Rivera, Christina G.

Introduction: During the early phase of the coronavirus disease 2019 (COVID-19), remdesivir was only approved for hospitalized patients. Our institution developed hospital-based, outpatient infusion centers for selected hospitalized patients with COVID-19 who had clinical improvement to allow for early dismissal. The outcomes of patients who transitioned to complete remdesivir in the outpatient setting were examined. Methods: Retrospective study of all hospitalized adult patients with COVID-19 who received at least one dose of remdesivir from 11/6/2020 to 11/5/2021 at one of the Mayo Clinic hospitals. Results: Among 3,029 hospitalized patients who received treatment with remdesivir for COVID-19, the majority (89.5%) completed the recommended the five-day course. Among them, 2,169 (80%) completed treatment during hospitalization, while 542 (20.0%) patients were dismissed to complete remdesivir in outpatient infusion centers. Patients who completed the treatment in the outpatient setting had lower odds of death within 28 days (aOR 0.14, 95% CI 0.06-0.32, p<0.001). However, their rate of subsequent hospital encounters within 30 days was higher (aHR 1.88, 95% CI 1.27-2.79, p=0.002). Among patients treated with remdesivir only in the inpatient setting, the adjusted odds of death within 28 days were significantly higher among those who did not complete the 5-day course of remdesivir (aOR 2.07, 95% CI 1.45-2.95, p<0.001). Conclusions: This study describes the clinical outcomes of a strategy of transitioning remdesivir therapy from inpatient to outpatient among selected patients. Mortality was lower among patients who completed the 5-day course of remdesivir.

Abstract GATA2 mutation can result in profoundly reduced monocytes, dendritic cells, natural killer cells, and B cells, and is associated with a predisposition for recurrent and disseminated nontuberculous mycobacterial (NTM) infections and myelodysplasias. Herein, we describe a unique case of 3 simultaneous disseminated NTM infections in a patient with GATA2 mutations.

Abstract As outpatient parenteral antimicrobial therapy (OPAT) becomes more common, it may be difficult to stay current with recent related publications. A group of multidisciplinary OPAT clinicians reviewed and ranked all OPAT publications published in 2021. This article provides a high-level summary of the OPAT manuscripts that were voted the “top 10” publications of 2021.

Abstract Background Outpatient parenteral antimicrobial therapy (OPAT) is an emerging area for pharmacist involvement. However, many residency training programs do not offer OPAT rotation opportunities for their residents. Objective To provide a blueprint for residency programs hoping to offer OPAT rotations for postgraduate year 1 (PGY1) or postgraduate year 2 (PGY2) pharmacy residents. Results As a rotation area with copious patient interaction, there are many unique accreditation objectives that can be taught and evaluated in an OPAT rotation. The OPAT rotation format may be longitudinal or block. Activities the resident can complete include predischarge evaluation, patient counseling, medication selection, physical examinations, laboratory monitoring, patient presentations, documentation, projects, and educational presentations. Conclusion OPAT rotations provide many opportunities for residents to satisfy the objectives required in residency training.

Abstract Although there is a lack of data in trimethoprim-sulfamethoxazole (TMP-SMX) serum monitoring utility for invasive nocardial infections, therapeutic drug monitoring is widely used to optimize dosing and avoid adverse reactions that may cause treatment interruption. We retrospectively reviewed all adults who received TMP-SMX to treat nocardial brain abscess and had SMX serum level testing from 2010 to 2020. Twenty-two patients received treatment with TMP-SMX for Nocardia species brain abscess and 16 (72.7%) had a reported SMX level, with a median patient age of 65.5 years (interquartile range, IQR 59.5–72.5). Compared to those who did not have a documented SMX serum level, patients with SMX levels had a shorter median course of TMP-SMX treatment (322 days [IQR 188–365] vs. 365 [IQR 224–365]; P = .31) and higher therapeutic induction dose (10 [62.5%] vs. 3 [50%]; P = .92). Similarly, they were more frequently on hemodialysis (3 [13.6%] vs. 1 [4.5%]; P = > .99). The median peak level was 158.5 (IQR 120–218) μg/mL, collected at 2 hours (75%) post-administration in the induction phase (81.3%). Patients with documented SMX levels had fewer reported drug toxicity (5 [31.3%] vs. 4 [66.7%]; P = .1) than those without SMX levels. Among the five patients who reported TMP-SMX-related toxicity, 4 (80%) had an SMX peak level >150 μg/mL. There was no difference in the cure, relapse, and death rates among the two groups. While SMX level was not associated with Nocardia species brain abscess cure rates and mortality, most patients with SMX peak >150 μg/mL experienced drug toxicity.

Abstract Background In 2018, the Clinical Microbiology Laboratory at our institution adopted updated daptomycin Enterococcus–susceptible dose-dependent breakpoints. While the introduction of susceptible dose-dependent (SDD) was intended to guide practice toward optimal dosing, the understanding and application of daptomycin SDD breakpoints for enterococci were unknown. Methods This mixed-methods study combined a clinician survey with a retrospective pre–post prescribing analysis. An 8-question survey was distributed to infectious diseases (ID) and internal medicine (IM) clinicians. A retrospective chart review of hospitalized adults with infections due to Enterococcus spp. was conducted before (pre-SDD) and after (post-SDD) adoption of SDD reporting for enterococci. Results Survey response rates were 40 of 98 (41%) for IM and 22 of 34 (65%) for ID clinicians. ID clinicians scored significantly higher than IM clinicians in knowledge of SDD. Chart review of 474 patients (225 pre- vs 249 post-SDD) showed that daptomycin dosage following susceptibility testing was significantly higher post-SDD compared with pre-SDD (8.5 mg/kg vs 6.4 mg/kg; P &lt; .001) with no difference in empiric dosing (6.3 mg/kg vs 6.2 mg/kg; P = .67). Definitive daptomycin use varied between the pre- and post-SDD periods (35.1% vs 16.9%; P &lt; .001). Conclusions The survey revealed that ID clinicians placed more importance on and had more confidence in the SDD category over IM clinicians. SDD reporting was associated with a change in definitive daptomycin dosing. ID specialist involvement is recommended in the care of infections due to enterococci for which daptomycin is reported as SDD given their expertise.

Abstract Background Outpatient parenteral antimicrobial therapy (OPAT) is the process of administering intravenous (IV) antimicrobials outside the acute inpatient setting. Oral antimicrobials for complex infections are referred to as complex outpatient antimicrobial therapy (COpAT). OPAT/COpAT programs are expanding, as are the opportunities for clinical Infectious Diseases (ID) pharmacists (RPHs) involvement. The current state of clinical (non-dispensing) role and the functions being performed by RPHs in OPAT/COpAT is unknown. Methods To define the current state of OPAT/COpAT pharmacy practice across the United States (US), specifically the clinical functions performed by RPHs, design of RPH involved OPAT/COpAT clinics, and compare training of RPHs who practice in OPAT/COpAT to ID RPHs who do not, a survey of a possible 31 questions was emailed to the American College of Clinical Pharmacists (ACCP) Infectious Diseases Practice and Research Network (PRN) email list. Results were focused on US-based respondents. Results Eighty-seven RPHs responded with 27 practicing in OPAT/COpAT. Training background did not differ between groups. Programs with an OPAT/COpAT RPH were more likely to have a formal OPAT team compared to those without an OPAT/COpAT RPH (p &lt; 0.001). OPAT/COpAT RPHs were early in their careers, with roughly half practicing &lt; 5 years in ID, and 66.7% practicing &lt; 5 years in OPAT/COpAT. Most OPAT/COpAT RPHs (66.7%) practiced at an academic medical center with a median full time equivalent (FTE) of 1 RPH. Most (63%) utilized a collaborative practice agreement and 81.5% shared job functions with other ID RPH roles, most commonly antimicrobial stewardship. Few (28%) OPAT/COpAT programs involved a dispensing component. The average daily census was 42 patients followed by an OPAT/COpAT RPH. There was wide variability in the types of tasks ID RPH performed in OPAT/COpAT, the three most important tasks are listed in Figure 1. OPAT Pharmacists Task Ranking by Importance There was wide variability in the types of tasks ID pharmacist performed in OPAT/COpAT. The most OPAT/COpAT pharmacists responded that adjusting medications based on lab values was in their top 3 most important clinical tasks. When ranking the top three most important tasks, selecting the initial OPAT/COpAT regimen was ranked first most often, followed by review of review of OPAT appropriateness for discharge, then adjusting medications based on lab values. Conclusion This is the largest known survey of OPAT/COpAT RPHs. RPH involvement in OPAT/COpAT in the US is an emerging trend with wide variability in program structure. Tasks performed by OPAT/COpAT RPHs varied significantly; however, OPAT/COpAT RPH respondents’ functions are largely clinical in nature. Disclosures All Authors: No reported disclosures

Abstract Background Lyme disease, the most common tickborne disease in the United States, may be prevented by taking a single 200-mg dose of oral doxycycline after a high-risk bite from a blacklegged tick. Currently, it is not known how Lyme disease post-exposure prophylaxis (PEP) might vary by region and healthcare system. We identified single-dose doxycycline medication orders in three healthcare systems in states with high incidence of Lyme disease and compared associated patient and provider characteristics. Methods Electronic health record data during 2012 – 2016 were obtained from three healthcare systems: Geisinger (Pennsylvania), Marshfield Clinic (Wisconsin), and Mayo Clinic (Minnesota/Wisconsin). Creation of analytic variables and analysis were harmonized across the three sites. Medication orders for single-dose doxycycline ≤200 mg that were accompanied by specific key words or diagnostic codes (e.g., tick bite; Lyme disease prevention) were considered evidence of PEP. Manual chart review was performed from a random subset to evaluate the algorithms used to identify PEP. Results Among 2,937,585 patients with at least one medication order or clinical encounter during the study period, 14,102 single-dose doxycycline orders for Lyme disease PEP for 13,172 unique patients were identified. The typical patient receiving PEP was older (mean age 51 – 58 years), male (56 – 59%), and non-Hispanic White (81 – 98%). The annual seasonality of medication orders was bimodal, with peaks occurring during April – July and October – November. The most common encounter setting was an outpatient clinic or urgent care center (80 – 91%); medication orders after patient phone calls in the absence of an in-person visit occurred frequently (14 – 19%) in two health systems. Chart abstractions (n=600) revealed instances of PEP prescribed inappropriately (e.g., bite from a non-blacklegged tick; patient with symptoms of acute Lyme disease). Conclusion Lyme disease PEP with a single dose of doxycycline was frequently prescribed in healthcare systems where there is a high incidence of Lyme disease. PEP was most commonly prescribed to non-Hispanic Whites over the age of 50 years. Public health initiatives for tickborne disease prevention should include clinician education on the appropriate use of Lyme disease PEP. Disclosures Anna M. Schotthoefer, PhD, HelixBind (Other Financial or Material Support, salary support) John Zeuli, PharmD, INSMED (Other Financial or Material Support, honoraria for educational speaking)