308. Re-purposing Beta-lactam Antibiotics as Fluoroquinolone Sparing Stepdown Therapy for the Treatment of Enterobacteriales Bloodstream Infections

Abstract Background Oral antimicrobial therapy for Enterobacteriales bloodstream infection (EB-BSI) is advantageous to reduce the risk of central line complications, cost of care, and length of stay. Fluoroquinolones (FQ) given their high bioavailability have been utilized as the standard for stepdown therapy (SDT) for EB-BSI. Given the recent increased warnings around FQ use including Clostridioides difficile infection (CDI) and the increasing FQ resistance alternative oral options for treatment are warranted. Recent literature has suggested beta-lactams (BLM) may be an option for EB-BSI. To enhance the antimicrobial stewardship goal of reducing FQ use, our team began recommending de-escalation to a BLM for EB-BSI and the objective of this study is to evaluate the outcomes of this approach. Methods This study was a retrospective chart review of patients with EB-BSI due to ceftriaxone sensitive monomicrobial E. coli, Klebsiella spp., or P. mirabilis who received a BLM or a FQ as SDT. Patients were excluded if < 18 years of age; pregnant; ANC < 1000 cells/µL; had endocarditis, a bone/joint, or a CNS infection; discharged to hospice or expired prior to discharge; anaphylactic BLM allergy; or prior kidney transplant. SDT was defined as a switch to a definitive oral antibiotic after empiric IV therapy. The primary outcome was clinical cure defined as completion of therapy without signs of infection (increase in WBC > 2000 cells/mL if WBC was ≥ 12,000 cells/mL, fever (>38°C), or change in antibiotic due to failure). Secondary outcomes included 30 day re-admission rates, reinfection rate defined as positive culture within 30 days of completion of therapy, antibiotic associated adverse events defined as side effects leading to discontinuation and/or CDI within 90 days from start of treatment. Results A total of 159 patients were included in the study (Figure 1). The BLM patients had a higher median age (78 vs 72, p=0.008), higher median PITT bacteremia score (2 vs 1, p=0.037), were less likely to be immunosuppressed (9% vs 25%, p=0.045), and had shorter median duration of therapy (13 vs 14, p=0.034). There was no difference in the primary or secondary outcomes (Table 2). Conclusion BLM may enhance stewardship efforts as a FQ sparing option for treatment of EB-BSI; however, prospective studies in this area are warranted. Disclosures All Authors: No reported disclosures

Download Full-text

Impact of Critical Care Consultation Requests for Avoidable Central Venous Catheters on Medical-Surgical Units

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.822 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s258-s258

Author(s):

Madhuri Tirumandas ◽

Theresa Madaline ◽

Gregory David Weston ◽

Ruchika Jain ◽

Jamie Figueredo

Keyword(s):

Critical Care ◽

High Risk ◽

Medical Center ◽

Academic Medical Center ◽

Retrospective Chart Review ◽

Bloodstream Infections ◽

Central Line ◽

Central Venous Catheters ◽

High Risk Population ◽

Central Venous

Background: Although central-line–associated bloodstream infections (CLABSI) in US hospitals have improved in the last decade, ~30,100 CLABSIs occur annually.1,2 Central venous catheters (CVC) carry a high risk of infections and should be limited to appropriate clinical indications.6,7 Montefiore Medical Center, a large, urban, academic medical center in the Bronx, serves a high-risk population with multiple comobidities.8–11 Despite this, the critical care medicine (CCM) team is often consulted to place a CVC when a peripheral intravenous line (PIV) cannot be obtained by nurses or primary providers. We evaluated the volume of CCM consultation requests for avoidable CVCs and related CLABSIs. Methods: Retrospective chart review was performed for patients with CCM consultation requests for CVC placement between July and October 2019. The indication for CVC, type of catheter inserted or recommended, and NHSN data were used to identify CLABSIs. CVCs were considered avoidable if a PIV was used for the stated indication and duration of therapy, with no anatomical contraindications to PIV in nonemergencies, according to the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).6Results: Of 229 total CCM consults, 4 (18%) requests were for CVC placement; 21 consultations (9%) were requested for avoidable CVCs. Of 40 CVC requests, 18 (45%) resulted in CVC placement by the CCM team, 4 (10%) were deferred for nonurgent PICC by interventional radiology, and 18 (45%) were deferred in favor of PIV or no IV. Indications for CVC insertion included emergent chemotherapy (n = 8, 44%) and dialysis (n = 3, 16%), vasopressors (n = 3, 16%), antibiotics (n = 2, 11%) and blood transfusion (n = 2, 11%). Of 18 CVCs, 9 (50%) were potentially avoidable: 2 short-term antibiotics and rest for nonemergent indications; 2 blood transfusions, 1 dialysis, 2 chemotherapy and 2 vasopressors. Between July and October 2019, 6 CLABSIs occurred in CVCs placed by the CCM team; in 3 of 6 CLABSI events (50%), the CVC was avoidable. Conclusions: More than half of consultation requests to the CCM team for CVCs are avoidable, and they disproportionately contribute to CLABSI events. Alternatives for intravenous access could potentially avoid 9% of CCM consultations and 50% of CLABSIs in CCM-inserted CVCs on medical-surgical wards.Funding: NoneDisclosures: None

Download Full-text

Infection preventionist staffing levels and rates of 10 types of healthcare-associated infections: A 9-year ambidirectional observation

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.507 ◽

2022 ◽

pp. 1-6

Author(s):

Robert J. Clifford ◽

Donna Newhart ◽

Maryrose R. Laguio-Vila ◽

Jennifer L. Gutowski ◽

Melissa Z. Bronstein ◽

...

Keyword(s):

Control Charts ◽

Bloodstream Infections ◽

Central Line ◽

Healthcare Associated Infections ◽

Full Time ◽

Staffing Levels ◽

Clostridioides Difficile ◽

Carbapenem Resistant ◽

Healthcare Associated ◽

Carbapenem Resistant Enterobacteriaceae

Abstract Objective: To quantitatively evaluate relationships between infection preventionists (IPs) staffing levels, nursing hours, and rates of 10 types of healthcare-associated infections (HAIs). Design and setting: An ambidirectional observation in a 528-bed teaching hospital. Patients: All inpatients from July 1, 2012, to February 1, 2021. Methods: Standardized US National Health Safety Network (NHSN) definitions were used for HAIs. Staffing levels were measured in full-time equivalents (FTE) for IPs and total monthly hours worked for nurses. A time-trend analysis using control charts, t tests, Poisson tests, and regression analysis was performed using Minitab and R computing programs on rates and standardized infection ratios (SIRs) of 10 types of HAIs. An additional analysis was performed on 3 stratifications: critically low (2–3 FTE), below recommended IP levels (4–6 FTE), and at recommended IP levels (7–8 FTE). Results: The observation covered 1.6 million patient days of surveillance. IP staffing levels fluctuated from ≤2 IP FTE (critically low) to 7–8 IP FTE (recommended levels). Periods of highest catheter-associated urinary tract infection SIRs, hospital-onset Clostridioides difficile and carbapenem-resistant Enterobacteriaceae infection rates, along with 4 of 5 types of surgical site SIRs coincided with the periods of lowest IP staffing levels and the absence of certified IPs and a healthcare epidemiologist. Central-line–associated bloodstream infections increased amid lower nursing levels despite the increased presence of an IP and a hospital epidemiologist. Conclusions: Of 10 HAIs, 8 had highest incidences during periods of lowest IP staffing and experience. Some HAI rates varied inversely with levels of IP staffing and experience and others appeared to be more influenced by nursing levels or other confounders.

Download Full-text

Fluoroquinolone versus Beta-Lactam Oral Step-Down Therapy for Uncomplicated Streptococcal Bloodstream Infections

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.01515-20 ◽

2020 ◽

Vol 64 (11) ◽

Author(s):

Kellie Arensman ◽

Maureen Shields ◽

Maya Beganovic ◽

Jessica L. Miller ◽

Erik LaChance ◽

...

Keyword(s):

Clinical Success ◽

Bloodstream Infections ◽

Pharmacokinetic Parameters ◽

Clinical Failure ◽

Beta Lactam ◽

Multivariable Logistic Regression Model ◽

Serious Adverse Events ◽

Content Type ◽

Clostridioides Difficile ◽

Step Down

ABSTRACT Fluoroquinolones (FQs) are often preferred as oral step-down therapy for bloodstream infections (BSIs) due to favorable pharmacokinetic parameters; however, they are also associated with serious adverse events. The objective of this study was to compare clinical outcomes for patients who received an oral FQ versus an oral beta-lactam (BL) as step-down therapy for uncomplicated streptococcal BSIs. This multicenter, retrospective cohort study analyzed adult patients who completed therapy with an oral FQ or BL with at least one blood culture positive for a Streptococcus species from 1 January 2014 to 30 June 2019. The primary outcome was clinical success, defined as the lack of all-cause mortality, recurrent BSI with the same organism, and infection-related readmission at 90 days. A multivariable logistic regression model for predictors of clinical failure was conducted. A total of 220 patients were included, with 87 (40%) receiving an FQ and 133 (60%) receiving a BL. Step-down therapy with an oral BL was noninferior to an oral FQ (93.2% versus 92.0%; mean difference, 1.2%; 90% confidence interval [CI], −5.2 to 7.8). No differences were seen in 90-day mortality, 90-day recurrent BSI, 90-day infection-related readmission, or 90-day incidence of Clostridioides difficile-associated diarrhea. Predictors of clinical failure included oral step-down transition before day 3 (odds ratio [OR] = 5.18; 95% CI, 1.21, 22.16) and low-dose oral step-down therapy (OR = 2.74; 95% CI, 0.95, 7.90). Our results suggest that oral step-down therapy for uncomplicated streptococcal BSI with a BL is noninferior to an FQ.

Download Full-text

Electronic Surveillance for Healthcare-Associated Central Line—Associated Bloodstream Infections Outside the Intensive Care Unit

Infection Control and Hospital Epidemiology ◽

10.1086/662181 ◽

2011 ◽

Vol 32 (11) ◽

pp. 1086-1090 ◽

Cited By ~ 35

Author(s):

Keith F. Woeltje ◽

Kathleen M. McMullen ◽

Anne M. Butler ◽

Ashleigh J. Goris ◽

Joshua A. Doherty

Keyword(s):

Intensive Care ◽

Blood Culture ◽

Predictive Value ◽

Chart Review ◽

Positive Culture ◽

Bloodstream Infections ◽

Central Line ◽

Electronic Surveillance ◽

Predictive Values ◽

Best Fit

Background.Manual surveillance for central line-associated bloodstream infections (CLABSIs) by infection prevention practitioners is time-consuming and often limited to intensive care units (ICUs). An automated surveillance system using existing databases with patient-level variables and microbiology data was investigated.Methods.Patients with a positive blood culture in 4 non-ICU wards at Barnes-Jewish Hospital between July 1, 2005, and December 31, 2006, were evaluated. CLABSI determination for these patients was made via 2 sources; a manual chart review and an automated review from electronically available data. Agreement between these 2 sources was used to develop the best-fit electronic algorithm that used a set of rules to identify a CLABSI. Sensitivity, specificity, predictive values, and Pearson's correlation were calculated for the various rule sets, using manual chart review as the reference standard.Results.During the study period, 391 positive blood cultures from 331 patients were evaluated. Eighty-five (22%) of these were confirmed to be CLABSI by manual chart review. The best-fit model included presence of a catheter, blood culture positive for known pathogen or blood culture with a common skin contaminant confirmed by a second positive culture and the presence of fever, and no positive cultures with the same organism from another sterile site. The best-performing rule set had an overall sensitivity of 95.2%, specificity of 97.5%, positive predictive value of 90%, and negative predictive value of 99.2% compared with intensive manual surveillance.Conclusions.Although CLABSIs were slightly overpredicted by electronic surveillance compared with manual chart review, the method offers the possibility of performing acceptably good surveillance in areas where resources do not allow for traditional manual surveillance.

Download Full-text

120. The Impact of Early Central Venous Catheter Removal in the Management of Enterococcus Central Line-Associated Bloodstream Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.195 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S90-S91

Author(s):

Hesham Awadh ◽

Melissa Khalil ◽

Anne-Marie Chaftari ◽

Johny Fares ◽

Ying Jiang ◽

...

Keyword(s):

Central Venous Catheter ◽

Retrospective Chart Review ◽

Bloodstream Infections ◽

Venous Catheter ◽

Central Line ◽

Mucosal Barrier ◽

Causative Organism ◽

Central Venous ◽

Central Venous Catheter Removal ◽

The Impact

Abstract Background There has been a rise in Enterococcus species Central Line-Associated Bloodstream Infections (CLABSI) ranking as the third overall causative organism according to the Center for Disease Control and Prevention (CDC) report issued in 2014. Central Venous Catheter (CVC) management including the need and timing of CVC removal is not well defined for enterococcus bacteremia (EB) in the 2009 Infectious Diseases Society of America (IDSA) management guidelines given the paucity of studies addressing CVC management. Methods We conducted a retrospective chart review on 543 patients diagnosed with EB between 2010 and 2018. We excluded patients without an indwelling CVC and those with mucosal barrier injury (MBI). We further evaluated 90 patients with EB that met the CDC definition for CLABSI without MBI or the IDSA definition for catheter-related bloodstream infections (CRBSI) and 90 patients with an indwelling CVC in place with documented non-CLABSI with another source. Results Early CVC removal (within 3 days of EB) was significantly higher in the CLABSI without MBI/CRBSI group compared with the non-CLABSI (43% vs. 27%; P = 0.02). Microbiological eradication associated with early CVC removal within 3 days of EB was significantly higher in the CLABSI without MBI/CRBSI group compared with the non-CLABSI (78% vs. 48%; P = 0.016). Complications were lower in the CLABSI without MBI/CRBSI compared with the non-CLABSI group (0% vs. 18%; P = 0.017). Defervescence, mortality (all-cause and infection-related mortality) and relapse were similar in both groups. Within each group, the outcome was similar irrespective of CVC management (removal within 3 days vs. retention). Conclusion In cases of EB, early CVC removal within 3 days of bacteremia is associated with a favorable outcome in the CLABSI without MBI/CRBSI group compared with the non-CLABSI group. Disclosures All authors: No reported disclosures.

Download Full-text

1360. Variation in Duration of Antibiotic Therapy for Central-line Associated Blood Stream Infections Caused by Gram Negative Bacilli in Hospitalized Children

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1542 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S691-S691

Author(s):

Grant R Whitmer ◽

Tonya Scardina ◽

Shan Sun ◽

Xiaotian Zheng ◽

Sameer Patel

Keyword(s):

Antibiotic Therapy ◽

Median Duration ◽

Positive Culture ◽

Bloodstream Infections ◽

Venous Catheter ◽

Central Line ◽

Effective Therapy ◽

Severe Neutropenia ◽

Solid Organ ◽

Gram Negative

Abstract Background Central-line associated bloodstream infections (CLABSIs) are associated with increased morbidity, mortality, and duration of hospitalization in children. Existing guidelines recommend a broad range (7-14 days) for duration of antibiotic therapy. Unnecessarily prolonged therapy may be associated with emergence of antibiotic resistance and adverse events. Methods We performed a retrospective review of all patients diagnosed with CLABSIs caused by Gram negative bacilli (GNB) at our institution from August 2009 to April 2019. CLABSI was defined as isolation of a GNB from the blood >48 hours after hospital admission with presence of a central venous catheter. Children who died before completion of treatment were excluded. Data collection variables included severe neutropenia (defined as absolute neutrophil count < 500), immunocompromised status (defined as receipt of bone marrow transplant, solid organ transplant, or immunosuppressive medication), and catheter removal. The duration of effective antibiotic therapy was calculated from the date of last positive culture to discontinuation. Effective therapy was defined as use of an agent to which the isolated organism was susceptible by antimicrobial susceptibility testing. The primary outcome was microbiological recurrence of the same organism and/or all-cause mortality within 30 days of discontinuation. Results Overall, 95 CLABSIs were included. Of 92 patients, 46 (50%) were immunocompromised. For patients with catheters removed prior to the end of therapy (n=48), the median duration of effective therapy was 13.5 days (IQR: 8.75-16 days). For patients who retained catheters throughout treatment (n=47), the median duration of effective therapy was 13 days (IQR: 9-15 days). Of these 95 CLABSIs, one patient (retained catheter) had microbiological recurrence within 30 days. Seven patients died (without microbiological recurrence), with range of duration of therapy of 6-14 days. Conclusion There was a wide variation in length of therapy for CLABSIs caused by GNB in children. Microbiological recurrence was rare, and mortality was unrelated to microbiological recurrence. Future studies should evaluate standardization of shorter duration therapy to avoid unnecessarily prolonged antibiotic exposure. Disclosures Sameer Patel, MD MPH, Merck (Grant/Research Support)Nexogen (Consultant)

Download Full-text

774. A New Outpatient Parenteral Antimicrobial Therapy (OPAT) Management Program Reduces Excess Antimicrobial Days of Therapy and Expedites Timely Central Line Removal

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.842 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S344-S344

Author(s):

Catherine Kidd ◽

Joshua C Eby ◽

Tania Thomas ◽

Megan Shah ◽

Zachary Elliott ◽

...

Keyword(s):

Retrospective Chart Review ◽

Bloodstream Infections ◽

Central Line ◽

Management Program ◽

Close Attention ◽

Outpatient Parenteral Antimicrobial Therapy ◽

Days Of Therapy ◽

The Difference ◽

The Impact

Abstract Background Patients discharged on parenteral antimicrobials often require in-person follow-up to determine antimicrobial discontinuation and coordination of central line (CL) removal at the end of therapy. Without close attention to timing of follow-up, antimicrobial courses may be extended beyond a planned end date until scheduled follow-up, leading to excess antimicrobial days of therapy (DOT) and CL retention. Excess DOT can result in increased cost of medication and CL supplies, antimicrobial exposure, and risk of CL-associated bloodstream infections or thrombosis. We sought to assess the impact of the University of Virginia (UVA) OPAT program on excess antimicrobial DOT and excess CL days. Methods This was a retrospective chart review of patients enrolled in the OPAT program at UVA between August 2018 and April 2019. The UVA OPAT program was started in August 2018. Quality improvement (QI) practice changes were implemented in February 2019 for improving follow-up and stopping antimicrobials at the projected end date. Patients were therefore divided into 2 cohorts – August through January 2018 and February through April 2019. Data collected included projected end date of therapy (EOT), actual EOT, actual removal date of CL, and follow-up date. Excess antimicrobial DOT and excess CL days were calculated by the difference in projected vs. actual dates. For continuous data, Student t-test was used. Results 248 patients enrolled in OPAT from August 2018 through April 2019. After implementation of QI efforts, mean time from projected EOT to follow-up appointment decreased from 10.0 days to 4.3 days for those with appointments after projected EOT. Mean excess antimicrobial DOT decreased from 2.8 ± 4.53 SD days to 1.6 ± 2.75 SD days (P = 0.026), and mean excess CL days decreased from 3.2 ± 4.63 SD days to 2.0 ± 2.89 SD days (P = 0.035). Conclusion The involvement of an OPAT program with close attention to outpatient follow-up and cessation of antimicrobials decreased the excess antimicrobial DOT and CL days and reduced variability in care. Reduction in antimicrobial overuse and CL overuse is expected to reduce cost and decrease the risk of medication- and CL-related collateral damage. Disclosures All authors: No reported disclosures.

Download Full-text

345. Early Oral Therapy for Streptococcus anginosus Purulent Brain Infections: A Single Center Experience

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.540 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S242-S242

Author(s):

Daniel S Dodson ◽

Heather R Heizer ◽

James Gaensbauer

Keyword(s):

Oral Therapy ◽

Fluid Collection ◽

Positive Culture ◽

Central Line ◽

Oral Antibiotic ◽

Inclusion Criteria ◽

Exact Test ◽

Streptococcus Anginosus ◽

Days Of Therapy ◽

Antibiotic Failure

Abstract Background Pediatric Streptococcus anginosus intracranial pyogenic are commonly treated with prolonged intravenous (IV) antibiotics, exposing patients to risks of a long-term central catheter. Antibiotics with high oral bioavailability, such as levofloxacin, may allow early oral transition. Methods To characterize patients with S. anginosus intracranial infections transitioned to oral therapy, we performed a retrospective review at Children’s Hospital Colorado from 1/2004 to 2/2019. Inclusion criteria were radiologic evidence of an infected parenchymal, subdural, or epidural fluid collection AND a positive culture for S. anginosus from an intracranial source, specific extracranial sources (sinus, scalp, orbit), or blood. The primary endpoint was oral antibiotic failure defined as worsening infection on oral therapy. Comparisons were done using Fisher’s exact test. Results 94 patients met inclusion criteria, 57 of whom were transitioned to oral therapy during treatment. Oral levofloxacin was used in 54 of the 57. 12% of oral transitions occurred in the first 14 days of therapy (range 3–8 days), and 35% in the first 28 days. Patients transitioned in the first 28 days were more likely to have an epidural collection (p:< 0.01), and less likely to have a subdural collection (p: 0.03) or brain abscess (p:< 0.01). Of the 57, none had oral antibiotic failure. Contributing reasons for oral transition included central line complications (18%), IV medication reaction (18%), hematologic abnormality presumed secondary to IV antibiotics (33%), and provider judgement (56%). Two patients required re-introduction of IV therapy for reasons other than clinical failure (one for medication non-adherence and one for adverse reaction to levofloxacin). Conclusion We observed success and tolerance of levofloxacin-based oral therapy for pediatric pyogenic intracranial S. anginosus brain infections and confirmed the frequent occurrence of adverse events associated with IV treatment. Transition to oral therapy should be considered, particularly if complications of IV therapy arise in treatment of an epidural infection. A subset of patients in our study transitioned within the first 14 days of therapy; prospective studies are needed to characterize the safety of such very early transition. Disclosures All Authors: No reported disclosures

Download Full-text