Tande, Aaron J.

Abstract Background The epidemiology of fungal infections in hematologic malignancies has changed in the past decade. Triazole prophylaxis has decreased Candida spp infections while infections due to other molds such as Aspergillus and Fusarium species have increased. Fusariosis has very poor prognosis, and after aspergillosis, is the most common invasive fungal infection in this patient population. We sought to describe fusariosis in patients with hematologic malignancy at the Mayo Clinic. Methods We performed a retrospective review of patients with culture-positive Fusarium infection from January 2003 to October 2016 at the Mayo Clinic, Rochester, MN. The records of patients were reviewed for demographics, diagnosis, treatment, and outcomes including mortality. Patients without a diagnosis of hematologic malignancy were excluded. Patients were classified with proven or probable Fusariosis based on the Revised Definitions of Invasive Fungal Disease from the EORTC/MSG Consensus Group. Results We identified 14 patients with hematologic malignancies (age range 17–76 years; median 60 years) with a confirmed culture diagnosis of Fusarium infection classified as proven (9 patients) or probable (5 patients). Two cases were isolated pulmonary infections, 3 extra-pulmonary, and 9 disseminated cases. Two patients had previously undergone stem cell transplantation. Eight patients (57%) were receiving antifungal prophylaxis at the time of diagnosis: 2 on voriconazole, 1 on posaconazole, 1 on fluconazole, 3 on echinocandins, and 1 on Amphotericin B. Nine patients (64%) were neutropenic at the time of diagnosis. Amphotericin was the initial treatment in 7 (50%) patients, with voriconazole added for 4 patients for combination therapy the first week. Voriconazole monotherapy was given initially in 5 patients. Seven patients (50%) were deceased at 6 weeks after culture positivity, with an additional 2 patients deceased by 12 weeks. Conclusion Fusarium infection outcomes in patients with hematologic malignancies are poor. Neutropenia was common in those diagnosed, and infections were more likely to be disseminated, with high mortality rates. Amphotericin was commonly used as initial treatment, with many physicians recommending combination therapy with two agents, commonly voriconazole. Disclosures All authors: No reported disclosures.

Abstract Background The interaction between influenza activity and environemental factor such as ultraviolet light index (UVI), atmospheric ozone (AO), and other related meteorological variables remains poorly understood. In the midst of climate change and increasingly poor performance of influenza vaccination, more information on influenza activity and its interaction with meteorological variables is critically needed. Methods Influenza A and B tests results by PCR from respiratory sources were collected from two large hospitals in Phoenix, AZ and Jacksonville, FL from January 1, 2014 to December 31, 2017. Publicly available meteorological data for each location was obtained from the National Oceanic and Atmospheric Administration. We excluded cases residing beyond 0.5° of longitude and latitude radius of the given meteorological data. A weekly index activity and maximum weekly values of meteorological variables were matched, and performed a correlation and regression analysis. Results A total of 5,238 influenza tests were performed during the study period. The influenza index showed an statistically significant weakly positive correlation with maximum CSUVI (r = 0.14; P = 0.0227) and mean zenith (r = 0.17; P = 0.0047). An statistically significant, positive correlation was observed between influenza index and atmospheric ozone (r = 0.23; P = 0.0001). Significant negative correlations were also observed with DBT, DPT, RH and HI (r = −0.27, r = −0.39, r = −0.13, r = −0.33, respectively; P < 0.04). The influenza index showed significant interactions in a univariate linear regression (Table 1). A relationship between influenza index and dew point temperature was observed in a multivariate model (OR = 0.66; CI95% 0.44–0.97). Conclusion To the best of our knowledge, this is the first report showing a significant interactions between influenza index, UVI and atmospheric ozone in two geographically distant locations. Further studies are needed to define the role of complex climatological patterns and influenza. Disclosures All authors: No reported disclosures.

Patients with febrile neutropenia (FN) often are subject to antibiotic and diagnostic test overuse. We sought to improve appropriate use of antimicrobials and diagnostic tests for patients with FN. We used a blended quality approach with Lean Six Sigma tools and iterative improvement of a clinical decision aid to guide providers through empirical antimicrobial selection and diagnostic evaluation of patients with FN during a yearlong period. We evaluated the incidence of nonadherence to best practice before, during, and after rollout of a clinical decision aid in conjunction with an educational initiative. At baseline, 71% of patients with FN had at least one critical deviation from best practice. During the project, the percentage decreased to 27.3%; 4 months after the project was completed, the percentage was 33.3% ( P = .04). A clinical decision aid can improve adherence to best practices for the empirical management of FN.

Abstract Background Limited data exist to evaluate safety-related outcomes in Outpatient Parenteral Antimicrobial Therapy (OPAT) patients treated with antimicrobial agents for Gram-positive infections. Methods This retrospective, single-center study enrolled Mayo Clinic OPAT patients between 2013 and 2017. The primary objective of the study compared rates of therapy modification due to drug-related toxicity for staphylococcal infections treated with ceftriaxone, cefazolin, nafcillin, oxacillin, vancomycin, daptomycin, ceftaroline, linezolid, or ertapenem. Secondary objectives included determination of the frequency and type of adverse drug events (ADEs) attributed to OPAT and rate of readmission due to ADEs attributed to OPAT. Results One hundred seventy-two patients were identified (cefazolin n = 54, ceftriaxone n = 49, vancomycin n = 30, daptomycin n = 16, nafcillin n = 9, ertapenem n = 6, ceftaroline n = 4, oxacillin n = 3, linezolid n = 1). The overall treatment completion rates were high (153/172, 89.0%). Patients completed an average of 35.3 days (7 to 95) of therapy with their original antibiotic. Fourteen patients required change to a different antibiotic due to antimicrobial toxicity (ceftriaxone=5; vancomycin=2; cefazolin = 2; daptomycin = 2; ceftaroline = 1; nafcillin = 1; oxacillin = 1) and five patients experienced treatment failure required an additional agent (ceftriaxone = 2; nafcillin = 2; linezolid = 1). Adverse drug events (ADEs) were the most common reason for antimicrobial adjustment (14/19, 73.7%). The most common ADEs were hypokalemia (28/172, 16.3%) and diarrhea (25/172, 14.5%). There were only two cases of Clostridium difficile. Thirty-day readmissions due to antimicrobial therapy were low with 11 patients. Conclusion OPAT with Gram-positive agents used for staphylococcal infections is effective, but antimicrobial modifications still occur. Clinicians should be aware of the risk of ADEs and readmissions in OPAT patients. A multidisciplinary approach may enhance management of ADEs and possibly preventing readmissions Disclosures All authors: No reported disclosures.

AbstractBackgroundNephrotoxins contribute to 20%–40% of acute kidney injury (AKI) cases in the intensive care unit (ICU). The combination of piperacillin-tazobactam (PTZ) and vancomycin (VAN) has been identified as nephrotoxic, but existing studies focus on extended durations of therapy rather than the brief empiric courses often used in the ICU. The current study was performed to compare the risk of AKI with a short course of PTZ/VAN to with the risk associated with other antipseudomonal β-lactam/VAN combinations.MethodsThe study included a retrospective cohort of 3299 ICU patients who received ≥24 but ≤72 hours of an antipseudomonal β-lactam/VAN combination: PTZ/VAN, cefepime (CEF)/VAN, or meropenem (MER)/VAN. The risk of developing stage 2 or 3 AKI was compared between antibiotic groups with multivariable logistic regression adjusted for relevant confounders. We also compared the risk of persistent kidney dysfunction, dialysis dependence, or death at 60 days between groups.ResultsThe overall incidence of stage 2 or 3 AKI was 9%. Brief exposure to PTZ/VAN did not confer a greater risk of stage 2 or 3 AKI after adjustment for relevant confounders (adjusted odds ratio [95% confidence interval] for PTZ/VAN vs CEF/VAN, 1.11 [.85–1.45]; PTZ/VAN vs MER/VAN, 1.04 [.71–1.42]). No significant differences were noted between groups at 60-day follow-up in the outcomes of persistent kidney dysfunction (P = .08), new dialysis dependence (P = .15), or death (P = .09).ConclusionShort courses of PTZ/VAN were not associated with a greater risk of short- or 60-day adverse renal outcomes than other empiric broad-spectrum combinations.