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Background The Oral versus Intravenous Antibiotics for Bone and Joint Infection Trial concluded that oral antibiotics administered during the first six weeks of therapy for orthopedic infections were non-inferior to parenteral antibiotics. Previously, we also conducted a retrospective cohort study of patients at our center with an orthopedic infection. Patients transitioned to oral therapy had significantly fewer adverse events and similar incidences of one year treatment failure compared to patients maintained on parenteral vancomycin. Methods To increase use of oral antibiotics for orthopedic infections, we created a protocol for changing IV to PO antibiotics prior to hospital discharge. We evaluated its effect on prescribing practices and healthcare utilization outcomes. Patients with an orthopedic infection were included if they were discharged within the 90-day pre- and post-protocol study periods, had an inpatient Infectious Disease consult, and were initiated on parenteral vancomycin while inpatient. The primary outcome compared the incidence of oral antibiotics prescribed at discharge. Secondary outcomes included incidence of adverse drug reactions, discharge dispositions, hospital length of stay, canceled follow-up appointments, unplanned readmissions, and early treatment failure. Results Fifty patients were included, 22 and 28 patients in the pre- and post-protocol groups, respectively. Twenty-three (82%) patients in the post-protocol group were prescribed oral antibiotics at discharge compared to 8 (36%) patients in the pre-protocol group. Twenty-three (82%) patients in the post-protocol group were discharged home compared to 13 (59%) patients in the pre-protocol group. Of note, 7 (25%) patients in the post-protocol group had early treatment failure compared to 1 (5%) patient in the pre-protocol group, and 8 (29%) patients in the post-protocol group compared to 4 (18%) patients in the pre-protocol group had an unplanned readmission. Conclusion Providing physicians with an oral antibiotic protocol for orthopedic infections significantly increased the number of oral antibiotic prescriptions at hospital discharge, but the higher rates of treatment failure observed after protocol implementation are concerning and warrant further investigation. Disclosures Russell J. Benefield, PharmD, BCPS-AQ ID, Paratek Pharmaceuticals: Grant/Research Support.

Background We previously demonstrated that standardizing the documentation of the outpatient parenteral antimicrobial therapy (OPAT) plan led to improved post-discharge outcomes. This study investigated whether centralizing the OPAT documentation to an infectious diseases (ID) pharmacist would lead to improved documentation quality and further improvements in post-discharge outcomes. Methods We conducted a single-center, retrospective study to evaluate outcomes associated with the centralization of the OPAT plan documentation to an ID pharmacist. The study was a multiphase quality improvement study consisting of a pre-intervention period and two intervention periods on each of the General ID consult services (first on Team 1 then on Team 2). The scope of the intervention was focused on the timeliness and completeness of OPAT note documentation, while other workflow processes involving OPAT remained unchanged. The primary objective was to compare hospital length of stay (LOS) between patients with OPAT Notes documented by an ID pharmacist versus ID providers. Secondary objectives were to compare post-discharge outcomes. Results A total of 350 patients met inclusion criteria; baseline characteristics were similar between the pharmacist and provider groups (Table 1). OPAT note documentation quality improved during the pharmacist intervention phases for each General ID team (Figure 1). The median LOS was 7.9 days in the pharmacist documentation group compared to 6.8 days in the provider group [Median difference, 1.1; 95% Confidence Interval (CI), -0.4 - 3.7]. Laboratory monitoring within 10 days of discharge, 30- and 60-day death or readmission rates, and late ID visit cancellations between the two groups were comparable (Table 2). ID clinic no show appointments occurred less often in the pharmacist documentation patients. Table 1:Baseline DemographicsFigure 1:Control Chart Comparisons of OPAT Notes Without All “Perfect Care” ElementsTable 2:Post-discharge outcomes for pharmacist compared to provider documentation patientsa: Pharmacist note patients are the reference for all comparisonsb: Adjusted for discharge destination and primary payorc: Adjusted for Charlson comorbidity indexd: Adjusted for age and primary payor Conclusion Improved OPAT note documentation did not translate into shorter hospital LOS. Post-discharge outcomes were similar between pharmacist and provider patients, although no show visits occurred less often when pharmacists documented the OPAT plan. Disclosures Russell J. Benefield, PharmD, BCPS-AQ ID, Paratek Pharmaceuticals: Grant/Research Support.

Background Patients discharged from the hospital on outpatient parenteral antimicrobial therapy (OPAT) require close monitoring, including weekly blood tests and an early posthospital follow-up visit. However, because patients often receive OPAT in a separate healthcare system from where they received inpatient care, the OPAT plan often fails, with less than 75% of OPAT patients receiving the recommended laboratory monitoring. We sought to determine whether changing our inpatient OPAT documentation method would improve postdischarge care. Methods As a quality improvement initiative, we conducted 2 Plan-Do-Study-Act interventions on our OPAT documentation. Our first intervention was to create a standardized OPAT Progress Note, and our second was to turn that note into a SmartForm (Epic) with discrete fields for the key information. We examined the effects of these changes on the rate of completion of recommended laboratory monitoring, attendance at outpatient follow-up visits, and 30-day readmission rates. Results Changing our documentation to a standardized Progress Note and then to a SmartForm with discrete fields led to an increase in the proportion of patients with a serum creatinine checked within 10 days of discharge (from 63% to 71% to 73%) and who attended an infectious disease clinic visit within 3 weeks of discharge (from 21% to 36% to 47%). However, the rate of readmissions for OPAT-related problems did not change, nor did a composite outcome of 30-day mortality/unplanned readmission. Conclusions Changes in how and where care plans are documented in the inpatient medical record can have significant effects on patient care outcomes after discharge.

Background The Oral versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA) trial determined oral antibiotics administered during the first six weeks of therapy were non-inferior to parenteral antibiotics. There was no difference in the incidence of serious adverse effects. The objective of this study was to evaluate the safety and effectiveness of de-escalating to oral therapy compared to continuing parenteral vancomycin therapy in patients with orthopedic infections in a real-world setting. Methods We conducted a single-center, retrospective cohort study of patients discharged between April 1, 2018 and April 1, 2020 with an orthopedic infection, a prescription for at least four weeks of parenteral vancomycin, and documented follow-up. The primary outcome was incidence of adverse events defined as provider documentation of the event and changes to therapy. The secondary outcome was incidence of 6-month treatment failure defined as repeat surgical intervention or therapy escalation. Results One hundred fifty-seven patients were included. Twenty-nine (18.5%) patients were de-escalated to oral therapy. Three (10%) patients in the oral therapy group had an adverse event compared to 35 (27%) in the vancomycin group (p=0.058). Of the 35 patients with an adverse event in the vancomycin group, eight were due to parenteral access-related complications. Treatment failure occurred in three (10%) patients in the oral therapy group compared to 27 (21%) patients in the vancomycin group (p=0.29). Three (10%) patients in the oral therapy group had an unplanned readmission compared to 25 (20%) patients in the vancomycin group (p=0.24). Baseline Characteristics, Unplanned Readmission Rates, and Incidence of Adverse Events and 6-Month Treatment Failure Conclusion Patients de-escalated to oral therapy had fewer adverse events and similar incidences of treatment failure compared to patients maintained on parenteral vancomycin. Switching to oral therapy avoids some adverse events related to parenteral access. Our results in an uncontrolled, real-world setting are consistent with the OVIVA trial. Though limited by sample size, our data indicate switching to oral therapy in patients with an orthopedic infection improves safety outcomes without compromising effectiveness compared to continued parenteral vancomycin therapy. Disclosures Russell J. Benefield, PharmD, Paratek Pharmaceuticals (Grant/Research Support)

Background Evidence supports streamlined approaches for inpatients with community-acquired pneumonia (CAP) including early transition to oral antibiotics and shorter therapy. Uptake of these approaches is variable, and the best approaches to local implementation of infection-specific guidelines are unknown. Our objective was to evaluate the impact of a clinical decision support (CDS) tool linked with a clinical pathway on CAP care. Methods This is a retrospective, observational pre–post intervention study of inpatients with pneumonia admitted to a single academic medical center. Interventions were introduced in 3 sequential 6-month phases; Phase 1: education alone; Phase 2: education and a CDS-driven CAP pathway coupled with active antimicrobial stewardship and provider feedback; and Phase 3: education and a CDS-driven CAP pathway without active stewardship. The 12 months preceding the intervention were used as a baseline. Primary outcomes were length of intravenous antibiotic therapy and total length of antibiotic therapy. Clinical, process, and cost outcomes were also measured. Results The study included 1021 visits. Phase 2 was associated with significantly lower length of intravenous and total antibiotic therapy, higher procalcitonin lab utilization, and a 20% cost reduction compared with baseline. Phase 3 was associated with significantly lower length of intravenous antibiotic therapy and higher procalcitonin lab utilization compared with baseline. Conclusions A CDS-driven CAP pathway supplemented by active antimicrobial stewardship review led to the most robust improvements in antibiotic use and decreased costs with similar clinical outcomes.

Background Weekly laboratory monitoring is routinely performed for patients treated with Outpatient Parenteral Antimicrobial Therapy (OPAT). However, minimal evidence exists to guide this practice. Methods This was a single-center, retrospective cohort study to assess the value of laboratory monitoring in patients being treated with beta-lactam OPAT. This study included adult patients discharged from University of Utah Health (UUH) between January 1, 2018, and July 31, 2019, on beta-lactam OPAT with follow-up care with a UUH Infectious Diseases (ID) Provider. Patients discharged to a skilled nursing facility or long-term acute care hospital, or who received OPAT for a duration less than 7 days, were excluded. The primary aim was to describe how often abnormal laboratory values led to a therapy modification or documented adverse drug reaction (ADR) for patients receiving beta-lactam OPAT. Abnormal laboratory values were defined by consensus criteria for clinical significance (e.g., RIFLE criteria for kidney injury). Therapy modification and ADR occurrence was determined by chart review for UUH ID Provider documentation. Results A total of 346 patients were included; two hundred seventy-four (79%) had abnormal laboratory values during OPAT. Of these, 12 patients had a modification to their OPAT due to abnormal laboratory values. The most common therapy modification due to abnormal laboratory values was a change of antibiotic (9/12). Two hundred thirteen of 274 patients (78%) with abnormal laboratory values were maintained on their OPAT regimen without a modification. Of the 67 therapy modifications observed, 55 (82%) were due to reasons other than abnormal laboratory results (Table 1). Abnormal laboratory values meeting criteria for clinical significance and possible ADR were observed in 469 instances. Of these, 43 (9%) were considered ADRs by the ID provider (Table 2). Table 1 describes therapy modifications for patients on beta-lactam OPAT Table 2 describes documented ADRs in the presence of abnormal labs for patients on beta-lactam OPAT Conclusion Weekly laboratory monitoring was associated with therapy modifications and documented ADRs in a small number of patients receiving beta-lactam agents as OPAT. This supports current guideline recommendations for laboratory monitoring, even for beta-lactam agents, which are considered relatively safe. Further investigation into the cost-effectiveness of this approach is warranted. Disclosures Russell J. Benefield, PharmD, Merck and Co (Grant/Research Support)Paratek Pharmaceuticals (Grant/Research Support)Rempex Pharmaceuticals (Grant/Research Support)

Background The outpatient parenteral antimicrobial therapy (OPAT) plan has frequently been omitted or incompletely communicated during transitions of care at our institution. Better communication of the OPAT plan at discharge has the potential to improve patient outcomes. Methods A standardized OPAT documentation tool (SmartForm) was developed in our electronic health record system for use by our inpatient Infectious Disease (ID) consult service. This intervention was part of an ongoing quality improvement project to improve communication of the OPAT plan at discharge. Outcomes were assessed prospectively during the post-intervention time period (11/18/2019 - 4/13/2020) and compared to the pre-intervention time period (10/14/2019 - 11/11/2019). Patients were included if discharged on IV antibiotics with follow up by a University of Utah Health ID provider. Patients discharged to long-term acute care facilities were excluded. Results Three hundred five patients were included: 231 in the post-intervention period and 74 in the pre-intervention period. Demographic characteristics were similar between time periods with the exception of older age (mean 60 vs 56 years), a greater percentage of patients receiving OPAT via an infusion center (19% vs 9%), and fewer patients receiving OPAT via home health (54% vs 64%) in the pre-intervention cohort. Documentation of an OPAT progress note occurred more frequently (94% vs 85%, p = 0.02) and patients were more likely to be enrolled in our OPAT program (77% vs 51%, p < 0.0001) after implementation of the OPAT SmartForm. Outpatient laboratory monitoring occurred with similar frequency during the pre- and post-intervention time periods (85% vs 82% of expected laboratory encounters completed, p = 0.31). Sixty-day unplanned hospital readmissions were reduced after implementation of the SmartForm (22% vs 35%, p = 0.02). Multivariable logistic regression identified Charlson comorbidity index (OR 1.10, 95% CI: 1.02–1.18) and the pre-intervention time period (OR 1.78, 95% CI: 0.99–3.18) as variables independently associated with readmission. Conclusion Implementation of an OPAT SmartForm was associated with improved documentation of the OPAT plan, increased enrollment in the OPAT program, and reduction in hospital readmissions. Disclosures Russell J. Benefield, PharmD, Merck and Co (Grant/Research Support)Paratek Pharmaceuticals (Grant/Research Support)Rempex Pharmaceuticals (Grant/Research Support)

Levofloxacin given at a standard dose of 500 mg daily is recommended for antibacterial prophylaxis in patients receiving myelosuppressive chemotherapy. Obese patients have been shown to exhibit enhanced clearance of levofloxacin and may be at risk for prophylactic failure. This single center, retrospective cohort study from June 2014 to May 2017 evaluated adult patients with estimated creatinine clearance ≥50 mL/min receiving their first cycle of a National Comprehensive Cancer Network defined intermediate-risk regimen. Primary endpoint was incidence of febrile neutropenia. Secondary endpoints included 30-day mortality and the correlation between estimated levofloxacin area under the concentration–time curve and rates of febrile neutropenia. Febrile neutropenia occurred in 26 patients: 12 (35.3%) obese and 14 (21.9%) non-obese ( P = 0.16). Six (23.1%) of these patients required intensive care, but there were no deaths within 30 days of a febrile neutropenia event. Estimated creatinine clearance was similar between obese and non-obese patients (median 97.5 vs. 91.8 mL/min, P = 0.39), as was estimated levofloxacin area under the concentration–time curve (median 85.6 vs. 90.8 mg×h/L, P = 0.39). There were no significant associations between body weight-related variables – total body weight (median 83.4 vs. 80.6 kg, P = 0.51), body mass index (mean 29.6 vs. 26.8 kg/m2, P = 0.35), or body surface area (1.98 vs. 1.99 m2, P = 0.68) – and febrile neutropenia in this cohort of patients with similar renal function. Obesity should not be a justification for more aggressive levofloxacin dosing schemes when used for febrile neutropenia prophylaxis.

Objectives Primary objective: To retrospectively review nafcillin plasma concentrations (CNAF) and determine nafcillin clearance (CLNAF) in a diverse sample of patients treated with nafcillin administered as a continuous infusion. Secondary objective: To identify clinical variables associated with CLNAF and nafcillin-related adverse drug reactions (ADRs). Methods Retrospective chart review of patients receiving nafcillin via continuous infusion at University of Utah Health Care from 2006 to 2013 who had at least one steady-state CNAF measured. CLNAF was determined by dividing the nafcillin rate of infusion by CNAF. Adverse drug reactions (ADRs) were defined using the National Institutes of Health, Division of Microbiology and Infectious Diseases criteria and scored for probability of association with nafcillin by using Naranjo criteria. Multivariate models were constructed to identify independent variables associated with CLNAF and ADRs. Main results Seventy-six CNAF from 54 patients were included. Median CLNAF was 13.9 L/hour (range ≤ 4.2 to 36.9 L/hr). Congestive heart failure (p=0.007), hyperbilirubinemia (p

Background Over 250,000 patients receive outpatient parenteral antimicrobial therapy (OPAT) in the United States each year. Vancomycin is commonly used in OPAT but has a high rate of discontinuations due to adverse drug reactions (ADRs). Being able to predict the occurrence of these ADRs and assess their impact could improve the overall quality of OPAT services when utilizing vancomycin. Methods This was a retrospective chart review of all adult University of Utah Health (UUH) patients who received vancomycin OPAT and had planned follow-up with UUH infectious disease (ID) providers between October 25, 2018 and July 31, 2019. Patients were excluded if they were less than 18 years of age, pregnant, did not have planned follow up with UUH ID physicians, or were on any form of renal replacement therapy. The primary outcome assessed was discontinuation of vancomycin due to ADR, as documented by the ID provider. Type of ADR leading to discontinuation and 30-day unplanned readmission were also assessed. Results One hundred fifty-eight patients met inclusion criteria (n=158). The mean age of patients was 55 years with a median Charlson comorbidity score of 3. Most patients utilized a non-UUH infusion service (116, 73% vs 42, 27%) and utilized vancomycin as their sole antibiotic (83, 53%). The majority of patients were being treated for orthopedic infections (78, 49%). Twenty-eight patients discontinued vancomycin OPAT due to an ADR (18%). The most common ADR leading to discontinuation was acute kidney injury (10, 36%). Variables associated with ADRs leading to discontinuation included utilization of UUH home infusion services (54% vs 21%, P < 0.001) and initial vancomycin plasma concentrations obtained less than 7 days after discharge (92% vs 71%, P < 0.001). The overall 30 day readmission rate was 10% and the rate among patients who experienced an ADR leading to discontinuation was higher than those who did not (25% vs 8%, P < 0.001). Conclusion The overall rate of discontinuation of vancomycin OPAT due to ADR in the UUH population is similar to what has been described in previous literature. The higher rate of unplanned readmission in the population of patients who experienced ADRs warrants further study. The results of this study will be utilized for future quality improvement interventions at our institution. Disclosures Russell J. Benefield, PharmD, Merck and Co (Grant/Research Support)Paratek Pharmaceuticals (Grant/Research Support)Rempex Pharmaceuticals (Grant/Research Support)

Implementation of Biofire FilmArray Blood Culture Identification Multiplex PCR panel (BCID) at a cancer hospital was associated with reduced time to appropriate antimicrobial therapy. Additional reductions were not observed when BCID was coupled with antimicrobial stewardship intervention.

We evaluated the effects of rifampin coadministration and MDR1 single nucleotide polymorphisms on the disposition of daptomycin in twelve healthy adults. There were no significant changes from baseline in the clearance (0.53 versus 0.55 liters/h, P = 1.00), volume of distribution (7.0 versus 7.2 liter, P = 0.62), or half-life (9.7 versus 9.6 h, P = 0.89) of daptomycin after exposure to rifampin.

Objectives: Emerging evidence supports the use of therapeutic drug monitoring (TDM) of β-lactams for intensive care unit (ICU) patients to optimize drug exposure, although limited detail is available on how sites run this service in practice. This multicentre survey study was performed to describe the various approaches used for β-lactam TDM in ICUs. Methods: A questionnaire survey was developed to describe various aspects relating to the conduct of β-lactam TDM in an ICU setting. Data sought included: β-lactams chosen for TDM, inclusion criteria for selecting patients, blood sampling strategy, analytical methods, pharmacokinetic (PK)/pharmacodynamic (PD) targets and dose adjustment strategies. Results: Nine ICUs were included in this survey. Respondents were either ICU or infectious disease physicians, pharmacists or clinical pharmacologists. Piperacillin (co-formulated with tazobactam) and meropenem (100% of units surveyed) were the β-lactams most commonly subject to TDM, followed by ceftazidime (78%), ceftriaxone (43%) and cefazolin (43%). Different chromatographic and microbiological methods were used for assay of β-lactam concentrations in blood and other biological fluids (e.g. CSF). There was significant variation in the PK/PD targets (100% fT>MIC up to 100% fT>4×MIC) and dose adjustment strategies used by each of the sites. Conclusions: Large variations were found in the type of β-lactams tested, the patients selected for TDM and drug assay methods. Significant variation observed in the PK/PD targets and dose adjustment strategies used supports the need for further studies that robustly define PK/PD targets for ICU patients to ensure a greater consistency of practice for dose adjustment strategies for optimizing β-lactam dosing with TDM. © The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.

Background Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection associated with high dose steroid use in non-HIV patients. Many patients on high dose steroids (>20 mg prednisone equivalents for 28 days or longer), developed PJP within a month of steroid use. This study aims to develop an electronic alert for providers to consider PJP prophylaxis for patients discharged on high-dose steroids. Methods Cases were obtained from the University of Utah Enterprise Data Warehouse between October 2014 and September 2017. A retrospective, manual chart review evaluated adults 18 years of age or older, with an inpatient PJP diagnosis made via direct fluorescent antibody or PCR. Patients with PJP due to HIV were excluded. Steroid dose and duration one month prior to diagnosis of PJP were evaluated. After retrospective analysis, via a multidisciplinary team, a best practice advisory (BPA) alert was created to flag providers to consider PJP prophylaxis at discharge, with consideration of creatinine levels and allergy profile to guide drug choices. The alert was trailed in a silent mode from January to April 2018 without provider notification so it could be modified to prevent inappropriate firing. The alert was approved for live use by the Clinical Decision Support Committee and is now active in the University of Utah Epic system as of April 10, 2018. Results In retrospective analysis, of 94 non-HIV patients diagnosed with PJP, 31/94 (33%) cases were in the setting of high dose steroids. 7/31 (23%) cases were exclusively with high dose steroids, while 24/31 (77%) cases were in combination with chemotherapy or other immune modulating agents. Data from the silent BPA from February to April 2018 demonstrated 23 cases triggered the alert, all of which were determined to be appropriate by chart review. Since live use, the BPA has fired 15 times, of which 14 cases met criteria for prophylaxis and 4/14 (29%) resulted in prophylaxis on discharge. Conclusion Chart review identified high dose steroids as a target for a quality improvement intervention, which led to development of a BPA. Data indicates room for improvement on discharge with prophylaxis. Goals include reducing morbidity, mortality and cost associated with PJP, as well as educating providers regarding the need for prophylaxis. Disclosures All authors: No reported disclosures.

Background Liposomal amphotericin B (L-amb) is an important antifungal agent which exhibits significant rates of dose-dependent nephrotoxicity. Animal studies demonstrate only small amounts of L-amb distribute into adipose tissue and obese animals show greater risk of nephrotoxicity with L-amb administration. This study aims to determine whether obese patients are at a higher risk of nephrotoxicity with weight-based doses of L-amb. Methods We performed a multi-center, retrospective cohort study of nephrotoxicity with L-amb in obese (BMI > 30) and non-obese adult patients at University of Utah Health and Intermountain Healthcare from January 1, 2014 through December 31, 2018. Our primary outcome was the rate of nephrotoxicity as determined by AKIN criteria. Patients receiving at least one dose of L-amb were identified for inclusion. Patients were excluded if they were already on a renal replacement at the time of L-amb initiation or they received L-amb prior to admission. Results We included 221 patients, 47 (21%) were obese and 174 (79%) were non-obese. Median total body weight was 109 kg in obese patients compared with 70 kg in non-obese patients. Dosage based on ideal body weight was higher in the obese group (median 6.9 mg/kg vs. 4.9 mg/kg). Obese patients were significantly more likely to experience acute kidney injury (AKI) than non-obese patients (55% vs. 37%, P = 0.03). Patients who experienced nephrotoxicity received a higher average daily dose than those who did not (365 mg vs. 333 mg, P = 0.03), had a higher median cumulative dose (3,130 mg vs. 1,700 mg, P < 0.001), and had a higher median total body weight (79.6 kg vs. 71.9 kg, P = 0.04.). Additionally, daily dose normalized to total body weight was not associated with AKI (median 4.7 mg/kg in patients with AKI vs. 4.8 mg/kg in patients without AKI, P = 0.86). However, daily dose normalized to ideal body weight was associated with AKI (median 5.5 mg/kg in patients with AKI vs. 4.9 mg/kg in patients without AKI, P = 0.02). Conclusion We identified a higher rate of nephrotoxicity among obese patients receiving L-amb compared with non-obese patients. These data suggest that dosing L-amb based on total body weight places obese patients at a higher risk of nephrotoxicity. This should be considered when assessing the risks and benefits of this dosing strategy in obese patients. Disclosures All authors: No reported disclosures.

Background Patients discharged on intravenous antibiotics require regular monitoring by an infectious disease (ID) specialist or other provider familiar with outpatient parenteral antibiotic therapy (OPAT). However, the lab monitoring and outpatient follow-up plan outlined prior to discharge is not always realized. We are working to understand what steps the discharging hospital can take to improve the outpatient monitoring and follow-up for patients on OPAT, who are discharged to a wide variety of institutions. We studied whether documenting the OPAT plan in a standardized note led to increased inclusion of that plan in the discharge documentation and thus to improved lab monitoring and outpatient follow-up for our patients. Methods We compared the pre- and post-intervention frequency of seven key OPAT elements (antibiotic, duration, end date, indication, follow-up appointment, recommend labs, fax number for labs) in the discharge documentation. Pre-intervention, this information was documented by the inpatient ID service in the Problem List (overview) section of the electronic health record. Post-intervention, OPAT plans were documented within standardized OPAT Progress Notes. Efficiency and clinical outcomes were: proportion of OPAT treatment weeks with laboratory monitoring; number of weeks the outpatient ID team had to track down missing laboratory results; number of “No Show” ID clinic visits; number of OPAT-related telephone encounters. Results There were 73 patients in the pre- and 68 in the post-intervention cohort. Having a formal OPAT Progress Note was associated with a significant increase in the number of OPAT elements included in the discharge documentation (7 vs. 5, P = 0.002). In addition, the entire OPAT note was included in the discharge documentation more frequently in the post-intervention cohort (3/73 vs.. 14/68, P = 0.007). However, except for reduced telephone encounters related to OPAT (2 vs. 1 per patient, P = 0.0001), there were no significant improvements in post-discharge clinical or efficiency outcomes. Conclusion Creating an OPAT Progress Note improves the capture of OPAT elements into discharge documentation. Except for reducing telephone encounters, no other benefits occurred. Future interventions will focus on improving the other measured outcomes. Disclosures All authors: No reported disclosures.

Purpose: We recently reported an increased incidence of serious bleeding events and mortality in patients with baseline bleeding precautions treated with drotrecogin alfa (activated) compared to patients without such precautions. Whether these observations were specific to our single medical campus is unclear. Methods: All patients who received drotrecogin alfa (activated) for the treatment of severe sepsis from January 2006 through September 2009 within the South Central Veterans Affairs Health Care Network were retrospectively reviewed using a regional clinical database. Demographic information, bleeding precautions that were exclusion criteria of the PROWESS trial, and 30-day post-discharge incidences of serious bleeding events and mortality were collected. Results: Seventy-nine patients from 5 medical centers were included. Serious bleeding events occurred in 4 of 24 patients (16.7%) with any bleeding precaution vs 1 of 55 patients (1.8%) without a bleeding precaution (P=0.03). All patients (5) who experienced a serious bleeding event died compared to 39 of 74 patients (52.7%) who did not (P=0.06). Seventeen of 24 patients (70.8%) with bleeding precautions died vs 27 of 55 patients (49.1%) without bleeding precautions (P=0.07). The number of serious bleeding events did not allow meaningful multivariate analyses. The mean number of failing organs was an independent predictor of 30-day post-discharge mortality (OR 1.63 for each organ failed, 95% CI 1.05– 2.6). Conclusions: The findings of this study were consistent with our prior observations and suggest the risk for serious bleeding events with drotrecogin alfa (activated) may outweigh any potential benefit in patients with baseline bleeding precautions.

Fungal endophthalmitis is a rare complication after cataract surgery and is associated with significant morbidity including vision loss. The common causative fungal pathogens implicated in fungal endophthalmitis after cataract surgery include Candida species (spp.) and molds such as Aspergillus spp. and Fusarium spp. Early diagnosis and effective antifungal treatment after a high index of clinical suspicion are required to reduce unfavorable complications and to preserve eye function. This review discusses epidemiology, pathogenesis, clinical features, diagnosis, management, and outcomes associated with fungal endophthalmitis after cataract surgery.

Posaconazole may be useful for salvage treatment (ST) for invasive fungal infections (IFIs). The aim of this study was to evaluate the efficacy of posaconazole ST with either posaconazole oral suspension (SUS) or delayed-released tablet (TAB) in patients with IFI. A retrospective review of patients who received posaconazole ST for IFI at the University of Utah Health Sciences Center between December 2007 and March 2014 was conducted. A total of 14 episodes of posaconazole ST for proven (9 episodes) and probable (5 episodes) IFI were identified in 14 patients. The median age was 54 years and the majority of patients (64.3%) had underlying haematological diseases. Posaconazole SUS and TAB were used in 11 episodes and 3 episodes respectively. The duration of posaconazole ST ranged from 28 to 370 days with a median of 65 days. Posaconazole ST with TAB achieved favourable serum posaconazole trough concentrations (median 1.4 μg mL-1 ) compared to posaconazole SUS (median 1.0 μg mL-1 ). The overall clinical success rate with posaconazole ST was 71.4% (10 of 14 episodes). One patient died of progression of IFI. Adverse events were noted in two patients. Posaconazole SUS or TAB may be used effectively for IFI ST.

Background Molecular based assays reduce time to organism identification for bloodstream infections (BSI) but have limited impact without Antimicrobial Stewardship (AS) intervention. The benefit of pairing molecular based assays with AS in immunocompromised hosts is unknown. Immunocompromised patients present unique challenges to AS efforts and evaluations of traditional AS interventions are needed in this patient population. The purpose of this analysis was to evaluate the utility of a molecular based assay for BSI with and without AS intervention at a cancer hospital. Methods A retrospective quasi-experimental pre-post study was performed to evaluate the impact of the FilmArray© Blood Culture Identification (BCID) panel with and without AS intervention on time to appropriate antimicrobial therapy defined as de-escalation to the narrowest spectrum agent taking into account need to cover concomitant infections and antibiotic allergies or intolerances. We included inpatients with positive blood cultures between 2014 and 2016 in three separate 100-day cohorts: prior to BCID implementation (pre); after BCID implementation without AS intervention (post); after BCID implementation with AS intervention (ASP) involving blood culture review and antimicrobial treatment recommendations. Results 130 of 155 subjects with a BSI during the study period were included. The pre (n = 52), post (n = 43), and ASP (n = 35) cohorts were balanced with the exception of more immunocompromised patients in the ASP compared with pre (91% vs 65%; P < 0.01) and post cohorts (91% vs 72%; P = 0.04). Time to appropriate antimicrobial therapy, although not statistically different, was shorter in the post and ASP groups as compared with the pre-BCID group [40.2 hours (pre) vs 24.6 hours (post) vs 25.9 hours (ASP); P = 0.46]. Conclusion Implementation of the BCID in a cancer hospital was associated with reduced time to appropriate antimicrobial therapy; however, additional reductions were not seen when coupled with AS intervention. Further large-scale evaluation is warranted due to unbalanced study groups and small study size to understand the role of rapid diagnostics and AS interventions for BSIs in immunocompromised populations. Disclosures R. Benefield, Merck: Grant Investigator, Research grant

Objective: To review the literature regarding the use of α2-agonists in the treatment and prevention of iatrogenic opioid abstinence syndrome (IOAS) in critically ill patients. Data Sources: Primary literature was identified through a search of MEDLINE (1950–June 2009), EMBASE (1988–June 2009), International Pharmaceutical Abstracts (1970–June 2009), and the Cochrane Library (1996–June 2009), using the names of individual α2-agonists and the following key words: children, opioid withdrawal, opioid, and adult. Relevant abstracts from the Society of Critical Care Medicine, reference citations from selected articles, and manufacturers’ product information were also reviewed. Study Selection and Data Extraction: All English-language articles identified from the data sources were evaluated. Three retrospective studies and 6 case reports/series representing 44 patients were included for analysis. Data Synthesis: Central α2-agonists are thought to minimize symptoms of IOAS by decreasing presynaptic outflow of catecholamines. Successful use of clonidine and dexmedetomidine for management of IOAS has been reported. Lofexidine, an α2-agonist not yet approved in the US, may offer similar withdrawal symptom relief but has yet to be studied in the intensive care setting. Although the quality of studies identified was limited, preliminary evidence does provide some support for the use of transdermal clonidine and injectable dexmedetomidine in the treatment and prevention of IOAS. These agents were shown to facilitate discontinuation of opioids and to minimize withdrawal symptoms with few reported adverse events. Conclusions: Central α2-agonists appear to be effective and safe second-line agents for treatment and prevention of IOAS. Further studies should be conducted to determine their role in the therapy of patients with IOAS.