1111. Characterization of Antibiotic Ordering in Patients with Mental Status Changes and Presumed Urinary Tract Infection in Patients 65 and Older

Abstract

Background
Altered mental status (AMS) is the most common diagnosis among those 65 and older who present to the emergency department (ED). Urinary tract infections (UTIs) account for 15.5% of hospitalizations in this population. The purpose of this study was to determine the incidence of initiation of antibiotics in the ED in patients 65 years and older with mental status changes and asymptomatic bacteriuria or negative urine cultures.

Methods
A retrospective chart review was performed to evaluate patients aged 65 and older from January 2017 through June 2018 who presented to the ED from home with AMS, a urinalysis that reflexed to culture, and were admitted to an internal medicine unit. The primary outcome was defined as the percentage of patients with AMS who received antibiotics in the ED with asymptomatic bacteriuria or negative urine cultures. Secondary outcomes included adherence to the CCHS UTI antibiotic guideline, incidence of early discontinuation of antibiotics, culture sensitivity to ordered antibiotic, and disposition after discharge.

Results
A total of 91 patients were included in this study. Seventy-five patients had asymptomatic bacteriuria and antibiotics were started in the ED in 63 (84%) of these patients. Fourteen patients had no growth on culture and seven of these patients (50%) had antibiotics initiated in the ED. Of those who received antibiotics (n = 82), there was 81.7% adherence to the Christiana Care UTI antibiotic selection guideline. Sensitivities were available for 41 isolates and 65.9% were sensitive to the initial antibiotic administered. Antibiotics were discontinued early in 29/82 (35.4%) of patients. Thirty-one patients (33.7%) were discharged to a skilled nursing facility.

Conclusion
These results indicate that the majority of patients aged 65 and older who presented to the emergency department with altered mental status and no other UTI symptoms such as dysuria, urinary frequency, or urgency were treated with antibiotics. When antibiotics are initiated the majority of providers are adhering to organizational guidelines for antibiotic selection and duration. The results will be shared with Emergency Department and Internal Medicine leadership to foster practice change.

Disclosures
All authors: No reported disclosures.

Full text

Poster Abstracts • OFID 2019:6 (Suppl 2) • S395
Disclosures. Al l authors: No reported disclosures.
1109. Use of Prospective Audit with Intervention and Feedback (PAIF) for Urine
Culture (UCx) Interpretation at a Veteran Affairs Medical Center
Nathan Nowalk, MD1; Eric Wu , MD1; Hal Zhang, MD1;
Andrew Hunter, PharmD, BCPS (AQ-ID)2; Prathit Kulkarni, MD1;
MariaC. Rodriguez-Barradas, MD2,3; 1Baylor College of Medicine, Houston,
Texas; 2Michael E.DeBakey VA Medical Center, Houston, Texas; 3Baylor College of
Medicine, Houston, Texas
Session: 136. Antibiotic Stewardship: Urine Cultures
Friday, October 4, 2019: 12:15 PM
Background. Diagnosis of urinary tract infections (UTI) vs. asymptomatic bac-
teriuria (ASB) is challenging and inappropriate treatment of ASB is common. PAIF
to prescribers decreases inappropriate antimicrobial use.We postulated that a quality
improvement strategy using PAIF aimed at interpretation of UCx would reduce anti-
microbials forASB.
Methods. Single-center QI project to evaluate PAIF for positive UCx on Veterans
admitted from December 11/2018 - 3/27/2019 to medicine teaching services at a VA
Medical Center. Residents and hospitalists received an educational conference on UTI
diagnosis one month prior to PAIF initiation. Using available soware (eradoc®), an
electronic alert was created to notify 3 project physicians of every positive UCx ( >10K
CFU). Chart review was performed against a diagnostic algorithm for UTI based on
the 2011 IDSA guidelines. Feedback was provided by a phone call to residents caring
for these patients.
Results. Charts of all 211 patients with positive UCx (mean age 74 y, 98%
male) were audited within 72 hours of culture positivity. Of this group, 38% (80/211)
were diagnosed as UTI by auditors vs. 45% (94/211) diagnosed as UTI by providers
(P=0.24). Between auditor diagnosis at 72 hours and provider diagnosis at discharge,
an absolute inter-rater agreement of 94% (Cohen’s kappa 0.86) was observed. In 7%
(14/211) of cases, the auditor diagnosed ASB, but the patient later received treatment
for UTI. Auditors recommended discontinuation of antimicrobials for 8 of these 14
patients. For these 8 patients who received feedback, antimicrobials were discontinued
in 4 cases. In the other 6 inappropriately treated ASB, providers had not started anti-
microbials at the time of the audit, but later treated for UTI. No recommendation for
starting antimicrobials was made by auditors.
Conclusion. Providers who had been exposed to academic detail on ASB, ap-
propriately diagnosed UTI in the majority of their patients. Auditor and provider dis-
agreements were rare, thus need for intervention was low. However, a small portion of
patients still received antimicrobials for ASB. We are now exploring PAIF for urinalysis
interpretation—an earlier upstream clinical decision point—and reviewing outcomes
on those assessed asASB.
Disclosures. Al l authors: No reported disclosures.
1110. Outcomes Following Implementation of a Urine Culture
Timothy Simpson, PharmD; Janet Wu, PharmD, BCIDP;
Chirag Choudhary, MD, MBA; Sneha Shah, PharmD, BCPS; Cleveland Clinic,
Cleveland, Ohio
Session: 136. Antibiotic Stewardship: Urine Cultures
Friday, October 4, 2019: 12:15 PM
Background. Antimicrobials are oen inappropriately initiated for asymptom-
atic bacteriuria (ASB). At our institution, urinalysis (U/A) and urine culture (UCx)
are ordered simultaneously, leading to an increased rate of catheter-associated UTI
(CAUTI) diagnosis and antimicrobial initiation. AUCx algorithm was implemented
in the medical intensive care unit (MICU) to guide the appropriate ordering of UCx
in patients with foley catheters. e purpose of this study was to assess the impact of
this UCx algorithm paired with nursing and prescriber education on overall patient
outcomes.
Methods. is was a single-center, pre- and post-analysis of patients admit-
ted to the MICU with an order for a U/A and/or UCx for suspected UTI. Patients
were excluded if they had a suspected co-infection from another source, absence of
foley catheter or UCx drawn prior to MICU admission. e pre-implementation
phase was November 1, 2017 to April 31, 2018, and the post-phase was May 1, 2018
to October 31, 2018. e primary objective was to compare the incidence of CAUTI
between pre- and post-implementation phases. Secondary objectives included rate of
adherence to the algorithm, number of UCx ordered, rate and days of antimicrobial
therapy for ASB, duration of catheterization and 30-day mortality between pre- and
post-implementationphase.
Results. ere were 94 patients in the pre-phase and 77 patients in the post-
phase. Baseline characteristics were similar between groups, except a greater propor-
tion of patients in the pre-phase had a catheter prior to admission (12.8% vs. 2.6%; P
= 0.02). Incidence of CAUTI decreased following algorithm implementation (16% vs.
6.5%; P = 0.05). Complete algorithm adherence was 2.6%, whereas partial adherence
was 49.4%. Number of UCx ordered were 126 (comprising 100% of patients) and 76
(comprising 86% of patients) in the pre- and post-phase, respectively. Antimicrobial
therapy for ASB was initiated in 55.3% of patients in the pre-phase vs. 37.7% in the
post-phase; P = 0.02. ere were no dierences in duration of ASB treatment, catheter-
ization or 30-day mortality.
Conclusion. Implementation of UCx algorithm paired with educational inter-
vention resulted in a signicant decrease in CAUTI and ASB treatment. Additional
interventions may be necessary to optimize adherence to the algorithm.
Disclosures. Al l authors: No reported disclosures.
1111. Characterization of Antibiotic Ordering in Patients with Mental Status
Changes and Presumed Urinary Tract Infection in Patients 65 and Older
Nicole Harrington, Pharm D, BCPS AQ-ID; Jessica Leri, PharmD;
Scott Shoop, PharmD, BCPS; Christiana Care Health System, Newark, Delaware
Session: 136. Antibiotic Stewardship: Urine Cultures
Friday, October 4, 2019: 12:15 PM
Background. Altered mental status (AMS) is the most common diagnosis among
those 65 and older who present to the emergency department (ED). Urinary tract
infections (UTIs) account for 15.5% of hospitalizations in this population. e pur-
pose of this study was to determine the incidence of initiation of antibiotics in the ED
in patients 65years and older with mental status changes and asymptomatic bacteriuria
or negative urine cultures.
Methods. Aretrospective chart review was performed to evaluate patients aged
65 and older from January 2017 through June 2018 who presented to the ED from
home with AMS, a urinalysis that reexed to culture, and were admitted to an in-
ternal medicine unit. e primary outcome was dened as the percentage of patients
with AMS who received antibiotics in the ED with asymptomatic bacteriuria or nega-
tive urine cultures. Secondary outcomes included adherence to the CCHS UTI anti-
biotic guideline, incidence of early discontinuation of antibiotics, culture sensitivity to
ordered antibiotic, and disposition aer discharge.
Results. Atotal of 91 patients were included in this study. Seventy-ve patients
had asymptomatic bacteriuria and antibiotics were started in the ED in 63 (84%)
of these patients. Fourteen patients had no growth on culture and seven of these
patients (50%) had antibiotics initiated in the ED. Of those who received antibiotics
(n = 82), there was 81.7% adherence to the Christiana Care UTI antibiotic selection
guideline. Sensitivities were available for 41 isolates and 65.9% were sensitive to the
Downloaded from https://academic.oup.com/ofid/article-abstract/6/Supplement_2/S395/5605909 by guest on 24 October 2019

S396 • OFID 2019:6 (Suppl 2) • Poster Abstracts
initial antibiotic administered. Antibiotics were discontinued early in 29/82 (35.4%)
of patients. irty-one patients (33.7%) were discharged to a skilled nursing facility.
Conclusion. ese results indicate that the majority of patients aged 65 and older
who presented to the emergency department with altered mental status and no other
UTI symptoms such as dysuria, urinary frequency, or urgency were treated with antibi-
otics. When antibiotics are initiated the majority of providers are adhering to organiza-
tional guidelines for antibiotic selection and duration. e results will be shared with
Emergency Department and Internal Medicine leadership to foster practice change.
Disclosures. Al l authors: No reported disclosures.
1112. Improving Urine Culturing Practices in a Neurocritical Care Unit through a
Multidisciplinary Algorithm-Based Approach
Dana Hazen, MPH, BSN, RN1; William Snyderman, MPH2;
Josh Sadowski, BS2; Kristen Kelley, MD3; Cole Beeler, MD3;
Douglas Web b , MD3; Lana Dbeibo, MD3;
Shannon Page, MSN, RN, AGCNS-BC, ANP, CCRN2; Armisha Desai, BCPS2;
Richard Rodgers, MD, FAANS, FACS2; Brian Brewer, MC, FACS3;
Ranjeet Singh, MD3; Lawrence Bortenschlager, MD3; 1Indiana University Health,
Indianapolis, Indiana; 2Indiana University Health Adult Academic Health Center,
Indianapolis, Indiana; 3Indiana University School of Medicine, Indianapolis, Indiana
Session: 136. Antibiotic Stewardship: Urine Cultures
Friday, October 4, 2019: 12:15 PM
Background. Asymptomatic bacteriuria is common in hospitalized patients with
urinary catheters. Inappropriate urine culturing as part of reexive response to fever
contributes to unnecessary and excessive antibiotic use, selection for resistant organ-
isms, increased risk for Clostridium dicile infections, and false elevation in cathe-
ter-associated urinary tract infection (CAUTI) rates. is project aimed to implement
an evidence-based urine culture algorithm in a 33-bed neurocritical care unit, a unit
with a historically elevated CAUTI rate due to a high prevalence of noninfectiousfever.
Methods. A multidisciplinary quality improvement project was initiated in
August 2018 by the Infection Prevention, Quality and Safety, Neurocritical Care,
Trauma, and Neurosurgery teams of an urban academic health center. e group
implemented a urine culture algorithm that was adapted from the Infectious Diseases
Society of America (IDSA) guidelines that clearly highlighted appropriate indications
for sending urine cultures. e team agreed to utilize a urinalysis with reex to culture
as the preferred method to evaluate for CAUTI. e algorithm was implemented in
September 2018. Outcomes were compared for pre-implementation (March-August
2018)and post-implementation (September 2018–February2019).
Results. e NHSN CAUTI rate decreased from 4.52/1,000 Foley days to
1.27/1,000 Foley days (P-value 0.037) as a result of the intervention. e number of
urine cultures ordered decreased by 82% aer implementation. No cases of bacteremia
or mortality secondary to a urinary source were identied during the project. Total
days of antibiotic therapy for the unit was similar between the pre- and post-imple-
mentation time periods (P=0.631).
Conclusion. Implementation of a urine culture algorithm in a neurocritical care
unit resulted in reduced CAUTI rate with less nancial and operational waste in un-
necessary orders and treatment, without resulting in adverse events to patients as a
result of missed diagnosis.
Disclosures. Al l authors: No reported disclosures.
1113. Outpatient Antimicrobial Stewardship: Targets for Urinary Tract Infections
KariA. Mergenhagen, PharmD1; BethanyA. Wattengel, PharmD2;
Sara DiTursi, PharmD3; Jennifer Schroeck, PharmD2; JohnA. Sellick, DO, MS2;
1VA Bualo, Getzville, New York; 2VA WNY Healthcare System, Bualo, New York;
3Catholic Health System, Bualo, New York
Session: 136. Antibiotic Stewardship: Urine Cultures
Friday, October 4, 2019: 12:15 PM
Background. Urinary tract infections (UTIs) remain one of the most com-
monly diagnosed infectious diseases in the United States in both the inpatient and
outpatient settings, accounting for 10.5 million outpatient visits in 2007. Of these
visits, 5.4 million were seen in primary care oces. Outpatient antimicrobial stew-
ardship programs are emerging and a focused approach to UTIs is needed to help
guide new programs.
Methods. Data were collected by retrospective chart review of outpatient males
at the VA Western New York Healthcare System using encounters from January 2005
to March 2018. Appropriate treatment was dened as antimicrobial prescribing in the
setting of at least 2 signs/symptoms of UTI. Categorical data were analyzed using the
chi-square test and continuous data using the Student t-test. Factors that diered sig-
nicantly (P < 0.05) between the comparator groups were built into a multivariate lo-
gistic regression model to determine factors associated with inappropriate prescribing,
which were presented as an Odds Ratio (OR) and 95% Condence Interval(CI).
Results. Atotal of 607 outpatients met criteria for inclusion, of which 40% were
treated inappropriately. Of the 60% treated appropriately (therapy was indicated and
empiric drug choice was correct), 95% of patients received a correct dose and 57%
received an appropriate duration. Several risk factors were identied for inappropriate
prescribing. Female patients were more likely to be treated inappropriately, OR 4.7
(95% CI, 2.4–9.1). Patients with a higher Charlson Comorbidity Index of 5–10 were 2.9
times more likely to be treated inappropriately (95% CI, 1.8–5.0). ose patients who
received a urine culture or imaging were more likely to be treated appropriately: OR 0.6
(95% CI, 0.4–0.9) and 0.5 (95% CI, 0.3–0.7), respectively.
Conclusion. Outpatient antibiotic prescribing for UTIs is suboptimal.
Outpatient stewardship programs may wish to educate providers on symptoms of UTI.
Interestingly, those with signs and symptoms consistent with UTI were more likely to
have a urine culture and/or imaging completed suggesting that providers were aware
of a true diagnosis of a UTI. Stewardship programs should pay special attention to
patients with numerous comorbidities as they are oen inappropriately treated.
Disclosures. Al l authors: No reported disclosures.
1114. Oral β-lactams for the Treatment of Escherichia co li Bacteremia Secondary
to Complicated Urinary Tract Infections Including Pyelonephritis
Nicole Harrington, PharmD, BCPS AQ-ID; Megan Doran, PharmD;
Stephen May, PharmD; Julianne Care, PharmD;
Jillian Laude, PharmD, BCPS; Stephanie Lee, MD; Christiana Care Health System,
Newark, Delaware
Session: 136. Antibiotic Stewardship: Urine Cultures
Friday, October 4, 2019: 12:15 PM
Background. Complicated urinary tract infections (cUTI) including pyeloneph-
ritis may result in bacteremia, increasing the rate of morbidity and mortality. e
Infectious Diseases Society of America recommends a uoroquinolone as empiric
therapy or trimethoprim/sulfamethoxazole as denitive therapy for acute pyeloneph-
ritis (AP). Oral β-lactams (BL) are considered sub-optimal based on historical ecacy
data with aminopenicillins and variable bioavailability. Increasing resistance and tox-
icity with preferred agents, justies further evaluation of oral BL for E.coli bacteremia
secondary to urinary source.
Methods. is was a single-center, retrospective cohort study of patients with
E.coli bacteremia secondary to AP or cUTI who received oral step-down therapy with
a BL or non-BL. e primary outcome was the rate of clinical success dened by micro-
biological cure, clinical cure, and infection-related readmission. Secondary outcomes
were time to oral step-down, total days of therapy, length of hospital stay, incidence
of therapy escalation, 30-day readmissions, and antibiotic-associated adverse events.
Results. Atotal of 46 patients were included, with 23 patients in each group.
e dierence in clinical success between the BL and non-BL groups was not statistic-
ally signicant (91.3% vs. 100%, P=0.489). e most frequent oral step-down agents
prescribed were cephalexin and ciprooxacin. e median time to oral step-down was
signicantly lower in the non-BL group (4.39 vs. 3.41days, P=0.038), and the median
duration of therapy in each group was 15days. No patients required therapy escalation
aer oral step-down or had infection-related readmission within 30days of discharge.
Conclusion. e observed clinical success rate of 91.3% remains consistent
with previous studies evaluating oral BL as step-down therapy for Enterobacteriaceae
bloodstream infections. e results of this study support the safety and ecacy of oral
BL as step-down therapy for E.coli bacteremia due to cUTI, although larger studies
may be benecial.
Disclosures. Al l authors: No reported disclosures.
1115. Reducing Broad-Spectrum Antibiotics for Uncomplicated Urinary Tract
Infections: AMultimodal Stewardship Intervention
MaryroseR. Laguio-Vila, MD1; MaryL. Staicu, PharmD2;
Mary LourdesBrundige, PharmD2; Jose Alcantara-Contreras, MD2;
Hongmei Yan g , PhD3; Ebbing Lautenbach, MD, MPH, MSCE4;
Ghinwa Dumyati, MD5; 1Rochester Regional Health, Rochester, New York; 2Rochester
General Hospital, Rochester, New York; 3University of Rochester Medical Center,
Rochester, New York; 4University of Pennsylvania, Philadelphia, New York; 5New
York Rochester Emerging Infections Program at the University of Rochester Medical
Center, Rochester, New York
Session: 136. Antibiotic Stewardship: Urine Cultures
Friday, October 4, 2019: 12:15 PM
Background. Urinary tract infections (UTIs) are the second most common
reason for antibiotics in hospitalized patients, with most receiving broad-spectrum
antibiotics (BSA) regardless of infection severity. e antimicrobial stewardship pro-
gram (ASP) conducted a multimodal stewardship intervention targeting reduction in
one BSA, ceriaxone, and promoted narrow-spectrum antibiotics (NSA) such as cefa-
zolin and cephalexin for uncomplicatedUTIs.
Methods. Phase 1: In February 2018, the ASP created a pocket card (Figure
1) containing (1) a urinary antibiogram outlining the most common urine patho-
gens and their local susceptibility to NSA and (2) NSA guidelines for UTIs with 0–1
systemic inammatory response syndrome (SIRS) criteria. ASP performed a daily
prospective audit with feedback on all new orders of ceriaxone and promoted pre-
scription of NSA. Phase 2: In August 2018, a Best Practice Alert (BPA) in the electronic
medical record (EMR) was designed to interrupt providers ordering ceriaxone with
the indication of a UTI, and prompted NSA prescription instead. Quarterly didactic
sessions on UTI antibiotic use and BPA functionality were done. We compared antibi-
otics usage rates across the 3 study phases (pre-intervention, phase Iand phase II) by
computing rate ratios (RRs) using Poisson regression.
Results. Compared with pre-intervention, phase 1 resulted in a signicant de-
crease in ceriaxone DOT (RR: 1.06, CI: 1.03–1.09, P < 0.001) and ceriaxone orders
for UTI (RR: 1.14, P < 0.001) and an increase in cefazolin DOT (RR: 0.89, P = 0.029)
and orders for UTI (RR; 0.12, P < 0.001). It also resulted in a signicant increase in
cephalexin DOT (RR: 0.92, P = 0.002) and orders for UTI (RR: 0.58, P < 0.001). In
phase 2, an additional signicant reduction in ceriaxone DOT (RR: 1.04, CI: 1.01–
1.08, P = 0.018) and orders for UTI (RR: 1.62, P < 0.001) and an increase in cefazolin
Downloaded from https://academic.oup.com/ofid/article-abstract/6/Supplement_2/S395/5605909 by guest on 24 October 2019