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Background Remdesivir (RDV) was the first agent with proven clinical benefit against COVID-19, shortening the time to recovery in a randomized placebo-controlled trial (RCT). Based on this trial, the Food and Drug Administration approved RDV via emergency use authorization. Despite its wide use, RDV remains controversial. Early use of RDV in patients requiring low flow nasal canula has robust evidence. However, benefit in mechanical ventilation (MV), high-flow nasal canula (HFNC) and non-invasive positive pressure ventilation (NIPPV) is conflicting. Multiple studies, most notably the SOLIDARITY and DisCoVeRy trial, have conflicting results on who benefits from RDV. Deploying novel therapeutics in this changing landscape is challenging. We seek to understand RDV practices and the role of antimicrobial stewardship (ASP) in hospitals across the US. Methods A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, presence of RDV therapeutic restrictions, and RDV use by degree of oxygen needs for each COVID-19 wave. Results A total of 78 responses were collected, representing wide geographic reach in the US (Figure 1). RDV was restricted in 53% of facilities. Hospitals without restrictions commonly used RDV for patients on MV, NIPPV and HFNC, with more use on HFNC than on NC during the first winter, Delta and Omicron waves (Figure 2). Use on MV declined with each surge. Hospitals with RDV restrictions had more use of RDV on NC than all other ordinal scales (Figure 3). Use in MV, NIPPV and HFNC compared to NC declined in the restricted group with each COVID-19 surge. Figure 1.Geographic distribution of hospitals represented in the survey Figure 2. Remdesivir use by oxygen requirements in hospitals without remdesivir therapeutic restrictions. Figure 3 Remdesivir use by oxygen requirements in hospitals without remdesivir therapeutic restrictions. Conclusion A wide gap between evidence-based guidelines and actual practice exists. This gap was wider in hospitals without COVID-19 therapeutic restrictions in place for RDV. In the unrestricted group, RDV was commonly used for MV, HFNC and NIPPV, where robust RCT evidence of benefit is lacking. Though this practice occurred in both groups, the restricted RDV group prioritized RDV use in NC and did so at higher percentages each subsequent COVID-19 surge. ASP restrictions can have an important role in guiding COVID-19 therapy. Disclosures All Authors: No reported disclosures. more...

Background During the COVID-19 pandemic, evolving literature and emerging therapies have led to significant controversies on what constitutes optimal therapy for hospitalized patients with COVID-19. In addition, multiple guidelines emerged exhibiting variable recommendations in key areas of therapeutic management. Thus, interpreting emerging data and deploying novel therapeutics during the pandemic has been challenging. Antimicrobial stewardship programs (ASP) have been proven to help promote evidence-based practices and are now common the United States (US). We seek to further understand the role of ASP during the COVID-19 pandemic. Methods A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, hospital size, facility type, and existence of active ASP. COVID-19 therapeutic restrictions and type of provider who decides on treatment allocation was surveyed. Results A total of 92 surveys were completed, representing wide geographic reach within the United States (Figure 1). Hospital size by beds were 14% less than 200 (13), 18.5% 201-300 beds (17), 15.2% 301-400 beds (14), and 52.2% over 400 beds (48). Community hospitals accounted for 31.5% (29), county/public hospital 3.3% (3, 3.3%), University-affiliated Community-Based Teaching Hospitals 10.9% (10), University-based Teaching Hospital 45.7% (42), and 8.7% selected other. ASP were present in 97.2% of hospitals. COVID-19 therapeutic restrictions were common (Figure 2). Infectious diseases (ID) approval was required in 87.9% of facilities (Figure 3). Figure 1Geographic distribution of hospitals represented in the survey Figure 2. Restricted COVID-19 therapies by medication type (%) Figure 3 Specialties or providers that are able to order or approve restricted COVID-19 therapies (%) Conclusion COVID-19 therapeutics were commonly restricted during the COVID-19 pandemic. Approval by ID clinicians was required almost universally (87.9%). The role of other specialties was significantly lower, representing less than 45% of hospitals. ID clinicians have played a vital role in guiding therapy and supporting ASP during the COVID-19 pandemic. This survey highlights the value of ID clinicians to healthcare systems in allocating resources and promoting evidence-based practices through ASP. Disclosures All Authors: No reported disclosures. more...

Background It is known that the pandemic increased the risk of severe illness from SARS-CoV-2 infection in immunocompromised patients as compared to the general public. To combat this issue, telemedicine was utilized in various settings, but there is very little data on the adequate continuity of care (COC) and sustainability of telehealth throughout the pandemic. There is even less data on the effects of the pandemic in special populations, such as people living with human immunodeficiency virus (PLWH) and within the correctional setting. The purpose of this study was to investigate rates of HIV virologic suppression (VS) and the sustainability of telemedicine throughout the SARS-CoV-2 pandemic. Methods This was a retrospective, pre-post cohort study of PLWH who received antiretroviral therapy (ART) within Illinois Department of Corrections (IDOC) / University of Illinois Chicago telemedicine clinic between 3/2019 and 3/2021. Patients who were released from IDOC or reincarcerated during the study period were excluded. The primary endpoint compared the rate of HIV VS pre-, peri- and post-SARS-CoV-2 restrictions. Secondary endpoints included change in immunologic function pre-, peri- and post-SARS-CoV-2 restrictions, incidence of SARS-CoV-2 infection, number of hospitalizations, development of virologic failure, and change in ART post-pandemic. Other factors known to influence COC were also collected. Results Of 320 patients screened, 225 were included. The majority were Black males (73.7%) and 95.1% had a CD4 T-cell count > 200 cells/mm3 at baseline. Approximately 88% of patients were on a single tablet regimen, with most receiving bictegravir/emtricitabine/tenofovir alafenamide. Rates of HIV VS are summarized in Figure 1 and secondary outcomes are summarized in table 1. Factors associated with disruption of COC included non-adherence to appointments (62.6%) and ART (4.4%). Figure 1Rates of HIV viral suppression ( Table 1 Secondary outcomes Conclusion Results demonstrated that PLWH within IDOC had sustained VS and COC throughout the SARS-CoV-2 pandemic with telemedicine. These results describe how the pandemic impacted PLWH in a correctional setting and future studies could contribute to creating national guidance for telemedicine models to streamline clinical practice. Disclosures All Authors: No reported disclosures. more...

Background The COVID-19 pandemic has caused a major public health crisis and is now a leading cause of death. At the start of the COVID-19 pandemic, treatment was limited to supportive care and off-label use of a variety of agents as we awaited the results of randomized controlled trials (RCTs). Our understanding of the disease has evolved and multiple evidence-based (EBM) treatment strategies supported by RCTs are now approved for use. Interpreting emerging data while responding to the pandemic can been challenging. We seek to understand the use of common medications during the COVID-19 pandemic. Methods A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, therapeutic options including convalescent plasma (CP), hydroxychloroquine (HCQ), baricitinib and tocilizumab during each COVID-19 wave. Results A total of 78 responses were collected, representing wide geographic reach in the US (Figure 1). Use of HCQ declined by 96% and use of CP declined by 85% (Figure 2). The decline in CP was gradual each wave despite RCTs showing lack of benefit. Tocilizumab was used in 71% and 76% of hospitals during the first wave, prior to RCT data supporting its use. Baricitinib was used in 42% of hospitals prior to RCT data supporting its use. There was a 90% increase in baricitinib use after RCT data emerged. Figure 1Geographic distribution of hospitals represented in the survey Figure 2 Use of Hydroxychloroquine, Convalescent Plasma, Tocilizumab and Baricitinib Throughout Different COVID-19 Waves Conclusion The use of therapies before proven benefit was common through the pandemic. Similarly, the use of therapies after benefit was in question continued. Hydroxychloroquine was widely used in the first wave and then halted by the majority of hospitals in subsequent COVID-19 surges. IL-6 and JAK-2 inhibitors were commonly used prior to evidence of benefit and were more widely adopted once evidence emerged. Convalescent plasma use was common despite lack of evidence and its use continued despite multiple negative RCTs. Overall, our survey shows a gap between evidence and practice. Communicating evidence-based treatment strategies is a vital priority for major professional societies. Translating evidence into practice remains challenging during public health emergencies like the COVID-19 pandemic. Disclosures All Authors: No reported disclosures. more...

Background The disease caused by SARS-CoV-2, COVID-19, has caused a global public health crisis. Lower respiratory tract infections (LRTIs) caused by COVID-19 has led to an increase in hospitalizations. Disease severity and concerns for bacterial co-infections can increase antimicrobial pressure. Our aim is to define and compare the impact of COVID-19 on antimicrobial use (AU) and antimicrobial resistance (AMR) in the Dominican Republic (DR) and the United States (US). Methods We performed a retrospective review of AU and antimicrobial susceptibility patterns from 2019-20 at a hospital in the US (H-US) and the DR (H-DR). Our sites are community teaching hospitals with 151 beds in H-US and 295 beds in H-DR. After AU was tabulated, percent changes between 2019-20 were calculated. Resistance patterns for extended-spectrum beta-lactamase producing (ESBL) E coli, ESBL Klebsiella pneumoniae (ESBL-Kp), carbapenem resistant Pseudomonas aeruginosa (CR-PSAR) and Klebsiella pneumoniae (CR-Kp) were tabulated and percent changes between 2019-20 were calculated. Results AU increased by 10% in H-US and 25% in H-DR, with carbapenem use increasing by 268% and 144% respectively. Ceftriaxone use increased by 30% in H-US and 33% in H-DR. Azithromycin increased 54% in H-US and 338% in the H-DR. Resistance increased from 10% to 28% for ESBL-Kp and from 10% to 12% for ESBL E coli at H-US. CR-PSAR decreased from 20% to 12%, while cefepime and piperacillin resistance increased from 5% to 20% and 3% to 16% respectively (Figure 1). At H-DR, ESBL-Kp resistance decreased from 68% to 64% and increased from 58% to 59% for ESBL E coli. CR-PSAR and cefepime resistance increased from 5% to 19% and from 9% to 29% respectively (Figure 2). Figure 1. Antimicrobial resistance (%) for select organisms at H-US in 2019 and 2020 Figure 2. Antimicrobial resistance (%) for select organisms at H-DR in 2019 and 2020 Conclusion COVID-19 had a major impact on antimicrobial consumption and resistance in the US and DR. A greater impact was seen on ESBL rates in the US whilst a greater impact on carbapenem resistance was seen in the DR. The rise in carbapenem use in H-US reflected a rise in ESBL rates. In the DR, ESBL producing organisms were common prior to COVID-19 and carbapenem use was more widespread. The impact of the COVID-19 pandemic on AU may accelerate AMR worldwide. The scale up of antimicrobial stewardship across the globe is urgently needed to curb AMR. Disclosures All Authors: No reported disclosures more...

Background Although integrase inhibitor (INSTI)-based regimens have been associated with weight gain, there is limited data on whether INSTIs cause long-term metabolic consequences. This study evaluated the effect of INSTIs on the development of metabolic comorbidities compared to non-nucleoside reverse transcriptase inhibitor (NNRTI) or protease inhibitor (PI)-based therapies in patients in the Illinois Department of Corrections. Methods This retrospective cohort study consisted of incarcerated adult patients living with HIV and receiving a guideline-recommended regimen between 7/12/10 and 12/31/19. Patients with a pre-existing diagnosis of diabetes, hypertension, or hyperlipidemia, or lack of medical follow-up data were excluded. The primary outcome was to compare the incidence of a metabolic comorbidity between regimens. Secondary outcomes compared the incidence of weight gain, diabetes, hypertension, and hyperlipidemia as separate outcomes between drug classes. Demographics and pertinent labs were collected. Data was analyzed with ANOVA, chi-squared, and paired t-tests. The primary outcome was adjusted for age, race, use of antipsychotic medications, and family history of metabolic comorbidities. Results A total of 206 patients were included in the analysis with mean follow-up time of 31.5 ± 19.4 months. Majority of patients were Black (69%) and male (91%). A total of 42 patients developed a metabolic comorbidity (Table 1). After adjustment for confounding factors, there was a significant difference in the development of comorbidities between the treatment groups (p=0.031) with INSTI use being more likely to develop a comorbidity than NNRTI (p=0.004). No difference was found between INSTI and PI use (p=0.518). Development of hypertension was significantly higher in the INSTI group than NNRTI group (p=0.014), while the development of diabetes and hyperlipidemia were not. Weight and BMI were significantly higher regardless of antiretroviral (Table 2). No differences were found in the primary outcome between agents within the same drug class or between 1st or 2nd generation INSTIs. Table 1. Results of Primary and Secondary Outcomes Table 2. Impact of HIV regimen on weight and BMI after 1 year Conclusion All antiretrovirals were linked to weight gain but INSTIs were associated with increased incidence of hypertension. Disclosures All Authors: No reported disclosures more...

Background The 2018 American Heart Association and American College of Cardiology (AHA/ACC) 2018 Guideline on the Management of Blood Cholesterol included human immunodeficiency virus (HIV) as an atherosclerotic cardiovascular disease (ASCVD) risk enhancer for the first time. Our study investigates if patients living with HIV in the Illinois Department of Corrections (IDOC) were prescribed appropriate HMG-CoA reductase inhibitor (statin) therapy following release of these guidelines based on risk. Methods This was a retrospective study of patients with > 1 visit in our multidisciplinary HIV IDOC Telemedicine Clinic from 1/1/19-6/1/19. Our prescriptive authority is limited to HIV and directly related conditions, and we provide recommendations to on-site providers for other comorbidities. Included patients were > 18 years of age, HIV positive, and incarcerated within IDOC. Excluded patients had existing ASCVD. Data from the first visit in the study period were extracted from the electronic medical record and analyzed utilizing descriptive statistics. Primary objectives were to quantify ASCVD risk and appropriate statin use in our population. Results Of the 158 patients included, average age was 42 years. The majority were male (89%), Black (73%), overweight/obese (117/148, 79%), on an integrase single-tablet regimen (78%), with CD4 >200 cells/µL (97%), and HIV RNA < 20 copies/mL (85%). Of the 18 females, 8 were transgender. Within the prior year, 65% had a lipid panel. For the 50 patients meeting criteria for 10-year ASCVD estimation, median (range) risk was 6.6% (0.8% - 31.9%). Only 12 patients were on statins. Of these, all were indicated per AHA/ACC guidelines with 10 prescribed appropriate intensity. An additional 45 patients had indications for statins but were untreated. In total, 47 patients (30%) were not receiving appropriate statin therapy. Conclusion Results of our study suggest ASCVD risk management is an area of improvement for inmates living with HIV, especially as we look towards caring for an aging HIV population. Future directions include comparing these data to data from a later time point to evaluate time for guideline uptake. Disclosures Thomas D. Chiampas, PharmD, BCPS, AAHIVP, Gilead (Employee) more...