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Background Outpatient parenteral antimicrobial therapy (OPAT) allows for long-course intravenous treatment of infections without lengthy hospital stays. Upon discharge, antimicrobial therapy may be broadened to ertapenem or daptomycin for “ease” of once-daily administration. Patients requiring subsequent readmission should be properly tailored to pre-OPAT regimens to minimize collateral damage and reduce cost. This study assessed the continuation of “ease of administration (EOA) regimens” upon hospital readmission during or immediately following OPAT. Methods This was a single-center, retrospective review of adult patients enrolled in OPAT and discharged between January 1, 2014 and September 30, 2017 on ertapenem or daptomycin for “EOA.” This was defined by the presence of the terms “convenience” or “EOA” in OPAT notes or by broadening of coverage to ertapenem or daptomycin upon OPAT enrollment despite adequate therapy with more narrow-spectrum agents. Patients receiving directed carbapenem or daptomycin therapy prior to OPAT enrollment were excluded. The primary outcome was the percentage of patients readmitted during or within 90 days of their OPAT course and maintained on an “EOA regimen” of antibiotics. Secondary outcomes included inpatient therapy cost, rates of Clostridium difficile infection, and adverse drug reactions. Demographics and outcomes were summarized using descriptive statistics. Results Of the 188 patients receiving an OPAT “EOA regimen,” 71 were readmitted, representing 113 unique readmissions. Patients were mostly male (81%) with a median age of 57 years. “EOA regimens” were continued in 27% of hospital readmissions. The Infectious Diseases team was consulted in 48% of cases, and the Antimicrobial Stewardship Team intervened in 26%, prompting de-escalation in a total of 28% of cases. C. difficile infections and adverse events occurred in 7% and 12% of readmissions respectively. The median drug acquisition cost of inpatient “EOA regimens” was $121 per readmission. Conclusion At our institution, OPAT “EOA regimens” were continued in 27% of hospital readmissions indicating a role for improved indication documentation and antimicrobial stewardship involvement. Disclosures C. McCoy, Merck Inc.: Scientific Advisor, Consulting fee. Allergan: Scientific Advisor, Consulting fee. M. V. Mahoney, Melinta Therapeutics: Consultant, Consulting fee. Cutis Pharma: Consultant, Consulting fee. Tetraphase Pharmaceuticals, Inc.: Consultant, Consulting fee. Roche Diagnostics USA: Consultant, Consulting fee.

Background Approximately 30% of patients at our institution have β-lactam (BL) antibiotic allergies documented in their medical record. This translates to high use of non-β-lactams (NBL) or other structurally dissimilar agents. Patients treated with NBL are three times as likely to experience an adverse effect or be readmitted for infection. BL allergy assessment, re-challenge and de-labeling remain an important target for antimicrobial stewardship (AST). Published protocols have been validated at large teaching institutions with improvements in documentation and the care of patients with labeled allergies, including drug challenge protocols and desensitization for true allergies. At BIDMC, a multidisciplinary committee developed a guidance document to include a series of standard questions, medical record review and appropriate clarifications for the medical record. The guideline also includes recommendations an algorithm for the approach to drug challenge or desensitization. Methods The guideline was launched in September 2016 and this study examined the first 4 months of use. The primary endpoint compared the number of full desensitizations requiring ICU admission, and number of graded/full challenges pre- and post-implementation. Aztreonam, which is structurally dissimilar to other BL, was used as a surrogate marker of avoidance of BL. Results Pre-implementation rates of graded challenges and full desensitizations were equivalent. This was bifurcated by 1,000% within 4 months such that the use of graded challenge was 10 times the desensitization rate (Figure 1). Aztreonam use decreased from a 2.33 patient days of therapy (pDOT) per 1,000 days in September to 1.74 in January (Figure 2). The decrease in utilization was most pronounced on the General Medicine units. Utilization was driven most heavily by patients being treated by the Hematology Oncology Service. No adverse reactions were documented during any post guideline β lactam challenges. Conclusion Introduction of a multidisciplinary guideline by AST and Allergy led to preferred utilization of graded challenge over full ICU desensitization and an overall decrease in aztreonam use. Figure 1 Figure 2 Disclosures All authors: No reported disclosures.

Background The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) recommend computerized decision support at the time of prescribing as an antimicrobial stewardship (AST) tool. Providing antimicrobial indications during prescribing can optimize infection-specific therapy through appropriate antimicrobial selection, dosing, and frequency. The Leapfrog group identifies this as a quality measure for their report card system. At Beth Israel Deaconess Medical Center (BIDMC), indication-based dosing has been incorporated in the computerized provider order entry (CPOE) system since 2006. At BIDMC, valacyclovir is only approved for the treatment of varicella zoster (VZV) infection or prophylaxis of solid organ transplant (SOT) patients at low risk for cytomegalovirus. These indications bypass the need for AST approval. Accuracy validation of the selected indications has not been formally performed. Methods A retrospective chart review was performed in patients prescribed valacyclovir during an 8-month period in 2016. Electronic medical records, laboratory reports, and pharmacy records were reviewed to identify the suspected/confirmed infection. The primary outcome was the concordance rate of selected CPOE valacyclovir indication compared with suspected/confirmed infection at the time of ordering. The secondary outcome was the proportion of valacyclovir use per institutional protocol. Results Overall, 117 patients were included, with a median age of 57.9 years, 51 (43.6%) were male, and 4 (3.4%) were located in an intensive care unit. Fifty-nine orders (50.4%) selected VZV as the indication, followed by 21 orders (17.9%) for SOT prophylaxis. Of orders with any CPOE indication, only 59/101 (58.4%) were concordant with suspected/confirmed infection. Of the valacyclovir orders with a VZV indication, 37 (62.7%) were concordant. Of the orders with SOT prophylaxis indications, 5 (23.8%) were concordant. Furthermore, only 46 orders (39.3%) were per BIDMC-protocol. Conclusion Concordance of CPOE indication selection and suspected/confirmed infection for valacyclovir was low. Using CPOE to grant automatic prospective approval must be monitored and audited for accuracy if employed as an AST tool. Disclosures All authors: No reported disclosures.

Background Solid organ transplant (SOT) patients are at high risk for Clostridium difficile infections (CDI) due to chronic immunosuppression and a propensity to receive antimicrobials. Management of CDI in SOT patients poses unique challenges as this population has disease-altered clinical and laboratory parameters. The objective of this study was to assess concordance between various CDI severity scales and the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA/IDSA) guidelines. Methods This retrospective study included all SOT recipients with a first CDI episode following transplant and time-matched (2:1) to non-SOT patients experiencing first CDI episodes between 2008 and 2016. The primary endpoint was concordance rates of CDI episodes considered mild-moderate or severe/severe-complicated in published CDI scales compared with the SHEA/IDSA guidelines. We also sought to compare the distribution of CDI severity across all scales between SOT and non-SOT patients. Results Overall, 32 SOT patients and 64 non-SOT patients were included. The SOT group had significantly higher leukopenia rates at CDI diagnosis; however, the magnitude of serum creatinine change did not differ between groups. According to the SHEA/IDSA scale, CDI episodes in SOT recipients were categorized as mild-moderate and severe/severe-complicated in 23 (72%) and 9 (28%) patients, respectively. Overall concordance rates among SHEA/IDSA guidelines and other scales ranged from 28% to 72%. Concordance rates were highest for mild-moderate CDI with Belmares and for severe/severe-complicated CDI with ESCMID (Table 1). No scale evenly categorized SOT and non-SOT patients across all severities (Figure 1). Conclusion Severity scales with heavy emphasis on white blood cell counts may not adequately categorize SOT patients. Immunocompromised status may need to be considered on its own when categorizing CDI severity and prescribing therapy. Disclosures C. D. Alonso, Merck: Grant Investigator and Scientific Advisor, Research grant sanofi pasteur: Investigator and Scientific Advisor, Research support GSK: Investigator, Research support; E. B. Hirsch, Merck: Grant Investigator, Grant recipient The Medicines Company: Speaker’s Bureau, Speaker honorarium