Citations

Background: Handshake antimicrobial stewardship (AMS), characterized by regular, face-to-face interactions with antimicrobial prescribers with broad review of all active antimicrobials, is considered an AMS best practice. This approach fosters relationship building and increases opportunities for targeted education compared to traditional AMS activities. Reports of handshake AMS within surgical services are limited. We evaluated the impact of once-weekly handshake AMS rounds among general surgery teams in a 368-bed academic medical center. Methods: An infectious diseases physician and pharmacist conducted weekly rounds in general surgery offices with surgical residents, chief residents, advanced practice providers (APPs), medical students, and occasionally attending surgeons. All patients on antimicrobials and without an active ID consult were reviewed and recommendations with targeted education were provided. The number, type, and acceptance rate of recommendations were collected prospectively. Antimicrobial utilization within general surgery was reviewed pre- (1/1/2024-12/31/2024) and post-implementation (1/1/2025-12/31/2025) of handshake AMS rounds. Antimicrobial use data are presented as days of therapy (DOT)/1000 days present (DP). Results: From January 7, 2025, through January 6, 2026, 47 handshake AMS sessions were performed. Over this period, 215 recommendations were provided, and 173 recommendations were implemented, yielding a recommendation implementation rate of 80.5% and an average of 4.6 recommendations/session. The most common accepted recommendation types were duration modification (n=42, 24.3%), antibiotic stop (n=38, 22.0%), and de-escalation (n=33, 19.1%). Average DOT/1000 DP on general surgery teams for all agents dropped from 481.3 pre- to 462.8 post-implementation (3.8% relative reduction, p=0.578). Broad-spectrum antibiotic use dropped by 17.5%, from 369.2 pre- to 304.6 post-implementation (p=0.055). Anti-MRSA agent utilization remained stably low, with an average of 45.4 pre- vs 49.0 DOT/1000 DP post-implementation. The use of enteral metronidazole increased, from 4.9% pre- to 18.2% enteral/IV DOT post-implementation. Surgical providers consistently expressed appreciation for the practice-changing education provided during handshake AMS rounds and the resulting enhancements in antimicrobial decision-making and patient care. Conclusion: Targeted, once-weekly handshake AMS rounds with general surgery resulted in high-yield interventions with a high acceptance rate. Handshake AMS rounds could be an effective stewardship intervention in surgical practices and is doable despite the challenges of unpredictable operating room/provider schedules.

Abstract Background Handshake antimicrobial stewardship (HAS) is an effective stewardship approach characterized by regular, face-to-face interactions with antimicrobial prescribers and broad review of all active antimicrobials. Benefits of this approach include enhanced relationship building and opportunities for targeted education. We conducted a mixed methods study to evaluate the impact of once-weekly HAS rounds among Hospital Internal Medicine (HIM) teams in an academic medical center. Methods An infectious diseases (ID) physician and pharmacist conducted weekly table rounds with a HIM teaching team consisting of a hospitalist, advanced practice providers (APPs), APP fellow(s), and sometimes medical students. All patients on antimicrobials and without an active ID consult were reviewed and recommendations were provided. Thereafter, the stewardship team solicited ad hoc questions from other HIM teams via walking rounds in their offices. The number, type, and acceptance rate of recommendations were collected prospectively. A survey was sent to all HIM providers to obtain feedback on HAS rounds. Results HAS rounds were conducted weekly from February 7, 2024, to February 19, 2025, with a total of 52 sessions. Over the study period, 340 recommendations were provided, and 314 recommendations were implemented, yielding a recommendation implementation rate of 92.4%. The most common recommendation types were antimicrobial discontinuation (n=76, 22.4%), duration modification (n=63, 18.5%), and de-escalation (n=39, 11.5%). The survey was sent to 102 HIM providers and completed by 19 for a response rate of 18.6%. All respondents stated HAS added value or greatly added value to their practice. Antimicrobial selection (n=16, 84.2%), de-escalation (n=12, 63.2%), and pharmacy expertise (n=6, 31.6%) were areas in which providers saw the greatest benefit. Eighteen providers (94.7%) recommended expansion of HAS to non-HIM services. Conclusion Targeted, once-weekly HAS rounds resulted in high-yield interventions that were frequently accepted and perceived as highly valuable by HIM providers. Once-weekly or intermittent HAS practices might be considered in practice settings where resources or logistical constraints limit broader, hospital-wide handshake stewardship practices. Disclosures All Authors: No reported disclosures

Abstract Objective: To retrospectively observe procalcitonin (PCT) and antibiotic ordering practices in patients hospitalized with community-acquired pneumonia (CAP). Design: Retrospective, exact matched, multicenter cohort study from October 1, 2018 – March 31, 2023. Setting: All hospitals across the Mayo Clinic Enterprise. Participants: Adult patients with CAP, identified using pneumonia diagnosis codes and receipt of systemic antibiotics with an indication of “respiratory tract infection” within 48 hours of hospitalization. Methods: PCT testing within the first 7 days of hospitalization was compared to non-PCT care (nPCT). The primary outcomes were treatment duration, antibiotic days of therapy (DOT), and length of stay (LOS). Results: 15364 patients met inclusion criteria. PCT testing occurred in 42.4% (6515/15364) of encounters, totaling 8214 PCT results. 12880 unique patient encounters were matched 1:1, 6440 in each group. Treatment duration was longer in the PCT group compared to the nPCT group (5.1 vs 4.6 days, respectively, P < 0.001). Patients in the PCT group also received more DOT (8.6 vs 7.6 DOT, P < 0.001) and had a longer LOS (6.8 vs 5.9 days, P < 0.001), respectively. There was no difference in 30-day all-cause mortality or C. difficile infection between groups. In a sensitivity analysis of nPCT patients compared to those with a peak value <0.25 ng/mL (i.e. normal result) there was no difference in treatment duration (4.6 days nPCT vs 4.7 days normal PCT, P = 0.104) or LOS (5.9 days nPCT vs 6.0 days normal PCT, P = 0.134). Conclusion: PCT testing in patients hospitalized with CAP was not associated with reduced antimicrobial utilization, LOS, or 30-day all-cause mortality.

Abstract Background Nocardia tends to cause infection in immunocompromised patients or those with chronic pulmonary disease. Nocardia is known to recur, prompting the practice of secondary prophylaxis in patients perceived at high risk. However, few data exist regarding the epidemiology of recurrent nocardiosis or the effectiveness of secondary prophylaxis. Methods We performed a multicenter, retrospective cohort study of adults diagnosed with nocardiosis from November 2011 to April 2022, including patients who completed primary treatment and had at least 30 days of posttreatment follow-up. Propensity score matching was used to analyze the effect of secondary prophylaxis on Nocardia recurrence. Results Fifteen of 303 (5.0%) patients developed recurrent nocardiosis after primary treatment. Most recurrences were diagnosed either within 60 days (N = 6/15, 40.0%) or between 2 to 3 years (N = 4/15, 26.7%). Patients with primary disseminated infection tended to recur within 1 year, whereas later recurrences were often nondisseminated pulmonary infection. Seventy-eight (25.7%) patients were prescribed secondary prophylaxis, mostly trimethoprim-sulfamethoxazole (N = 67/78). After propensity-matching, secondary prophylaxis was not associated with reduced risk of recurrence (hazard ratio, 0.96; 95% confidence interval, .24–3.83), including in multiple subgroups. Eight (53.3%) patients with recurrent nocardiosis required hospitalization and no patients died from recurrent infection. Conclusions Recurrent nocardiosis tends to occur either within months because of the same Nocardia species or after several years with a new species. Although we did not find evidence for the effectiveness of secondary prophylaxis, the confidence intervals were wide. However, outcomes of recurrent nocardiosis are generally favorable and may not justify long-term antibiotic prophylaxis for this indication alone.

A woman in her 50s presented with a 4-day history of left knee pain, erythema, swelling as well as malaise and rigours 1 month after undergoing a left knee meniscectomy. She was diagnosed with left native knee septic arthritis and underwent arthroscopic irrigation and debridement of the knee; cultures from synovial tissue grew Rhodococcus erythropolis. Rhodococcus spp are soil-dwelling and livestock-dwelling bacteria which occasionally cause disease in immunocompromised hosts. Infection in immunocompetent hosts is rare, and septic arthritis secondary to Rhodococcus erythropolis has not been reported previously.

Abstract Mpox, caused by infection with Monkeypox virus, usually presents as a mild, self-limited illness in immunocompetent persons that resolves within 2–4 weeks. Serious complications have been reported when mpox lesions involve vulnerable anatomic sites, such as the eye, and in those with substantial immunosuppression. We describe a patient with advanced human immunodeficiency virus infection and sustained viral shedding of mpox with ocular involvement, which resulted in vision loss.

Abstract Background There is scarce data surrounding the epidemiology of invasive fungal infections (IFI) after pancreas transplantation (PT). Our centers’ PT protocols recommend universal fluconazole prophylaxis for at least 1 month, which is extended to 1 year for recipients who live in Coccidioides endemic areas. The purpose of our study was to evaluate the epidemiology of IFIs after PT while on our antifungal prophylaxis protocol. Methods A retrospective cohort study was performed among adult patients who underwent PT at Mayo Clinic sites in Arizona, Florida, or Minnesota between January 1, 2010 and December 31, 2020. IFI was defined based on EORTC/MSGERC criteria. The primary aim was to describe epidemiology and timing of IFI after PT, particularly in the context of the universal antifungal prophylaxis protocol. Results Among 482 pancreas transplant recipients, 35 developed IFIs (7.3%). All patients received antifungal prophylaxis per protocol for a median duration of 33 days (Figure 1). Median duration from time of transplant to IFI was 16 (IQR 10.5-28.2) days for Candida IFIs versus 529 (IQR 192.5-1195.0) days for non-Candida IFI. 20 IFIs (57.1%) were secondary to Candida species with 45% of these cases caused by either C. glabrata or C. krusei (Figure 2). 90% were on antifungal prophylaxis (85% fluconazole) at time of diagnosis of invasive candidiasis. All the Candida IFIs were intra-abdominal infections. Amongst the 15 non-Candida IFIs (42.9%), 9 were secondary to endemic mycoses and 4 were secondary to invasive molds. Conclusion Our study shows a high incidence of IFIs secondary to Candida, with few patients diagnosed with non-Candida IFIs (Figure 3). Non-Candida IFIs, mostly secondary to endemic mycoses, occurred more than a year after transplant. Patients are at highest risk for Candida IFIs within the first 30 days after PT, likely secondary to organ space surgical site infections, despite receipt of antifungal prophylaxis. Breakthrough invasive candidiasis occurred in 90% of cases. Though our study lacked a comparator group without prophylaxis, these data question the effectiveness of fluconazole prophylaxis after PT. Disclosures All Authors: No reported disclosures

Abstract Background The BioFire® FilmArray® Gastrointestinal Pathogen Panel (GIPP) tests for 22 potential pathogens in stool, including Clostridioides difficile. C. difficile nucleic acid is detected via nested polymerase chain reaction (PCR) targeting toxin A (TcdA) and/or toxin B (TcdB) genes. While PCR-based diagnostic methods are highly sensitive, they lack specificity to differentiate colonization from C. difficile infection (CDI). Mayo Clinic Arizona (MCA) uses enzyme immunoassay (EIA) testing for toxin A/B and glutamate dehydrogenase antigens with reflex to PCR for discordance as the primary algorithm for diagnosing CDI; however, GIPP PCR testing circumvents this algorithm. When used in patients with low pretest probability for CDI, clinical false positives can lead to inappropriate diagnosis and treatment of colonization. GIPA Results in the Electronic Medical Record Pre-Intervention MCA Standalone C. difficile Testing Algorithm Abbreviations – EIA, enzyme immunoassay; GDH, glutamate dehydrogenase; NAAT, nucleic acid amplification test Methods We convened a multidisciplinary quality improvement team to reduce the detection and treatment of C. difficile colonization secondary to GIPP test results. Surveys were sent to providers and nurses as part of a formal gap analysis and included questions around ordering patterns, knowledge of appropriate tests, and associated costs. Baseline data was compiled from GIPP orders in MCA from 1/1/2022-9/30/2022. Results There were 1978 GIPP orders for 1694 patients during the study period (∼7 GIPPs/day). Most orders (65%) originated from ambulatory settings. The most common positive target was C. difficile (355/723, 49%), which resulted in treatment for suspected CDI in 94.9% (337/355) of cases. Of the 49 providers who responded to the survey, 86% ordered the GIPP at least monthly. Testing for C. difficile was the 2nd most common reason for ordering the GIPP. Most providers underestimated the cost of the panel and were unfamiliar with the differences between the GIPP and EIA testing algorithm. Nurses sought clarification on stool samples suitable for GIPP testing. Following education and modifications to ordering in the electronic health record, the decision was made to remove the C. difficile target from the GIPP. Provider Understanding of C. difficile Testing Methods GIPA Results in the Electronic Medical Record Post-Intervention Conclusion Multiplex PCR panels are comprehensive but require careful implementation to facilitate diagnostic stewardship. Facilities with robust standalone C. difficile testing algorithms may consider removing the C. difficile target from the GIPP. Disclosures All Authors: No reported disclosures

Abstract Background Inappropriate use of carbapenems is a major driver of antimicrobial resistance. The intensive care unit (ICU) at Mayo Clinic Arizona had a higher meropenem (MER) days of therapy (DOT) per 1000 patient days (PD) compared to other Mayo Clinic Enterprise sites, despite low rates of Pseudomonal resistance to narrower spectrum anti-pseudomonal beta-lactams. Methods A multidisciplinary team of infectious diseases (ID) and critical care medicine (CCM) physicians and pharmacists was created to reduce inappropriate use of MER in the ICU. The baseline rate of appropriateness was determined by evaluating all MER days in the ICU during Q4 2019 and Q4 2020. Each MER day was designated as appropriate or inappropriate based on pre-determined criteria after review by at least one ID and one CCM member. Discordant days were evaluated by the whole team to achieve consensus. The team provided education to the CCM department on the initiative, baseline data, and strategies to reduce inappropriate MER use. The active intervention included prospective audit and feedback of all patients on MER performed by the ID clinical pharmacists Mon-Fri 0700-1530 in Q4 2022. DOT/1000 PD was assessed for the pre-intervention and intervention periods. Results The baseline rate of inappropriate MER use in the ICU was 52% (442/846 days). The two most common reasons for inappropriate MER use in the baseline period were: susceptible organism for which a narrower agent could have been used (93/442, 21%), and infectious workup/cultures negative (89/442, 20%). During the intervention period, the inappropriate rate of MER use was reduced to 23%, below the pre-determined goal of 30%. The MER DOT/1000 PD in the baseline period were 103.9 (Q4 2019) and 151.5 (Q4 2020) versus 66.1 (Q4 2022) in the intervention period. There was no difference in ICU sepsis-related mortality in the pre-intervention vs intervention period (13.4 vs 0%, p=0.04). Conclusion A multidisciplinary team approach, including education and prospective audit and feedback, reduced inappropriate MER use in the ICU of an academic medical center from 52 to 23%. An associated decrease in MER DOT/1000 patient days was also observed. Disclosures All Authors: No reported disclosures

Abstract Background Clostridioides difficile infection (CDI) is a common and potentially life-threatening infection. Transplant recipients are vulnerable to CDI due to immune suppression and frequent antibiotic exposure. CDI can lead to serious complications in these patients, including allograft failure. In a population of pancreas transplant recipients, we aimed to identify epidemiologic characteristics and risk factors associated with CDI within 90 days of transplant. Methods We performed a retrospective cohort study of adults who underwent pancreas transplantation between January 1, 2010, and December 31, 2020, at three centers in Arizona, Florida, and Minnesota. Patients were excluded if they developed pancreas allograft failure within 48 hours of transplantation. The primary outcome was diagnosis of CDI within 90 days of transplantation and the secondary outcome was pancreas allograft failure. The main analyses were performed by Cox regression. Results A total of 482 patients were included, of which 35 (7.3%) developed CDI within 90 days (Table 1). Within the subset of 35 CDI patients, the median time to CDI was 17.0 (IQR 13.0–28.5) days (Figure 1) with most (83%) diagnosed with non-severe CDI. Most patients with CDI were on current systemic antibiotics (94%), primarily for prophylaxis (73%). CDI treatment was vancomycin for the majority of patients (71%) and metronidazole for the rest (29%). One patient had a fecal transplant for recurrence, and none required surgery. In multivariable cox regression of associations with 90-day CDI, significant associations were anastomotic leak (HR 3.04, 95% CI 1.2-7.4; p=0.015) and simultaneous pancreas-kidney transplantation (HR 8.70, 95% CI 1.15-66.7; p=0.036); age (HR 0.97, 95% CI 0.94-1.01; p=0.110) was not significant. In a secondary analysis, CDI was not associated with pancreas allograft failure (p=0.719).Table 1.Characteristics of 482 patients who underwent pancreas transplantation. Conclusion This study identified preceding anastomotic leak as a risk factor for 90-day CDI after pancreas transplantation, likely due to subsequent intra-abdominal infection and antibiotic use. simultaneous pancreas-kidney transplantation is another risk factor due to additional comorbidity. Transplant providers should be cognizant of the risks of CDI and mitigate these risks as possible. Disclosures All Authors: No reported disclosures