-resistant gram-negatives. Methods Prospective audit and feedback was utilized daily in combination with weekly stewardship rounds between an Infectious Diseases pharmacist and physician in the Intensive Care Units. A second Infectious Diseases physician attended weekly interdisciplinary rounds on meropenem high-use units. Meropenem Days of Therapy (DOT) per 1,000 patient days and the incidence of meropenem resistant Pseudomonas aeruginosa and Klebsiella pneumoniae were compared by the chi-square test of proportions. Results Between 2018 and 2019 the institution’s meropenem DOT per 1,000 patient days decreased 33%, from 57 to 38 days per 1,000 patient days (difference, 19 days per 1,000 patient days; p< 0.001). In the hospital antibiogram, the meropenem susceptibility of Pseudomonas aeruginosa over the same time period increased from 71% to 77% of isolates (difference, 6%; p = 0.009). A non-significant decrease in the susceptibility of meropenem to Klebsiella pneumoniae was also observed from 92 to 90% (difference, 2%: p = 0.1658). Conclusion These data support the need for antimicrobial stewardship efforts targeting broad-spectrum antimicrobials such as meropenem. In the setting of a sustained decrease in meropenem use over 12 months, we observed a significant improvement in the percent susceptibility rate of Pseudomonas aeruginosa to meropenem for the first time in five years. Disclosures All Authors: No reported disclosures

Background Secondary bacterial/fungal infection in patients with pandemic strains of Influenza has been well documented in the literature. Little is known about the development of secondary bacterial or fungal infections in patients with COVID-19. Additionally, COVID patients receiving tocilizumab as treatment may be at higher risk for developing a secondary infection due to theoretical risk of immunosuppression. Table 1 Table 2 Methods A retrospective analysis of all COVID positive patients admitted to a 128 bed community hospital in Westchester County, NY from March 1 – May 31, 2020. The data was analyzed to determine incidence of secondary infections based on positive cultures in patients and further stratified based on receipt of tocilizumab. Results Out of 445 COVID positive patients reviewed, 69 (15.5%) had positive bacterial/fungal cultures. Average age of the patient population reviewed was 64 (range 1 – 106) and 60% of the patients were male. As of May 31, 2020, 114 of the patients had expired, 281 were discharged, 23 were transferred, and 27 were still admitted to the hospital. Of the 445 total patients, 42 received at least 1 dose of tocilizumab. Out of those patients, 6 patients (14.3%) had subsequent positive cultures. (Table 1) This was not statistically significant (p = 0.8185). Most common positive specimens were in urine (n=38), blood (n=33), and respiratory specimens (n=20). Most commonly found co-pathogens were Escherichia coli (n=22), Coagulase-negative staphylococci (n=11), and Pseudomonas aeruginosa (n=9). Of the 69 patients with positive cultures, 27 received ICU level of care. (Table 2) Conclusion A small retrospective study found that the incidence of bacterial or fungal co-infection for COVID positive patients was high but did not find receipt of tocilizumab was associated with secondary infections. This suggests areas for future study and further investigation as hospitals consider use of immunomodulatory therapies in the treatment of COVID-19. Disclosures All Authors: No reported disclosures

This randomized controlled trial at an inner city community hospital examined the effect of a robotic pet (cat or dog) on cognition, loneliness, depression, delirium, falls, restraint use, and 1:1 companion use in 160 adults over age 65. The study utilized robotic pets which have an audible heartbeat and interact by purring or barking, turning their heads, opening/closing their eyes, snuggling, wagging their tails, moving their paws, and showing their bellies. The average cost of a robotic pet ranged from $100-$125. Participants were randomized to one of two groups (80 participants per group). Participants in the experimental group received their choice of a cat or dog robot for the duration of their hospital stay. Since the robotic pets could not be disinfected, the robots were single patient use. Patients were encouraged to take the robotic pet home with them. Participants in the control group received a daily 15 minute visit from a nursing student. Measures (Mini-cog, 3 Item UCLA loneliness scale, GDS, and CAM) were administered upon study enrollment and prior to discharge. Patients who had the robotic pet during hospitalization had less delirium, loneliness, fewer falls, and less 1:1 companion use (p

BACKGROUND: Parenchymal liver biopsy is important for diagnosis and management for many liver disease patients. Percutaneous image-guided liver biopsy is currently the most widely used method; however, endoscopic ultrasound (EUS)-guided liver biopsy with newer flexible large-bore core needles represents an emerging approach for sampling. EUS-guided liver biopsy (EUS-LB) offers certain advantages over traditional methods such as doppler assistance to avoid intervening vessels and the ability to image both hepatic lobes to minimize sampling error. AIMS: Our aim is to evaluate the feasibility and safety of EUS-LB in obtaining adequate tissue samples for diagnosis of unexplained liver disease and to compare our results to percutaneous liver biopsy at our institution. METHODS: We conducted a retrospective chart review of patients who underwent EUS-LB at Santa Clara Valley Medical Center in San Jose, California between January 1 and September 30, 2017. All patients who underwent EUS-LB had 2 passes taken. For comparative purposes, we also identified patients who underwent a percutaneous liver biopsy for similar indications. We collected data on procedure duration, adverse events, complete portal tracts (CPTs), inflammation grade, and fibrosis grade. RESULTS: To date, there have been 8 patients who have undergone EUS-LB with a 19-gauge Acquire needle (Boston Scientific) at our institution. The indications for EUS-LB included unexplained abnormal LFTs (n=6), staging of hepatitis B (n=1), and cirrhosis of unclear etiology (n=1). The average procedure duration for EUS-LB and percutaneous liver biopsy was 19 minutes and 28 minutes, respectively. The average number of CPTs was 9.4 (range 6–13) and 9.1 (range 6–14), respectively. Three-quarters of patients in the EUS-LB group were determined to have mild inflammation (6/8, 75%). Most patients had 0 stage of fibrosis (7/8, 87.5%). Recovery time for EUS-LB patients averaged 30 minutes while percutaneous liver biopsy patients were all placed in observation for 240 minutes prior to discharge. No patients experienced any adverse events. CONCLUSIONS: EUS-LB is feasible, safe, and produces a comparable sample adequacy for histologic examination compared to percutaneous liver biopsy at our community hospital. In addition, EUS-LB requires less time to complete, both in procedure time and recovery time. Further study regarding EUS-LB is warranted for optimal technique (e.g. the use and amount of suction) as well as direct comparison to percutaneous approach in terms of possible cost reduction and improved patient satisfaction. FUNDING AGENCIES: None

Background Staphylococcus aureus bacteremia (SAB) is associated with 30-day all-cause mortality rates approaching 20–30%. The purpose of this case–control study was to evaluate risk factors for 30-day mortality in patients with SAB at a community hospital. Methods As part of an antimicrobial stewardship program (ASP) initiative mandating Infectious Diseases consultation for episodes of SAB, our ASP prospectively monitored all cases of SAB at a 341-bed community hospital in Jefferson Hills, PA from April 2017–February 2019. Cases included patients with 30-day mortality from the initial positive blood culture. Only the first episode of SAB was included; patients were excluded if a treatment plan was not established (e.g., left against medical advice). Patient demographics, comorbidities, laboratory results, and clinical management of SAB were evaluated. Inferential statistics were used to analyze risk factors associated with 30-day mortality. Results 100 patients with SAB were included; 18 (18%) experienced 30-day mortality. Cases were older (median age 76.5 vs. 64 years, P < 0.001), more likely to be located in the intensive care unit (ICU) at time of ASP review (55.6% vs. 30.5%, P = 0.043), and less likely to have initial blood cultures obtained in the emergency department (ED) (38.9% vs. 80.5%, P < 0.001). Variables associated with significantly higher odds for 30-day mortality in univariate analysis: older age, location in ICU at time of ASP review, initial blood cultures obtained at a location other than the ED, and total Charlson Comorbidity Index (CCI). Variables with P < 0.2 on univariate analysis were analyzed via multivariate logistic regression (Table 1). Conclusion Results show that bacteremia due to MRSA and total CCI were not significantly associated with 30-day mortality in SAB, whereas older age was identified as a risk factor. Patients with initial blood cultures obtained at a location other than the ED were at increased odds for 30-day mortality on univariate analysis, which may raise concern for delayed diagnosis. Disclosures All authors: No reported disclosures.

Background The implementation of antimicrobial stewardship program (ASP) is one of the basis for the control of multidrug-resistant bacteria (MDR), optimization of antibiotic use, minimization of adverse events, and reduction of unnecessary costs. We demonstrate the design, development, and participation in ASP program following CDC and Prevention Core Elements strategies.1,3,4 The objective is to evaluate the impact of clinical pharmacists working in conjunction with infectious disease (ID) physician on tracking and documenting antibacterial utilization in per patient-days, pharmacist clinical interventions, prescriber practices, and antibiotic purchases. Methods We conducted a multidisciplinary-team project of pharmacist-led prospective-audit-with-feedback ASP from 2015 to 2018. The ID physician and clinical pharmacist conducted patient care rounds twice weekly to make recommendations that include de-escalation, intensification of treatment, alternative therapy, dose optimization, order clarification, stop date/duration, additional monitoring, education, restriction enforcement, consult, IV to PO conversion, rejection of recommendation, and total monitored interventions requiring no changes. Results Pharmacist tracked between 150 and 200 interventions monthly through the EMR system, reflecting both self-stewardship and during rounds with ID physician. Figures 2–8: Charts display the number of patient-days of therapy per 1,000 days at risk and yearly SVMH Antibacterial Utilization Rates compared nationally to other Teaching and Nonteaching hospitals.5 Below each graph exhibits yearly Drug Spend per patient-days of Therapy.6 Conclusion Overall, the antibiotic utilization rates decreased over 4 years, particularly with aztreonam, meropenem, and levofloxacin.The formalization of an antimicrobial stewardship partnership between ID physician and pharmacy team led to increases in pharmacist-recommended interventions, streamlining of antimicrobial therapy, as well as decreases in antimicrobial purchasing costs. Proactively working in conjunction with hospitalists allows the pharmacists to play a critical role in sustaining a robust ASP service at our community hospital. The ASP at SVMH can serve as a model for other community hospitals with similar resources. Disclosures All authors: No reported disclosures.

Background: Catheter-associated urinary tract infection (CAUTI) is a common hospital acquired infection which can lead to prolonged hospitalisation and mortality. Ang Mo Kio-Thye Hua Kwan Hospital is a 360-bedded Community Hospital in Singapore, providing inpatient rehabilitation and subacute care. The majority of patients are geriatric and referred from tertiary hospitals.

In elderly surgical patients, multiple comorbidities and diminished reserve lead to increased post-operative complications and higher cost. We developed a Geriatric Surgery Co-management (GSC) program, as an innovative partnership between geriatrics and colorectal surgery, to improve patient care for elderly colorectal surgery patients in the post-operative setting. This retrospective study analyzed colorectal surgery patients aged 70 or older admitted to a community hospital before GSC program implementation. Historical control (HC) was compared to patients admitted after implementation of the GSC program. GSC patients received a post-operative comprehensive geriatric assessment, identification of risk factors for and prevention of geriatric syndromes, management of comorbidities and optimization of pain management. The data was collected via National Surgical Quality Improvement Program and chart review. The HC (n=104) and GSC (n=44) groups were comparable at baseline. The most common type of surgery was colectomy in both groups (59% of all cases). The mean length of stay (LOS) was 5% shorter (-0.6 days) in GSC (p-value= 0.74); more pronounced in older and sicker patients: 15% shorter (-1.5 days) in patients ≥80 years old, 22% shorter (-1.7 days) in patients with Charlson comorbidity index ≥ 3 (p-values=0.47 and 0.25, respectively). Postoperative cardiac arrhythmia was markedly diminished from 12/104 (11%) in HC compared to 0/44 (0%) in GSC (p-value=0.02). The mean total hospital charge was $9,500 (18%) less per patient in GSC (p-value=0.1). Our results suggest that a multidisciplinary approach to postoperative care for geriatric colorectal surgery could decrease LOS, improve patient outcomes while decreasing hospital costs.

Background Clostridium difficile is the leading cause of healthcare-associated infection. As incidence rises, its epidemiology is also evolving. 20–50% of cases are now community-acquired; C. difficile cases arise from more diverse sources than previously thought. In this study, we investigated the diversity of C. difficile within a community hospital. Methods Stool samples were collected from symptomatic adults with a positive C. difficile PCR admitted to Duke Regional Hospital from July 2016 to July 2017. Healthcare-associated CDI was defined by any admission to a hospital, nursing or dialysis facility in the preceding 30 days. C. difficile was isolated by ethanol shock followed by plating on CDSA media. DNA was extracted using a chelex-based protocol. PCR ribotyping was conducted using the Bidet primers and agarose gel electrophoresis. A dendrogram was constructed in Bionumerics by the un-weighted pair-group method with the threshold for identical strains set at 95% similarity. Results C. difficile was successfully isolated from 85% of submitted specimens. For this pilot study, PCR ribotyping was performed on a convenience sample of 70 isolates. C. difficile exhibited substantial diversity: 47 distinct ribotypes were observed among 70 isolates (Figure 1). Fourteen clusters involving identical strain types were observed, totaling 35 isolates. Identical strain types suggestive of direct transmission were evenly split between hospital- (18 of 35, 51%) and community-acquired (17 of 35, 49%) cases. The median time between clustered cases was 50 days (range: 7 to 331 days). Thirty-five of 70 (50%) of all isolates exhibited entirely unique strain types. Conclusion C. difficile isolates in our community hospital exhibited tremendous genetic diversity. The high proportion of strains with entirely unique ribotypes suggests diverse sources of acquisition. These results are consistent with a growing body of literature in which 30–50% of C. difficile isolates are genetically distinct, even when direct transmission was suspected. We are currently expanding our survey to include a network of regional hospitals and clinics, with the goal of better characterizing C. difficile’s diverse and still poorly understood sources. Figure 1. Dendrogram of C. difficile PCR ribotypes. Disclosures All authors: No reported disclosures.

Background Antimicrobial stewardship programs (ASP) have been implemented in many hospitals, including NICU departments. Although tertiary hospitals have successfully introduced ASPs by antimicrobial stewardship teams, lots of community hospitals without pediatric infectious disease specialists have difficulty implementing ASP. We present a successful implementation of simple and feasible NICU antimicrobial stewardship program in a Japanese community hospital. Methods We developed a protocol of antimicrobial treatment in the NICU department of Nara Prefecture General Medical Center, Nara, Japan and have implemented it from September 2017. The protocol consists of antimicrobial treatment criteria (criteria for starting antimicrobials for neonates with suspected early-onset infection, criteria of prolonged antimicrobial treatment for more than 48 hours and duration of treatment), weekend report of blood culture result from microbiology department and stopping ordering antimicrobials beforehand for the next day. We compared days of therapy (DOT) during the post-implementation period (September 2017 to March 2018) with that of the pre-implementation period (March 2013 to August 2017). Results During the pre- and post-ASP implementations, 913 and 92 patients were admitted to NICU. Mean DOT/1,000 patient-days were 217.9 and 56.6 in pre- and post-ASP implementations (P < 0.001) with 74.0% reduction of antimicrobial prescriptions. Mortality rates were 0.4% and 0.0% (P = 0.54), and 4.6% and 5.3% of patients had sepsis (P = 0.76), respectively. Weekend reports of blood culture result were performed in six patients and shortened their length of antimicrobial treatment during the post-ASP implementation period. Conclusion This ASP program was easily implemented in a NICU department of a community hospital and significantly reduced antimicrobial prescription. This kind of simple protocol may be successfully scaled-up in resource limited community hospitals without any pediatric infectious disease specialists or antimicrobial stewardship teams. Disclosures All authors: No reported disclosures.

The UTRGV DHR Internal Medicine Program conducted a study addressing end of life (EOL) care focused on our Hispanic community in regards to communication and trust between patients, caregivers, and healthcare providers. Our residents train at a community hospital which cares for an 89% Hispanic population of 1.2 million, spanning over 4 counties of the Rio Grande Valley. Trainees are often involved in family meetings while treating hospitalized, terminally ill patients. Although family meetings are a standard approach in palliative care, Hispanic family meetings tend to occur more often and with a larger, extended family unit. Our intent was to educate our residents to initiate conversations about EOL care choices promoting delivery of patient-centered, family oriented care utilizing culturally appropriate information regarding EOL issues. Baseline surveys were provided to all 39 trainees which assessed anxiety, incompetence, and communication skills in delivering bad news during family meetings. An advanced care planning process was implemented over 3 months with a goal to engage patients in EOL conversations, initiation, and completion of advanced directives. Residents received weekly training on interactive methods and ethical concepts including group discussions, role-playing, and demonstrations which were culturally and linguistically appropriate. We found that physician competence in conducting Hispanic family meetings is vital. Residents completed a post-training survey resulting in 100% improved attitudes and behaviors such as confidence, satisfaction, caring and empathy. They felt more comfortable and prepared to speak to a larger family unit who was likely to ask a lot of questions and request multiple meetings.

Background Lower respiratory tract infections (LRTIs) are one of the most common infectious disease-related emergency department (ED) visits in the United States. The ID Society of America and the Agency for Healthcare Research and Quality support the use of procalcitonin (PCT) for antimicrobial stewardship (ASP) in LRTI. Though not widely available, awareness and access to PCT is rising. At our facility, PCT became available in February 2018. The aim of our study is to assess the impact of PCT at an urban community hospital and identify possible targets for ASP interventions. Methods Retrospective review of cases from February to August 2018. Cases from the ED were selected for review. Appropriateness of testing was assessed, defined as guideline-based use for cessation of antibiotics in uncomplicated LRTIs without critical illness or immunosuppression. Demographic variables and clinical characteristics, such as, diagnosis, antimicrobial use and PCT levels were obtained. Results PCT was ordered 268 times hospital-wide, of which 160 (60%) were in the ED. Ages ranged from 0–90, with an average of 47. Most cases were male (51%). Appropriate testing for LRTI occurred in 33 (29%) cases. Antimicrobials were used in 75% of cases with low (< 0.5) PCT levels (Figure 1). Length of stay (LOS) was higher in groups that received antimicrobials (Figure 2). Testing was not appropriate in 127 cases (71%), with upper respiratory (21%), soft-tissue (17%), genitourinary (15%) and abdominal (13%) infections as the most common reasons for testing. Other diagnosis included alcohol withdrawal, seizures and altered mental status. Cumulative cost of PCT testing was $24000, of which $19050 was not consistent with guidelines. Conclusion Clinicians routinely ordered PCT in the ED. Antimicrobials were used for LRTIs despite low PCT levels. This may have contributed to higher LOS and excess antimicrobial use. Unwarranted PCT testing had a cost of $19050. As PCT becomes widely available in hospitals across the United States, education and decision support by ASP to clinicians may be needed to enhance guideline-appropriate evidence-based use of PCT. Targeted ASP interventions in the ED may have cost savings by reducing excess testing, length of stay and improving antimicrobial use. Disclosures All authors: No reported disclosures.

Background Overuse of antibiotics in Respiratory Syncytial virus (RSV) bronchiolitis in children has been reported between 29–80%. Our antibiotic stewardship program (ASP) utilized a validated communication tool using TeamSTEPPS ® 2.0 principles to improve pharmacy-physician communication and improve audit-feedback technique (AFT). Methods We trained pharmacists and physicians in TeamSTEPPS ® 2.0 using simulation-based training. The key component of the training was: closed-loop communication and using a scripted pharmacy communication tool. The scripted pharmacy communication tool was modified from the “DESC” script used in TeamSTEPPS ® 2.0, which includes (1) Describing the situation, (2) Expressing concern, (3) providing Solutions, (4) stating Consequences and coming to an agreement. We incorporated this to improve the audit-feedback technique. We aimed to: (1) Reduce overall percentage of antibiotic (abx) use in RSV bronchiolitis by 25%, (2) reduce use of ceftriaxone, (3) reduce average antibiotic days of therapy (DOT). Results Our baseline data from 2017–18 RSV season showed a 42% (48/113) use of abx, of which 10% were deemed inappropriate. When compared with the 2018–2019 season, no differences were noted in patient demographics. The median length of stay between the two time periods was similar (2.9 days, IQR 1.9–4.8 days vs. 3.1 days, IQR 2.1–5.1 days, P = 0.17). More patients were admitted to the pediatric intensive care unit (PICU) in the 2018–2019 period: 35/96 (36.4%) as compared with 17/113 (15%) in the previous season. Although similar proportions of patients received abx (42% vs. 41%) in the two groups (Figure 1), average abx DOT, significantly decreased in the 2018–2019 period as compared with 2017–2018 (Figure 2). There was also a decrease in the use of ceftriaxone during the 2018–2019 (Figure 3). All physicians and pharmacists were satisfied with the communication technique and thought that it improved their interaction and understanding of the ASP process. Conclusion Though we did not reduce the overall abx use in RSV bronchiolitis, we did reduce the average abx DOT and use of ceftriaxone in our institution. The use of a validated communication tool to improve prospective AFT was crucial to the success of the ASP program. Disclosures All authors: No reported disclosures.

Background Antibiotic Stewardship (ASP) standards for hospitals became effective January 1, 2017. Core Elements implementation guidelines have been challenging for rural hospitals usually lacking on-site expertise. Our 170-bed Community Hospital / rural referral center has dedicated resources for on-site ASP. Our team includes on-site Infectious Disease (ID) Specialist and dedicated ASP pharmacist. Over first 2 years, our model shows very high provider acceptance, improvement in antimicrobial use pattern and reduction in the number of Clostridioides difficile infections (CDI). Methods The ASP Pharmacist conducted a daily review of ASP targets. He met with on-site ID Physician 3 days weekly to discuss interventions and review complex cases. The ASP team - ID Medical Director, ASP Pharmacist, Microbiologist, Invention Preventionist and Hospitalist met monthly to discuss outcomes and facility-wide interventions. ASP audit included: positive cultures, patients on multiple or broad-spectrum antimicrobials, patients receiving dual nephrotoxic drugs, carbapenems, fluoroquinolones, candidates for IV to PO conversion The audit results were communicated in-person to attending physician and documented in electronic medical record. Results ASP team recommendations were accepted in 94% of cases ID consult was recommended in 4.69% and was accepted 100%. Top 20 IV antimicrobial use decreased by 10%. Fluoroquinolones (29%) and carbapenems (28%) showed highest decrease. Cephalosporins showed small increase. Hospital-acquired CDI rate decreased from 0.83 cases/ 1000 patient-days (PD) pre-ASP to 0.53 cases/ 1000 PD post-ASP. General CDI diagnosis decreased from 3.21 cases/1000 PD pre-ASAP to 2.23 cases/ 1000 PD post-ASP Conclusion An on-site, ID Specialist reviewed and dedicated ASP Pharmacist driven program at a rural referral center/ Community Hospital significantly improved antibiotic use and decreased Clostridium Difficile Infections in the first 2 years. Direct feedback of ASP review to providers resulted in an excellent acceptance rate. On-site ID and ASP Pharmacist collaboration is logistically difficult to achieve but expanding our model to rural referral centers should be considered. More research is needed to determine the cost-effectiveness of onsite, dual led programs. Disclosures All authors: No reported disclosures.

Background PCR-based rapid diagnostic tests (RDTs) provide rapid and accurate infectious gastroenteritis (IGE) etiologies within hours. However, there are limited data evaluating the impact of these panels on the appropriate management for diarrheagenic E. coli strains (DECS). This study evaluated the impact of the BioFire® FilmArray® GI panel on the appropriate antimicrobial management of DECS. Methods A retrospective analysis was conducted at a large community hospital in San Antonio, TX. Patients with a positive infectious diarrhea diagnostic panel (IDDP) for DECS from October 1, 2016 through September 30, 2018 and admitted for ≥48 hours were included. Patients were excluded if they had a positive IDDP for multiple DECS. An algorithm based on all available literature was used to classify appropriate management of DECS, which included patients having prolonged diarrhea (≥7 days), immunocompromised hosts (ICHs), or the presence of systemic symptoms. Antimicrobial therapy changes based on IDDP results, presence of an ID consult, and incidence of hemolytic uremic syndrome (HUS) were evaluated. Results A total of 374 patients were included for analysis. Overall, the IDDP did not lead to a change of therapy in 290 cases. However, the IDDP resulted in 84 antimicrobial changes including initiation of appropriate antibiotics (n = 48) and de-escalation/discontinuation (n = 22), primarily in special populations, such as ICHs. The IDDP results led to appropriate therapy optimization in 63%, 17%, 16%, and 9% of enteroinvasive E. coli (EIEC), enteroaggregative E. coli (EAEC), enteropathogenic E. coli (EPEC), and enterotoxigenic E. coli (ETEC) cases, respectively. In contrast, 81% of Shiga toxin-producing E. coli (STEC) cases were inappropriately managed with antibiotics, and 33% developed HUS. Only 14% of all DECS cases generated an ID consult. Conclusion Of note, this study found that the IDDP did not lead to a change in the management of most pathotypes. However, it was associated with positive changes in the management of DECS in specific patients, particularly ICHs. RDTs assist providers in the timely identification and treatment of IGE pathogens, but both antimicrobial and diagnostic stewardship remain critical for the optimal management of DECS. Disclosures All authors: No reported disclosures.

Background Nasal decolonization with mupirocin to reduce infection risk, has been associated with mupirocin-resistant Staphylococcus aureus (SA). A community hospital identified two patients colonized with methicillin and mupirocin-resistant SA (MRSA), one scheduled for surgery, one for inpatient IV antibiotic therapy. Instead of mupirocin, an alcohol based nasal antiseptic was applied to these patients twice daily for 5 days, resulting in a negative MRSA nasal screening test in both patients. Neither patient developed an infection during or after treatment. Building on this success, a plan was made to assess the impact of universal nasal decolonization to replace screening and contact precautions for MRSA colonized patients, and to reduce surgical site infections (SSI). Methods A 12-month project using a before and after design, was initiated in April 2018. The project involved twice daily application of alcohol-based nasal antiseptic for all inpatients, and preoperatively for all surgical patients in addition to existing preoperative chlorhexidine bathing. No other practice change was made during this period. Assessment of impact was planned by comparing the incidence of MRSA bacteremia and SSI at baseline (2017) and after project implementation, in addition to costs avoided with reduction of nasal screening and CP. Results Compared with baseline, between April 2018 and March 2019, there was a decrease in MRSA bacteremia from 3/1,000 patient-days to 0/1,000 patient-days, a reduction in CP from 3.78 to 1.53/1,000 patient-days, a reduction in nasal screens from 3,874 to 605, and a reduction of all-cause (Gram-negative and Gram-positive) SSI after all surgical procedures from 3/4,313 procedures to 0/4,872 procedures. After accounting for the cost of the nasal antiseptic, the reduction in gowns, gloves and nasal screening tests resulted in $104,099.91costs avoided. Conclusion House-wide application of alcohol-based nasal antiseptic in place of screening and contact precautions, resulted in a reduced incidence of both MRSA bacteremia and SSI for all types of surgical procedures, in addition to significant costs avoided. Disclosures All authors: No reported disclosures.

Background Staphylococcus aureus bacteremia (SAB) is associated with high morbidity and mortality rates. Data on epidemiology and outcomes of SAB in children is not as well described as in adults. The primary objective of this study was to describe clinical and microbiological cure rates of SAB in hospitalized children. Secondary objectives included time to clinical and microbiological cure, mortality, proportions of methicillin-sensitive and resistant SA (MSSA, MRSA) bacteremia, and antibiotic usage pattern. Methods This was an electronic chart abstraction conducted at a community hospital in the South Bronx, NY, of all pediatric cases of SAB ( Results Of 41 patients, neonates comprised 12%, 1- to 23-month-old infants 56% and 2- to 17-year-olds 31%. Overall, 76% of patients had bacteremia due to MSSA, and 24% MRSA. MRSA was isolated in 37% of HA SAB compared with 14% of CA SAB (P = 0.15). The two highest risk factors identified for SAB were peripherally inserted central catheters lines (PICC, 29%) and skin and soft-tissue infections (22%). SAB in the neonatal period was associated with PICC lines when compared with children outside the neonatal period (80% vs. 22%, P = 0.02). Using available data, clinical and microbiological cure rates were similar at 73%. The median time to clinical cure was 5 days (interquartile range [IQR] 2–10) and to microbiological cure, 2 days (IQR 1–4). A 2-month-old infant died (mortality 2.4%). Initial antibiotic selection was vancomycin (39%), clindamycin (39%), and nafcillin (7%). The proportion of SA resistant to clindamycin was 22%. Conclusion Pediatric SAB was uncommon in this community hospital experience over 7 years and is associated with PICC lines in neonates. MSSA was more prevalent than MRSA. Initial antibiotic selection had anti-staphylococcal coverage in 85% of cases, while clindamycin resistance occurred in 22% of SA isolates. Disclosures All authors: No reported disclosures.

Background Studies suggest up to 60% of antibiotics prescribed in the intensive care units (ICUs) may not be optimized. The antimicrobial stewardship team (AST) at Abbott Northwestern consists of infectious diseases trained pharmacists, pharmacy residents, and/or advanced pharmacy practice experience (APPE) pharmacy students and provides prospective audits and feedback on all inpatients not being seen by infectious diseases specialists and currently receiving any anti-infectives. Comprehensive daily profile reviews are performed and recommendations are communicated via a physician sticky note in the electronic medical record (EMR) and/or via a direct page. Beginning January 2018, the AST started reviewing patients in the two ICU units earlier to ensure recommendations were completed prior to multidisciplinary rounds. The AST also initiated sending a message within the EMR alerting the decentral pharmacists prior to rounds. Methods A retrospective chart review was conducted on recommendations made by the AST between February and April 2017 (control group) and February and April 2018 (intervention group) for patients on two ICU units (ICU 1 and ICU 2). Time to acceptance and acceptance rates were calculated for the control and intervention period. A one-tailed t-test was performed for the time to acceptance analysis and a Chi-squared test was performed to compare acceptance rates. Results were deemed statistically significant when P < 0.05. Results Time to acceptance for the recommendations showed a significant decrease from 25.9 to 13.7 hours with the new process in ICU 1 (P = 0.038). Provider acceptance rate increased significantly from 77.8% to 88.4% in ICU 2 (P = 0.037). Conclusion Changing the workflow of the prospective audit and feedback process by the AST had a meaningful impact by decreasing the response time (time to acceptance) and increasing acceptance rates of the recommendations in the ICUs. The revised process improved communication between the AST, decentral pharmacist, and attending provider, which in turn may have contributed to the positive outcomes. Disclosures All authors: No reported disclosures.

Background Evidence suggests that combination therapy for Pseudomonas pneumonia only provides mortality benefit in critically ill patients. In November 2015, the Antimicrobial Stewardship Subcommittee at Baptist Memorial Hospital-Memphis (BMH-Memphis) developed a combination Pseudomonasantibiogram and guideline, based on local susceptibilities, for critically ill patients with Hospital Acquired Pneumonia (HAP), Health Care Associated Pneumonia (HCAP), or Ventilator Associated Pneumonia (VAP). Methods This is a single center, retrospective study evaluating patients admitted to the BMH-Memphis medical intensive care unit (MICU) and surgical intensive care unit (SICU) with a diagnosis-related group (DRG) code for HAP, HCAP, or VAP.The primary objective of this study was to compare levofloxacin days of therapy per 1000 patient-days (DOT/1000 patient-days) before and after implementation of the combination Pseudomonas antibiogram guideline at BMH-Memphis. Secondary objectives included a comparison of individual levofloxacin orders, 30-day mortality, hospital length of stay (LOS), ICU LOS, 90-day incidence of extended spectrum β-lactamases (ESBLs), and 30-day readmission rates and incidence of Clostridium difficile. Adverse events including acute kidney injury and QTc prolongation were also evaluated pre- and post-implementation of the guideline. Results A total 150 patients were included in this study to meet power for the primary objective. Levofloxacin DOT/1000 patient-days was reduced by 3.4 days in the post-implementation period (P < 0.001) with a 63% reduction in individual levofloxacin orders (P < 0.001). Furthermore, there were significantly lower 30-day mortality rates in the post-implementation period, which persisted in a multivariate logistic regression analysis (P = 0.01). There was no difference in hospital or ICU LOS, 30 day readmission rates or incidence of Clostridium difficile,or 90-day incidence of ESBLs. There was also no difference in adverse events between the two study periods. Conclusion This study demonstrates that the implementation of a combination anti-pseudomonal guideline can decrease levofloxacin use while reducing 30-day mortality rates without increasing hospital or ICU LOS. Disclosures All authors: No reported disclosures.

Background PCR technology can be used for precise detection of infectious agents and improves antibiotic stewardship through: Accelerated de-escalation of therapy Rapid identification of pathogens Detection of resistance genes. In our center, basic respiratory Panel detect 11 targets and cost $100 while Complete panel detect 31 targets and cost $230.The purpose of the study is to improve utilization of these panel testing in a large community hospital. Methods Retrospective chart review of all patients with an order for a complete or basic panel and excluding Patients discharged or deceased prior to result reporting or insufficient specimen quantity to perform. Each patient was evaluated for appropriate respiratory panel collection site and antibiotic regimen changes within 48 hours of results. The preintervention period conducted from 10/2015- 12/2015, evaluated how respiratory panels were being utilized in antibiotic decision-making. Three primary interventions were enacted: Eliminated nasal swabs as a source option for respiratory panels in the clinical information system, restricted complete panel ordering to ID physicians and Eliminated PCR ordering options from all order sets. The postintervention period conducted from 5/2016 – 8/2016, re-evaluated the utilization and costs of respiratory panels. Results 270 tests ordered preintervention (13% basic and 87% complete) and 196 postintervention (84% basic and 16% complete), nasal swab was done in 78% in preintervention vs. 8% in postintervention, action was taken in 51 vs. 44 in pre-vs. post intervention. cost in preintervention period was 57,420 in preintervention vs. 23,660 in post intervension. No difference between ID vs. non-ID specialist in utilization of PCR. Conclusion Nasal swab collections for PCR decreased post-intervention from 78% to 8%. Appropriate sources for PCR specimen, such as sputum, were utilized during the post-intervention period. Post-intervention utilization of the panel results was comparable to pre-intervention period. Elimination of PCR respiratory panels from order sets and restrictions of complete respiratory panel ordering to ID physicians resulted in $33,760 saved. Disclosures All authors: No reported disclosures.

Background Intravenous vancomycin (VAN) continues to be a workhorse for suspected or documented methicillin-resistant Staphylococcus aureus (MRSA) infections. VAN over-prescribing, and suboptimal dosing or monitoring can be detrimental to efficacy, safety, and resource utilization. A local antimicrobial stewardship program (ASP) was implemented in September 2015 as an expansion of a pre-existing health-system ASP. The local ASP included an infectious diseases (ID) pharmacist, partial FTE ID physician, ASP software, and a goal to decrease inappropriate vancomycin use and improve safety. Methods We performed a serial cross-sectional study assessing the impact of ASP interventions on VAN consumption and AKI incidence at a single-center community hospital from October 2015 through March 2018. ASP interventions included a revised vancomycin dosing and monitoring guideline, education, and prospective audit and feedback by clinical pharmacists working under the guidance of ID pharmacist and physician. Antibiotic days of therapy (DOT) were tracked and reported quarterly with Theradoc® software. Acute kidney injury was defined as an increase of ≥0.5 mg/dL or 50% in serum creatinine from baseline in all hospitalized patients with baseline

Background Prospective audit and feedback is a primary tool for antimicrobial stewardship, but inefficient communication and provider non-participation can limit the impact. To address these issues, a customizable electronic alert system was created to deliver antimicrobial stewardship recommendations to providers upon opening the electronic medical record. If no provider declined the recommendation after 24 hours, the recommendation was implemented by the antimicrobial stewardship program per protocol. This study describes the experience of an opt-out antimicrobial stewardship pilot at a community hospital. Methods This is a pragmatic, quasi-experimental, single center study describing the frequency of accepted recommendations delivered during a 12 week intervention period. Recommendation responses are categorized by intent of the recommendation, day of antibiotic therapy, prescribed antibiotics, responding provider specialty, and clinical reasoning. Secondary outcomes are target antimicrobial days of therapy (DOT) per 1000 patient days and healthcare facility-onset Clostridium difficileinfections (HO-CDI) per 10,000 patient days for the three months before, during, and three months after the intervention period. Results In total, 804 of 1170 (69%) antibiotic recommendations were accepted yielding an average of 10 accepted recommendations per day. Of those accepted, 113 (14%) recommendations were implemented by the antimicrobial stewardship program per protocol. Antibiotic recommendations to de-escalate therapy were accepted more often than recommendations to discontinue therapy, 376/524 (72%) and 414/631 (66%), respectively. Target antibiotic DOT per 1000 patient days decreased from 775.2 in three months prior to 631 during the pilot (P < 0.05). HO-CDI per 10,000 patient days decreased from 16.24 to 11.70 (P = 0.12). After cessation of the intervention, antibiotic DOT and HO-CDI rates increased, 681 and 15.55, respectively. Conclusion The combination of opt-out antimicrobial stewardship with electronic delivery of recommendations demonstrated an efficient and effective approach to prospective audit and feedback. Future applications are broad including antimicrobial stewardship telepharmacy. Disclosures All authors: No reported disclosures.

Background Recurrent CDI is common despite antibiotic therapy. FMT is effective to reduce recurrent infections. We report our experience with Commercialized FMT (cFMT) products by providing ready-to-use capsules, for oral administration, or solution, for administration via colonoscopy. Methods The study was approved by IRB for adult patients with at least 3 episode of recurrent CDI despite antibiotic therapy, patients with severe infection were excluded. cFMT was administered in the hospital or at outpatient center. Each patient was evaluated 8 weeks post-transplant to assess for sustained clinical cure and side effects. The economic impact of cFMT was evaluated using historical data from EHR including: CDI rate, CDI readmission rate, rate of CDI-associated death, cost of CDI admissions, and rate of use of each antimicrobial regimen Results 33 patients enrolled (solution/colonoscopy 20 and capsule 13). Mean age was 74 vs. 67 y, female 56% vs. 64%, recurrent episode 4 vs. 3.1, CDI severity score 1.4 vs. 1.2. 95% (19/20) of patients who received cFMT via colonoscopy experienced sustained clinical cure vs. 85% (11/13) of patients who received capsule. One patient experienced an adverse event from capsule with nausea and vomiting, which resolved without sequelae. 2 of the 3 patients that experienced treatment failure received cFMT from the same donor Due to recurrent episodes. The cost of cFMT was $635 for capsules and $485 for solution which was far less than recurrent CDI associated cost. Conclusion cFMT is a viable alternative to traditional FMT and was both clinically and economically beneficial in patients with recurrent CDI in a community hospital. Further studies needed to confirm above findings. Disclosures All authors: No reported disclosures.

Background Clostridium difficile infection (CDI) contributes to significant increases in healthcare-associated morbidity and mortality. Multiple strategies have been promulgated to accurately diagnose and to control healthcare facility-onset (HO) CDI. Sharp Memorial Hospital is a 438-bed tertiary care community hospital. In 2014, the standardized infection ratio (SIR) CDI was 1.406 (2006–2008 baseline) with a p value of 0.0005. We report the results of a multi-disciplinary approach that has reduced our HO-CDI SIR. The National Healthcare Safety Network definitions and methodologies were used throughout the study. Methods Various multi-disciplinary interventions were implemented over a 12 month period from April 2015 through March 2016 that included enhanced administrative support and the creation of a multi-disciplinary CDI Steering Committee (Figure 1). A Lean Six Sigma approach was launched that included a two-day rapid process improvement (RPI) workshop in July 2015 with participation of an interdisciplinary team of frontline staff, leaders from the 2 units with high CDIs, Infection Prevention, and Environmental Services. Subsequently, lessons learned from the RPI were disseminated throughout the hospital. The laboratory and information technology staff and the antimicrobial stewardship program also contributed. Results Compared with the intervention period, the post intervention period (April 2016 through March 2017) documented a significant increase in the number of samples submitted for CDI testing ≤ 3 days after admission and a significant decrease in the number of samples submitted > 3 days after admission. There were significant decreases in the HO-CDI SIR from 0.947 to 0.676 (p value 0.0485) and in quinolone days of therapy from 265 to 246 (p value 0.0001). Conclusion We have demonstrated a significant decrease in our HO-CDI using a multi-pronged approach that highlighted a return and reinforcement of back to basics infection prevention. High HO-CDI SIR in previous years might indicate missed community-onset, community-onset healthcare facility-associated cases. We did not employ other technologies such as the hands-free disinfection devices. Sustainability remains a future challenge. Disclosures All authors: No reported disclosures.

Background We evaluated the cost impact of blood cultures contaminated with coagulase negative Staphylococci species (CoNS) at a community hospital in the Seattle metropolitan area. Data were used to justify acquisition of the rapid diagnostics system, Verigene. Methods All blood isolates of CoNS from January 2017 were included. Data were evaluated by patient. The cost analysis included length of hospital stay, days of vancomycin therapy, vancomycin drug concentrations, and pharmacist time spent on vancomycin drug monitoring. Documented adverse drug effects and renal dysfunction were recorded. Based on preliminary data using Verigene, we estimated a 1-day time to organism identification and antibiotic de-escalation following culture draw. Results 72 blood cultures with CoNS were identified among 51 patients. Physician-documented CoNS infection was present in 5 patients (10%). Of 46 patients with CoNS contamination, 26 (57%) were initially treated with vancomycin, 14 (30%) had therapeutic drug monitoring of vancomycin. One patient was hospitalized 4 additional days due to delay in implanting a cardiac pacing device while infection was ruled out. Four patients were monitored for infection which contributed to hospital stay; each had comorbidities also requiring ongoing hospitalization. Excess care included 20 drug concentrations, 39 days of vancomycin, and 4 additional days of hospitalization. This contributed to a cost/month of $12,992 which annualized to $187,104. One patient with documented CoNS infection had C. difficile infection while on vancomycin; 16 patients had baseline renal impairment either acutely on admission or due to chronic kidney disease. Conclusion Reducing time to identification of blood culture contamination represents an opportunity to improve patient care by minimizing unnecessary antibiotic therapy, drug monitoring, and reducing hospital length of stay. Our institution anticipates an annual cost savings of $143,504 based on rapid identification of CoNS in blood. This justifies the acquisition and operation of a rapid diagnostics system. Disclosures All authors: No reported disclosures.