Outcomes In Pediatric Endoscopic Skull Base Surgery: A Systematic Review

Objectives: The frequency of endoscopic skull base surgery in pediatric patients is increasing. This study’s aim is to systematically review the literature for endoscopic skull base surgery outcomes in children/adolescents ages 0-18 years. Design: A systematic review of the literature was performed in PubMed and SCOPUS databases querying studies from 2000-2020 using PRISMA guidelines. Final inclusion criteria included: case series with 10+ patients with pediatric patients age ≤18 years, endoscopic or endoscopic-assisted skull base surgery, and outcomes reported. Setting: Tertiary care medical center Participants: Children/adolescents ages 0-18 years who underwent endoscopic skull base surgery Main Outcome Measures: Patient demographics, pathology, reconstructive technique, intra-operative findings, intra-operative and post-operative surgical complications. Results: Systematic literature search yielded 287 publications. Of these, 12 studies discussing a total of 399 patients age 0-18 years met inclusion criteria for final analysis. 7 of 12 studies discussed a single pathology. The most common pathology was a skull base defect causing CSF leak. The majority of skull base repairs were made with free tissue grafts. The most common post-operative complication was CSF leak (n=40). Twelve cases of meningitis occurred post-operatively with two of these episodes resulting in death. Conclusions: Endoscopic skull base surgery has been performed recently in the pediatric population in a variety of disease states. Inconsistent individual-level data and reporting standards are present in existing studies posing challenges for comparative analysis. Standardized reporting will aid future reviews and meta-analysis for rare skull base pathology.

The Effect of Pharmacist-Led Intervention on Surgical Antibacterial Prophylaxis (SAP) at an Orthopedic Unit

Perioperative antibiotic use is a common reason for antibiotic misuse. Evidence suggests that adherence to SAP guidelines may improve outcomes. The purpose of this study was to analyze the impact of pharmacist-led antibiotic stewardship interventions on SAP guideline compliance. The study was conducted at an Orthopedic Department of a tertiary care medical center. SAP compliance and antibiotic exposure in the pre-intervention and intervention period was compared using chi-square, Fisher exact, and Mann-Whitney tests, as appropriate. Prophylactic antibiotic use in orthopedic joint arthroplasties (overall guideline adherence: agent, dose, frequency, duration), clinical outcomes (length of stay-LOS, number of surgical site infections-SSIs), antibiotic exposure and direct antibiotic costs were compared between pre-intervention and intervention periods. Significant improvement in mean SAP duration (by 42.9%, 4.08 ± 2.08 vs. 2.08 ± 1.90 days, p ˂ 0.001), and overall guideline adherence regarding antibiotic use (by 56.2%, from 2% to 58.2%, p ˂ 0.001) were observed. A significant decrease was observed in antibiotic exposure in SAP (by 41%, from 6.07 ± 0.05 to 3.58 ± 4.33 DDD/patient, p ˂ 0.001), average prophylactic antibiotic cost (by 54.8%, 9278.79 ± 6094.29 vs. 3598.16 ± 3354.55 HUF/patient), and mean LOS (by 37.2%, from 11.22 ± 6.96 to 7.62 ± 3.02 days, p < 0.001); and a slight decrease in the number of confirmed SSIs was found between the two periods (by 1.8%, from 3% to 1.2%, p = 0.21). Continuous presence of the clinical pharmacist led to significant improvement in SAP guideline adherence, which was accompanied by decreased antibiotic exposure and cost.

Abstract 13198: Impact of Targeted Resident Education on Perceptions of Communication and Participation in Cardiac Arrest

Introduction: Debriefing sessions after in-hospital cardiac arrest have been demonstrated to improve teamwork and survival outcomes. Though recommended in 2020 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, implementation remains low. Hypothesis: We postulated that a didactic training session provided to code leaders would increase rates of participation of AHA-recommended post-arrest debriefing sessions. Methods: Surveys were distributed to hospital personnel who participate in code blue/ERTs at an academic, tertiary-care medical center. Questions were graded on Likert scale to assess provider-reported perceptions of teamwork, communication, and confidence in conducting and participating in Code Blues. Participants were stratified in groups depending on whether they had previously participated in debriefing sessions. Primary outcomes were quantified using a Likert-type scale ranging from 1 to 5. Surveys were compared to surveys from prior years to assess if the intervention of a code blue didactics lecture delivered to code leaders resulted in any change in overall participation rate in the debriefing protocol. Results: Among 181 participants (61% female), 32% were residents, 54% nurses, 1.7% respiratory therapists. Self-evaluated current knowledge of ACLS protocols was significantly higher in the debriefing group (p = 0.0098), while there were no differences in perceived communication (p=0.76), and confidence in leading (p = 0.2) and participating (p = 0.2). We did not find a statistically significant difference in debriefing participation rate after our intervention (57% pre vs 58% post intervention, p=0.8), even when stratified by hospital role: critical care nurses (50% vs 71%, p=0.3), non-ICU nurses (68% vs 57%, p=0.3) and residents (67% vs 50%, p=0.2). Conclusions: Our study demonstrated that participation in post-code debriefing sessions was associated with a statistically significant increase in knowledge of cardiac arrest protocols. A code blue didactics lecture did not result in a statistically significant increase in post-arrest debriefing participation. Further study to elucidate methods to enhance adoption of this crucial, guideline recommended practice is warranted.

176. Topical Antibiotic and Antiseptic Use in the Operating Room: An Opportunity for Antimicrobial Stewardship?

Background Data suggest that topical antibiotic and antiseptic use in the operating room is common but not commonly monitored by antimicrobial stewardship programs. Although some data suggest a benefit in certain surgical procedures, the CDC and WHO advise against the routine use of topical antibiotics in surgery due to uncertainty and heterogeneity in the overall data. Methods We conducted a retrospective 28-day period prevalence study of topical antibiotic and antiseptic use during surgical procedures performed in the operating room by 6 surgical specialties at a tertiary care medical center. For the subset of patients undergoing orthopedic surgeries, we evaluated the types of topical antibiotics received and the rates of surgical site infections (SSI) and adverse drug events within 28 days of the procedure. Results Of 744 surgical procedures reviewed, topical antibiotics were used in 127 (17.1%), topical antiseptics in 71 (9.5%), and both in 18 (2.4%) (Table 1). Antiseptic use was higher in orthopedics relative to all other surgical specialties while topical antibiotic use was higher in neurosurgery. Hand, vascular and plastics had distinguishably lower use. In the orthopedic subgroup, after exclusions, 218 procedures were evaluated. Topical antibiotics were used in 42 (19.2%). Topical antibiotic therapy was more likely to be administered if prosthetic material was implanted, the procedure was emergent, or if a Staphylococcus aureus infection was present. Vancomycin was the most commonly used topical antibiotic and powder was the most commonly used type of application. As shown in table 2, SSI occurred more often when both topical antibiotics and antiseptics were applied; however, SSI events were relatively uncommon, and these were more likely to have infection present at the time of surgery. Adverse events were rare. Conclusion In our institution we noted significant variability in use of topical antibiotic and antiseptic therapy among surgical specialties as well as within the orthopedic surgical specialty. Although opportunities to standardize use/nonuse of these therapies exist, this may be challenging due to the uncertainty and heterogeneity of currently available data. Disclosures All Authors: No reported disclosures

233. Osteomyelitis of the jaw: A retrospective analysis of clinical, microbiologic characteristics and antimicrobial treatment at a Tertiary Care Medical Center

Background Osteomyelitis of the jaw is a relatively rare entity in the post antibiotic era. The aim of this study is to describe clinical characteristics, microbiology and antibiotics use (oral vs intravenous) for treatment. We review 5 years of experience at Banner University Medical Center-Phoenix (BUMC-P) of proven cases of OM jaw by clinical, pathological, radiological criteria. Methods Retrospective study of cases. From January 2011 to November 2015 ,157 cases of osteomyelitis of the jaw, we excluded cases of radiation therapy or neoplasia to the head and neck region, a history of antiresorptive medication use. A total of 34 patients with diagnosis of osteomyelitis of the jaw were reviewed. All patients met criteria for diagnosis of osteomyelitis and underwent surgical debridement and received antibiotics that included parenteral, orals and combined. We reviewed clinical, microbiology, antibiotic use. A successful outcome was defined as elimination of clinical symptoms, restoration of function and if available radiographic evidence of arrest and resolution of bony necrosis. Results This retrospective study involved 34 patients. Most common organisms were oropharyngeal flora 22 samples (65%): streptococcus anginosus group. 4 samples grew unusual gram negative bacteria. 10 (29%) samples grew fungal species. Antimicrobial regimen was divided in: intravenous (n=14) (41.2%), oral (n=7) (20.6%) and combination intravenous followed by orals as follows: 13 (38.2 %).The average antibiotic duration was 8.1 + 4.7 weeks. We were able to follow up 30 patients, average follow up was 32.1-44.7 weeks. The overall success rate was (n=24) 80% with uneventful healing and. (n=6) (20%) treatment failure. There was more failure in the oral antibiotics group (n=3). Conclusion This study is limited by small numbers. Surgery and cultures should guide treatment of osteomyelitis of the jaw. The use of oral antimicrobial therapy was associated to a higher likelihood of treatment failure. Although rarely linked as a cause of osteomyelitis, the authors think that the cultivation of candida spp should prompt appropriate coverage. More study is required to understand the efficacy of oral antimicrobial therapy in treating osteomyelitis of the jaw. Disclosures All Authors: No reported disclosures

1312. Evaluation of a Multiplexed PCR Pneumonia Panel in a Tertiary Care Medical Center

Background Syndromic PCR testing for lower respiratory pathogens may give rapid, actionable results to aid in management decisions for suspected pneumonia cases. We sought to evaluate the performance of a multiplexed PCR pneumonia panel compared to routine microbiologic work-up in a tertiary care patient population. Methods Sputum and bronchoalveolar lavage (BAL) samples from Keck Medical Center (Los Angeles, CA) inpatients submitted for clinical microbiology work-up Dec 2019-Jun 2020 were tested by a multiplexed PCR panel (FilmArray Pneumonia Panel, BioFire Diagnostics). We compared panel results for typical bacterial pathogens to those of quantitative culture and susceptibility testing. We retrospectively determined the incidence of non-panel respiratory pathogens as detected by standard of care tests in this patient cohort. Results 68 of 180 samples yielded 80 positive bacterial PCR results: 34 were detected by both PCR panel and culture and 46 by PCR panel only, yielding a sensitivity of 100% (34/34) for pathogens detected and specificity of 73.1% (114/156) among negative cultures (normal flora or no growth). Concordant results had PCR Bin values ≥10^5 copies/mL whereas all 18 targets detected at 10^4 copies/mL were culture-negative. Among resistance gene targets, the panel detected 12 MRSA specimens, of which MRSA grew in only 4 cultures; E. coli and CTX-M in 1 specimen from which grew normal flora; and multiple gram-negative organisms and KPC in 1 specimen from which culture isolated carbapenem-resistant P. aeruginosa. Quantitation from positive BAL cultures (n=25) correlated weakly with PCR Bin values (R-squared=0.17). Non-PCR panel pathogens were detected in 22 of 180 (12.2%) specimens through routine methods (16 molds, 3 AFB, and 3 non-fermenter gram-negative bacteria). Conclusion The pneumonia panel had excellent sensitivity for its target bacterial pathogens, but results were often positive in negative cultures. This could be due to antecedent antibiotic therapy, differences in reporting threshold versus culture, or inability of PCR to discern results from normal flora. Non-panel pathogens were detected in a significant proportion in our population. The pneumonia panel should be implemented and interpreted carefully with consideration of antimicrobial stewardship. Disclosures All Authors: No reported disclosures