Citations

The hospice setting is unique for patient care and requires different techniques to study than other populations.

Abstract Background At hospice enrollment, patients are asked preferences regarding antibiotic use. Limited evidence on how these medications impact survival makes it difficult for clinicians to offer clear guidance. To support decision-making and antimicrobial stewardship, we assessed the association between antibiotic use and survival in outpatient hospice patients. Methods The association between antibiotic use and survival was evaluated using a time-dependent Cox proportional hazards model, adjusted for age, sex, Charlson Comorbidity Index, and hospice-qualifying conditions (HQCs). The cohort included patients enrolled in a large health system’s outpatient hospice program between June 20, 2017, and January 1, 2023. Results Among 6169 patients with an HQC, 1233 received at least one antimicrobial prescription during the study period. The median time from hospice enrollment to first prescription was 16 days (IQR 3-83). Antimicrobial prescribing patterns varied by HQC category. In time-dependent Cox models, antibiotic use was associated with increased hazard of death (aHR 1.47; 95% confidence interval [CI], 1.37–1.57).Stratified analyses showed the strongest association with increased mortality in patients with cancer HQCs (aHR 1.67; 95% CI, 1.50–1.87) and a survival benefit in those with infectious HQCs (aHR 0.60; 95% CI, 0.40–0.89). Discussion Physicians, patients, and families often overestimate the benefits of antibiotics near the end of life. The observed increase in mortality shortly after antibiotic initiation suggests that symptoms prompting antibiotic use may reflect the dying process rather than treatable infection. Knowledge of the limited role of antibiotics in prolonging life in hospice settings may improve decision-making and enhance the quality of end-of-life care.

Background: There are limited oral treatment options available for resistant Gram-negative bacterial (GNB) infections. Minocycline, a second-generation tetracycline antibiotic, offers good bioavailability and broad-spectrum coverage that may be an option for GNB infections. Methods: We conducted a retrospective review of minocycline susceptibility testing performed on GNB isolates at the Mayo Clinic reference lab between 2013 and 2022. Minocycline susceptibility was evaluated with a focus on difficult-to-treat organisms and relevant anatomic source. Organisms included resistant isolates of Escherichia coli and Klebsiella pneumoniae ; high-risk ampC-derepressors, including Citrobacter freundii, Enterobacter cloacae, and K. aerogenes; and clinically challenging non-Enterobacterales, Acinetobacter species, Achromobacter species, and Stenotrophomonas maltophilia . Results: Of 217,206 GNB isolates, 18,148 Enterobacterales (EB) and 8,190 non- Enterobacter isolates were tested for minocycline susceptibility. Of these, 80% of all EB and 92% of non-EB isolates were susceptible. Among E. coli isolates with ceftriaxone, ciprofloxacin, meropenem, or multidrug resistance, minocycline susceptibility was 78%, 76%, 70%, and 70.9%, respectively. Among the K. pneumoniae isolates with ceftriaxone, ciprofloxacin, meropenem, or multidrug resistance, minocycline susceptibility was 46%, 38%, 37%, and 39.3%, respectively. 85% of C. freundii , 81% of E. cloacae, and 85% of K. aerogenes isolates were susceptible to Minocycline. 83.5% of Achromobacter species isolates, 66% of Acinetobacter species isolates, and 99.1% of S. maltophilia isolates were susceptible. Conclusions: Our study reports the largest collection of minocycline susceptibility findings in GNB. Minocycline showed in vitro activity against many difficult-to-treat GNB isolates, including ceftriaxone- and multidrug-resistant E. coli and some K. pneumoniae isolates, common Amp-C-producing species, and non-fermenting GNB, including Stenotrophomonas , Acinetobacter , and Achromobacter .

Abstract The use of antibiotics in the hospice setting is complicated by differing patient goals, elevated side effects, and limited information regarding effectiveness. Here, we describe a case and apply the four-quadrant approach (4QA). This includes analyzing the case through the lenses of (1) medical indications related to improving function and reducing symptoms; (2) patient preferences, which vary among patients from complete avoidance of antibiotics to a therapeutic dosage to treat infection; (3) quality-of-life factors that include managing infectious symptoms versus antibiotic side effects; and (4) contextual features, which include antimicrobial resistance concerns and cost considerations. Antibiotics may be beneficial in some cases and should not be denied to patients enrolled in hospice care. More robust evidence-based information about outcomes is needed to inform discussions at the time of enrollment. Applying the 4QA to a case can help determine the best approach for each individual patient.

ABSTRACT Background VEXAS is a relatively newly described immunocompromising condition with hematopoietic stem cell transplant increasingly being used. Little is known regarding infections in this high‐risk population. Methods We conducted a retrospective review of ten adult patients diagnosed with VEXAS who underwent HSCT in the Mayo Clinic Rochester and the Arizona medical record system. Results Nine out of ten individuals developed bacterial infection with bacteremia found in eight individuals despite being on prophylaxis at the time of infection. Six of the ten individuals were found to have viral infection; there were no documented invasive fungal infections and only one individual had a parasitic infection. Conclusion Providers should have a high suspicion for infection, especially bacterial, in this patient population, regardless of prophylaxis use. Patients should also be educated on signs and symptoms of infection.

Background Patients are enrolled into hospice for a variety of conditions. There are few recent data on the differences of survival duration after hospice enrollment, particularly regarding age, sex, and reason for hospice admission. Methods Using previously obtained data, we calculated age at enrollment, reported sex, and classified patients into nine classes of hospice-qualifying conditions (HQC). We then applied Wilcoxon rank-sum analysis comparing median survival and the percent of patients surviving at least 6 months. Findings 53.38% of patients were female. The median age was 83.03 years. The median survival duration overall was 17.36 days (Inter-quartile range 5.35-62.08). Median survival was lowest for “Infectious” HQC (4.69d) and highest for “Other” (28.53d). Women survived longer than men (19.34 vs 15.37 days). Those older than median survived longer (20.51 days vs 15.03). Overall, 9.47% of enrollees survived at least 6 months. This was more common for women (10.99%), those older than 83 (12.44%), and those enrolled for dementia (16.46%). Discussion Relevant information of what can be expected after hospice enrollment is crucial for families and patients. These differences also indicate potential bias in assessment of hospice applicability, enrolling women, older patients, and patients with specific diagnoses earlier in their disease course.

Background Patients enrolling in hospice care are asked their preferences for antibiotic treatment. There is little information regarding which patients are more likely to receive antibiotics. To better inform discussions, we sought to characterize the use of antibiotics in the outpatient hospice setting. Methods We performed a retrospective review of patients enrolled in outpatient hospice within the Mayo Clinic Health System from 1/1/2017 through 1/1/2023. We calculated what percent of patients received antibiotics based on Hospice Qualifying Condition (HQC), age at enrollment, sex, survival time, and Charlson Comorbidity Index and calculated adjusted odds ratios (aOR). We documented which antibiotics were prescribed based on HQC. Results Of 6452 patients identified, 1259 (19.5%) received antibiotic prescriptions. Cephalosporins were the most common class of antibiotics prescribed (22.8% of antibiotics prescribed), followed by fluoroquinolones (20.3%) and penicillin derivatives (14.9%). Patients with Pulmonary HQCs were most likely to receive antibiotics (28.6% aOR 1.85 [1.51-2.25]), those with neurologic HQCs were least likely (14.9% aOR 0.66 [0.53-0.83]). There was no difference of age for those receiving antibiotics (80.7 yr) vs those not receiving (80.3 yr [ P = 0.25]), or for sex (male vs female aOR 1.10 [0.96-1.26). 4.6% of those surviving <7d received antibiotics (aOR .22 [0.17-0.29]), compared to 47.7% of those surviving >6mo (aOR 4.46 [3.50-5.69]). Discussion 19.5% of patients will receive antibiotics during their hospice course, with more frequent prescriptions in those surviving longer periods and those enrolled for pulmonary conditions. It is important to clarify patient preferences regarding antimicrobial utilization at the time of hospice enrollment.

Abstract Background At the time of hospice enrollment, patients are asked whether they would potentially want antibiotics. This is little information regarding which patients are more likely to receive these antibiotics or the impact on comfort or longevity. To help guide discussions with patients and families and target future stewardship interventions, we sought to characterize the use of antibiotics in the outpatient hospice setting. Methods We performed a retrospective review of patients enrolled in hospice with the Mayo Clinic Health System -Midwest from 1/1/2017 through 1/1/2023. For those with documented Hospice Qualifying Condition (HQC), we assessed age at enrollment, gender, survival time (ST), and Charleston Comorbidity Index (CCI). We documented which antibiotics were prescribed and compared the rate of prescription based on the above characteristics. Results We identified 6452 patients with identifiable HQC. Of these, 1281 patients (19.8%) received 4173 antibiotic prescriptions. After removing refilled prescriptions, there were 2037 new prescriptions. Cephalosporins were the most common class of antibiotics prescribed (24.4% of antibiotics prescribed), followed by fluoroquinolones (19.9%), penicillin derivatives (14.4%), and trimethoprim (10.4%) (fig 1). Pulmonary (28.6%) and GI (31.9%) HQCs were most likely to receive antibiotics, neurologic was least likely (fig 2). There was no difference of age for those receiving antibiotics (80.6 yr) vs those not receiving (80.3 yr [p=0.53]), or for gender (male vs female OR 0.97 [0.86-1.10). CCI was higher in those patients who received antibiotics (4.3) than those not receiving (3.93, p&lt; 0.001). Patients were more likely to receive antibiotics the longer they survived on hospice (4.7% surviving &lt; 7d, 47.7% surviving &gt;6mo – fig 3). Conclusion Antibiotics are an important pharmaceutical tool in the hospice setting. Nearly 20% of patients in hospice will receive antibiotics during their hospice course, with higher chance in those surviving longer periods and those enrolled for GI or pulmonary reasons. Discussions of antibiotic are crucial for these groups, and antimicrobial steward efforts should consider focusing on these patients. Disclosures All Authors: No reported disclosures

Abstract Background Minocycline is a second-generation tetracycline with a broad antimicrobial spectrum. It is often used in chronic suppression of musculoskeletal infections, given activity against gram positive organisms. Efficacy of Minocycline against gram negative skin and soft tissue infection has not previously been defined. In this study, we review in vitro minocycline efficacy against isolates from skin, muscle, and bone sources.Fig 1.Organisms isolated Methods We conducted a retrospective review of all minocycline susceptibility testing performed on musculoskeletal GNB isolates performed at the Mayo Clinic reference lab between 2013-2022. We describe the isolates broken down by site of culture and organism isolated. Then, we calculated the overall susceptibility of these isolates to Minocycline and susceptibility of the most common 6 organisms isolated.Fig 2.Sites of gram negative isolation Results During the study timeframe, we identified 13,567 gram negative isolates from musculoskeletal sites. Of 330 species identified, 19 were identified in at least 100 isolates (fig 1). Of 36 unique sites, 19 sites were each identified in at least 100 isolates (fig 2). 1920 isolates were tested for susceptibility to minocycline. Of these, 1584 (82.5%) were susceptible to minocycline. Of the most common organisms identified and tested for minocycline susceptibility, 99% of Stenotrophomonas maltophilia, 83% of Enterobacter cloacae, 80% of Escherichia coli, 68% of Acinetobacter baumanii, 1% of Proteus mirabilis, 53% of Klebsiella pneumoniae, 65% of Serratia marcescens isolates were susceptible to minocycline (fig 3). Pseudomonas aeruginosa isolates were not tested, due to innate resistance.Fig 3.Minocycline susceptibility compared to key organisms Conclusion A majority of skin and soft tissue cultures positive for Gram negative isolates were below the waist line. Of these, we reported organisms most commonly found. Minocycline showed in vitro activity against some commonly isolated gram negative organisms, especially E.coli, Acinetobacter, and Stenotrophomonas. Further research is needed into the efficacy of minocycline in gram negative skin and soft tissue infections, but it may represent a viable oral option, especially in the end of life. Disclosures All Authors: No reported disclosures