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Nonspecific respiratory symptoms overlap with coronavirus disease 2019 (COVID-19). Prompt diagnosis of COVID-19 in hospital employees is crucial to prevent nosocomial transmission. Rapid molecular SARS-CoV-2 testing was performed for 115 symptomatic employees. The case positivity rate was 2.6%. Employees with negative tests returned to work after 80 (±28) minutes.

Background The University of Washington Tele-Antimicrobial Stewardship Program (UW-TASP) provides antimicrobial stewardship education and training to rural and critical access hospitals (CAHs) in the United States through collaborative tele-mentoring. In 2021, UW-TASP implemented a pilot stewardship cohort to reduce antibiotic treatment of asymptomatic bacteriuria (ASB). We sought to quantify the overall prevalence of ASB and proportion treated in participating hospitals. Methods Patients undergoing urine testing were identified through local electronic medical records and microbiology data. CAHs adjudicated their own cases and reported demographics, symptoms of urinary tract infection, systemic inflammatory response symptoms (SIRS), location at the time of culture, laboratory results, and antibiotic treatment through a RedCap collection tool. The data form was created and analyzed by UW-TASP faculty. This study was waived by the University of Washington institutional review board. Results Nineteen CAHs in 5 states participated in this pilot. Eight submitted urine analysis and culture data for 417 patients. Seventy-seven percent of patients were female and the median age was 70. The emergency department was the most common culture collection location (274/417, 66%), followed by ambulatory care clinics (111/417, 27%), and nursing facilities (13/417, 3%). SIRS criteria and/or organ dysfunction were present in 149/417 patients (36%). Two hundred sixty patients (62%) had a positive culture with Escherichia coli being the most common implicated organism (167/260, 64%). ASB was identified in 69/260 patients (27%), and antibiotics were prescribed for 53/69 (77%) of those with ASB. Oral antibiotics were prescribed for 311 (75%) patients. Of those, 22% were prescribed a fluoroquinolone. Median treatment duration was 7 days (range, 1-14). Conclusion Although the prevalence of ASB was only 27% among 417 patients, treatment of ASB was high at 77%. High numbers of culture collections from the emergency department and ambulatory care settings identify these locations as future foci for stewardship interventions in CAHs. Low hanging fruit for intervention include reducing unnecessary fluoroquinolone use and reducing duration of antibiotic therapy. Disclosures Chloe Bryson-Cahn, MD, Alaska Airlines: Advisor/Consultant.

Background Critical access hospitals (CAHs) in the United States service nearly one fifth of the US population, predominantly in rural areas. CAHs are required to provide antimicrobial stewardship (AMS) services, however, access to infectious diseases and antimicrobial stewardship expertise is limited. We assessed the feasibility of implementing a tele-AMS intervention in CAHs. Methods We piloted a one-year, biphasic, intensive quality improvement collaborative of self-selected CAHs to address asymptomatic bacteriuria (ASB). In phase 1, we engaged multidisciplinary teams from participating hospitals, facilitated goal-setting, and implemented a monthly curriculum to train local stewards regarding appropriate diagnosis and management of urinary tract infections (UTIs). In phase 2, we focused on quality improvement education and data collection. We discussed stewardship strategies and addressed barriers identified on a one-on-one basis. Results Nineteen CAHs in five states across the Western region participated in this pilot. Nine of 19 attended all 8 monthly didactic sessions. The median number of one-on-one sessions attended per site was 3 (range, 1-4). Eighteen of 19 hospitals set a goal and documented it in a Plan-Do-Study-Act framework. Six CAHs set a goal related to staff and/or patient education, 10 CAHs focused on workflow and processes surrounding identification of UTI including reflex of urine analyses to urine culture, and 2 CAHs set goals to prospectively review cases of ASB treated with antibiotics and provide feedback to prescribers. Commonly encountered barriers included turnaround time for urine culture data, difficulty obtaining data from the electronic medical record, resistance to change among personnel, high staff turnover, limited time and availability to perform stewardship, and short duration of the collaborative. Conclusion We successfully launched a tele-stewardship training program to mentor CAH antimicrobial stewards to identify and manage ASB and use quality improvement tools. A standardized approach to address asymptomatic bacteriuria or other AMS goals are unlikely to be successful in CAHs without significant tailoring to fit specific site and process needs. Disclosures Chloe Bryson-Cahn, MD, Alaska Airlines: Advisor/Consultant.

Asymptomatic bacteriuria (ASB) is common among hospitalized patients and often leads to inappropriate antimicrobial use. Data from critical-access hospitals are underrepresented. To target antimicrobial stewardship efforts, we measured the point prevalence of ASB and detected a high frequency of ASB overtreatment across academic, community, and critical-access hospitals.

Across 20 vaccine breakthrough cases detected at our institution, all 20 (100%) infections were due to variants of concern (VOCs) and had a median Ct of 20.2 (IQR, 17.1–23.3). When compared with 5174 contemporaneous samples sequenced in our laboratory, VOCs were significantly enriched among breakthrough infections (P < .05).

Background Following a meropenem shortage, we implemented a postprescription review with feedback (PPRF) in November 2015 with mandatory infectious disease (ID) consultation for all meropenem and imipenem courses > 72 hours. Providers were made aware of the policy via an electronic alert at the time of ordering. Methods A retrospective study was conducted at the University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC) to evaluate the impact of the policy on antimicrobial consumption and clinical outcomes pre- and postintervention during a 6-year period. Antimicrobial use was tracked using days of therapy (DOT) per 1000 patient-days, and data were analyzed by an interrupted time series. Results There were 4066 and 2552 patients in the pre- and postintervention periods, respectively. Meropenem and imipenem use remained steady until the intervention, when a marked reduction in DOT/1000 patient-days occurred at both hospitals (UWMC: percentage change −72.1% (95% confidence interval [CI] −76.6, −66.9), P < .001; HMC: percentage change −43.6% (95% CI −59.9, −20.7), P = .001). Notably, although the intervention did not address antibiotic use until 72 hours after initiation, there was a significant decline in meropenem and imipenem initiation (“first starts”) in the postintervention period, with a 64.9% reduction (95% CI 58.7, 70.2; P < .001) at UWMC and 44.7% reduction (95% CI 28.1, 57.4; P < .001) at HMC. Conclusions PPRF and mandatory ID consultation for meropenem and imipenem use beyond 72 hours resulted in a significant and sustained reduction in the use of these antibiotics and notably impacted their up-front usage.

Gram-negative bacteremia secondary to focal infection such as skin and soft-tissue infection, pneumonia, pyelonephritis, or urinary tract infection is commonly encountered in hospital care. Current practice guidelines lack sufficient detail to inform evidence-based practices. Specifically, antimicrobial duration, criteria to transition from intravenous to oral step-down therapy, choice of oral antimicrobials, and reassessment of follow-up blood cultures are not addressed. The presence of bacteremia is often used as a justification for a prolonged course of antimicrobial therapy regardless of infection source or clinical response. Antimicrobials are lifesaving but not benign. Prolonged antimicrobial exposure is associated with adverse effects, increased rates of Clostridioides difficile infection, antimicrobial resistance, and longer hospital length of stay. Emerging evidence supports shorter overall duration of antimicrobial treatment and earlier transition to oral agents among patients with uncomplicated Enterobacteriaceae bacteremia who have achieved adequate source control and demonstrated clinical stability and improvement. After appropriate initial treatment with an intravenous antimicrobial, transition to highly bioavailable oral agents should be considered for total treatment duration of 7 days. Routine follow-up blood cultures are not cost-effective and may result in unnecessary healthcare resource utilization and inappropriate use of antimicrobials. Clinicians should incorporate these principles into the management of gram-negative bacteremia in the hospital.

Background: COVID-19 has a widely variable clinical syndrome that is difficult to distinguish from bacterial sepsis, leading to high rates of antibiotic use. Early studies indicate low rates of secondary bacterial infections (SBIs) but have included heterogeneous patient populations. Here, we catalogue all SBIs and antibiotic prescription practices in a population of mechanically ventilated patients with COVID-19 induced acute respiratory distress syndrome (ARDS). Methods: This was a retrospective cohort study of all patients with COVID-19 ARDS requiring mechanical ventilation from 3 Seattle, Washington hospitals in 2020. Data were obtained via electronic and manual review of the electronic medical record. We report the incidence and site of SBIs, mortality, and antibiotics per day using descriptive statistics. Results: We identified 126 patients with COVID-19 induced ARDS during the study period. Of these patients, 61% developed clinical infection confirmed by bacterial culture. Ventilator associated pneumonia was confirmed in 55% of patients, bacteremia in 20%, and urinary tract infection (UTI) in 17%. Staphylococcus aureus was the most commonly isolated bacterial species. A total of 97% of patients received antibiotics during their hospitalization, and patients received nearly one antibiotic per day during their hospital stay. Conclusions: Mechanically ventilated patients with COVID-19 induced ARDS are at high risk for secondary bacterial infections and have extensive antibiotic exposure.

On January 19, 2020, the first case of a patient with coronavirus disease 2019 (COVID-19) in the United States was reported in Washington State. On February 29, 2020, a patient infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) passed away in a hospital in Seattle-King County, the first reported COVID-19-related death in the United States. That same day, a skilled nursing and rehabilitation facility in the county reported that several of its residents tested positive for SARS-CoV-2 and that many staff had symptoms compatible with COVID-19. The University of Washington Medicine health system (UW Medicine), which is based in Seattle-King County and provides quaternary care for the region, was one of several health care organizations called upon to address this growing crisis. What ensued was a series of swiftly enacted decisions and activities at UW Medicine, in partnership with local, state, and national public health agencies, to respond to the COVID-19 pandemic. Tapping into the multipronged mission areas of academic medicine, UW Medicine worked to support the community, innovate in science and clinical practice; lead policy and practice guideline development; and adopt changes as the crisis unfolded. In doing so, health system leaders had to balance their commitments to students, residents and fellows, researchers, faculty, staff, and hospital and health center entities, while ensuring that patients continued to receive cutting-edge, high-quality, safe care. In this Invited Commentary, the authors highlight the work and challenges UW Medicine has faced in responding to the global COVID-19 pandemic.

Two near-identical clinical Streptococcus pyogenes isolates of emm subtype emm43.4 with a pbp2x missense mutation (T553K) were detected. Minimum inhibitory concentrations (MICs) for ampicillin and amoxicillin were 8-fold higher, and the MIC for cefotaxime was 3-fold higher than for near-isogenic control isolates, consistent with a first step in developing β-lactam resistance.

Across 20 vaccine breakthrough cases detected at our institution, all 20 (100%) infections were due to variants of concern (VOC) and had a median Ct of 20.2 (IQR=17.1-23.3). When compared to 5174 contemporaneous samples sequenced in our laboratory, VOC were significantly enriched among breakthrough infections (p < .05).

With the availability of widespread SARS-CoV-2 vaccination, high-throughput quantitative anti-spike serological testing will likely become increasingly important. Here, we investigated the performance characteristics of the recently FDA authorized semi-quantitative anti-spike AdviseDx SARS-CoV-2 IgG II assay compared to the FDA authorized anti-nucleocapsid Abbott Architect SARS-CoV-2 IgG, Roche elecsys Anti-SARS-CoV-2-S, EuroImmun Anti-SARS-CoV-2 ELISA, and GenScript surrogate virus neutralization assays and examined the humoral response associated with vaccination, natural protection, and breakthrough infection. The AdviseDx assay had a clinical sensitivity at 14 days post-symptom onset or 10 days post PCR detection of 95.6% (65/68, 95% CI: 87.8-98.8%) with two discrepant individuals seroconverting shortly thereafter. The AdviseDx assay demonstrated 100% positive percent agreement with the four other assays examined using the same symptom onset or PCR detection cutoffs. Using a recently available WHO International Standard for anti-SARS-CoV-2 antibody, we provide assay unit conversion factors to international units for each of the assays examined. We performed a longitudinal survey of healthy vaccinated individuals, finding median AdviseDx immunoglobulin levels peaked seven weeks post-first vaccine dose at approximately 4,000 IU/mL. Intriguingly, among the five assays examined, there was no significant difference in antigen binding level or neutralizing activity between two seropositive patients protected against SARS-CoV-2 infection in a previously described fishing vessel outbreak and five healthcare workers who experienced vaccine breakthrough of SARS-CoV-2 infection – all with variants of concern. These findings suggest that protection against SARS-CoV-2 infection cannot currently be predicted exclusively using in vitro antibody assays against wildtype SARS-CoV-2 spike. Further work is required to establish protective correlates of protection for SARS-CoV-2 infection.

Background Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one third of this usage is considered unnecessary. In 2019, our institution implemented the MITIGATE Toolkit, endorsed by the Centers for Disease Control and Prevention to reduce inappropriate antibiotic prescribing for viral respiratory infections in emergency and urgent care settings. In February 2020 we identified our first hospitalized patient with SARS-CoV(2). In March, efforts to limit person-to-person contact led to shelter in place orders and substantial reorganization of our healthcare system. During this time we continued to track rates of unnecessary antibiotic prescribing. Methods This was a single center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. We provided monthly individual feedback to urgent care prescribers, (Sep 2019-Mar 2020), primary care, and ED providers (Jan 2020 – Mar 2020) notifying them of their specific rate of unnecessary antibiotic prescribing and labeling them as a top performer or not a top performer compared to their peers. The primary outcome was rate of inappropriate antibiotic prescribing. Results Pre toolkit intervention, 14,398 patient visits met MITIGATE inclusion criteria and 12% received an antibiotic unnecessarily in Jan-April 2019. Post-toolkit intervention, 12,328 patient visits met inclusion criteria and 7% received an antibiotic unnecessarily in Jan-April 2020. In April 2020, patient visits dropped to 10–50% of what they were in March 2020 and April 2019. During this time the unnecessary antibiotic prescribing rate doubled in urgent care to 7.8% from 3.6% the previous month and stayed stable in primary care and the ED at 3.2% and 11.8% respectively in April compared to 4.6% and 10.4% in the previous month. Conclusion Rates of inappropriate antibiotic prescribing were reduced nearly in half from 2019 to 2020 across 3 ambulatory care settings. The increase in prescribing in April seen in urgent care and after providers stopped receiving their monthly feedback is concerning. Many factors may have contributed to this increase, but it raises concerns for increased inappropriate antibacterial usage as a side effect of the SARS-CoV(2) pandemic. Disclosures All Authors: No reported disclosures

Concerns about severe acute respiratory syndrome coronavirus 2 exposure in health care settings may cause patients to delay care. Among 2992 patients testing negative on admission to an academic, 3-hospital system, 8 tested positive during hospitalization or within 14 days postdischarge. Following adjudication of each instance, health care–associated infection incidence ranged from 0.8 to 5.0 cases per 10 000 patient-days.

Background Inappropriate testing for Clostridioides difficile leads to overdiagnosis of C difficile infection (CDI). We determined the effect of a computerized clinical decision support (CCDS) order set on C difficile polymerase chain reaction (PCR) test utilization and clinical outcomes. Methods This study is an interrupted time series analysis comparing C difficile PCR test utilization, hospital-onset CDI (HO-CDI) rates, and clinical outcomes before and after implementation of a CCDS order set at 2 academic medical centers: University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC). Results Compared with the 20-month preintervention period, during the 12-month postimplementation of the CCDS order set, there was an immediate and sustained reduction in C difficile PCR test utilization rates at both hospitals (HMC, −28.2% [95% confidence interval {CI}, −43.0% to −9.4%], P = .005; UWMC, −27.4%, [95% CI, −37.5% to −15.6%], P Conclusions Computerized clinical decision support tools can improve C difficile diagnostic test stewardship without causing harm. Additional studies are needed to identify key elements of CCDS tools to further optimize C difficile testing and assess their effect on adverse clinical outcomes.

STUDY DESIGN Retrospective hospital-registry study. OBJECTIVE To characterize the microbial epidemiology of surgical site infection (SSI) in spinal fusion surgery and the burden of resistance to standard surgical antibiotic prophylaxis. SUMMARY OF BACKGROUND DATA SSI persists as a leading complication of spinal fusion surgery despite the growth of enhanced recovery programs and improvements in other measures of surgical quality. Improved understandings of SSI microbiology and common mechanisms of failure for current prevention strategies are required to inform the development of novel approaches to prevention relevant to modern surgical practice. METHODS Spinal fusion cases performed at a single referral center between January 2011 and June 2019 were reviewed and SSI cases meeting National Healthcare Safety Network criteria were identified. Using microbiologic and procedural data from each case, we analyzed the anatomic distribution of pathogens, their differential time to presentation, and correlation with methicillin-resistant Staphylococcus aureus screening results. Susceptibility of isolates cultured from each infection were compared with the spectrum of surgical antibiotic prophylaxis administered during the index procedure on a per-case basis. Susceptibility to alternate prophylactic agents was also modeled. RESULTS Among 6727 cases, 351 infections occurred within 90 days. An anatomic gradient in the microbiology of SSI was observed across the length of the back, transitioning from cutaneous (gram-positive) flora in the cervical spine to enteric (gram-negative/anaerobic) flora in the lumbosacral region (correlation coefficient 0.94, P

The emergence of coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 (SC2) virus, in late December 2019 has placed an overwhelming strain on healthcare institutions nationwide. The modern healthcare system has never dealt with a pandemic of this magnitude, the ramifications of which will undoubtedly lead to lasting changes in policy and protocol development for viral testing guidelines, personal protective equipment (PPE), surgical scheduling, and residency education and training. The State of Washington (WA) had the first reported case and death related to COVID 19 in the United States (US). Oral and maxillofacial surgeons are at a unique risk of exposure to SC2 and developing COVID-19 due to our proximity of working in and around the oro- and nasopharynx. This article summarizes the evolution of COVID-19 guidelines in four key areas: 1. preoperative SARS-CoV-2 (SC2) testing, 2. personal protective equipment (PPE) stewardship, 3. surgical scheduling guidelines, and 4. resident education and training for oral and maxillofacial surgery (OMS) at the University of Washington, Seattle, WA.

Background Healthcare workers (HCWs) who serve on the front lines of the coronavirus disease 2019 (COVID-19) pandemic have been at increased risk for infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in some settings. Healthcare-acquired infection has been reported in similar epidemics, but there are limited data on the prevalence of COVID-19 among HCWs and their associated clinical outcomes in the United States. Methods We established 2 high-throughput employee testing centers in Seattle, Washington, with drive-through and walk-through options for symptomatic employees in the University of Washington Medicine system and its affiliated organizations. Using data from these testing centers, we report the prevalence of SARS-CoV-2 infection among symptomatic employees and describe the clinical characteristics and outcomes among employees with COVID-19. Results Between 12 March 2020 and 23 April 2020, 3477 symptomatic employees were tested for COVID-19 at 2 employee testing centers; 185 (5.3%) employees tested positive for COVID-19. The prevalence of SARS-CoV-2 was similar when comparing frontline HCWs (5.2%) with nonfrontline staff (5.5%). Among 174 positive employees reached for follow-up at least 14 days after diagnosis, 6 reported COVID-related hospitalization; all recovered. Conclusions During the study period, we observed that the prevalence of positive SARS-CoV-2 tests among symptomatic HCWs was comparable to that of symptomatic nonfrontline staff. Reliable and rapid access to testing for employees is essential to preserve the health, safety, and availability of the healthcare workforce during this pandemic and to facilitate the rapid return of SARS-CoV-2–negative employees to work.

BackgroundSARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) testing remains the cornerstone of laboratory-based identification of patients with COVID-19. As the availability and speed of SARS-CoV-2 testing platforms improve, results are increasingly relied upon to inform critical decisions related to therapy, use of personal protective equipment, and workforce readiness. However, early reports of RT-PCR test performance have left clinicians and the public with concerns regarding the reliability of this predominant testing modality and the interpretation of negative results. In this work, two independent research teams report the frequency of discordant SARS-CoV-2 test results among initially negative, repeatedly tested patients in regions of the United States with early community transmission and access to testing.MethodsAll patients at the University of Washington (UW) and Stanford Health Care undergoing initial testing by nasopharyngeal (NP) swab between March 2nd and April 7th, 2020 were included. SARS-CoV-2 RT-PCR was performed targeting the N, RdRp, S, and E genes and ORF1ab, using a combination of Emergency Use Authorization laboratory-developed tests and commercial assays. Results through April 14th were extracted to allow for a complete 7-day observation period and an additional day for reporting.ResultsA total of 23,126 SARS-CoV-2 RT-PCR tests (10,583 UW, 12,543 Stanford) were performed in 20,912 eligible patients (8,977 UW, 11,935 Stanford) undergoing initial testing by NP swab; 626 initially test-negative patients were re-tested within 7 days. Among this group, repeat testing within 7 days yielded a positive result in 3.5% (4.3% UW, 2.8% Stanford) of cases, suggesting an initial false negative RT-PCR result; the majority (96.5%) of patients with an initial negative result who warranted reevaluation for any reason remained negative on all subsequent tests performed within this window.ConclusionsTwo independent research teams report the similar finding that, among initially negative patients subjected to repeat SARS-CoV-2 RT-PCR testing, the occurrence of a newly positive result within 7 days is uncommon. These observations suggest that false negative results at the time of initial presentation do occur, but potentially at a lower frequency than is currently believed. Although it is not possible to infer the clinical sensitivity of NP SARS-CoV-2 RT-PCR testing using these data, they may be used in combination with other reports to guide the use and interpretation of this common testing modality.

Background β-Hemolytic streptococci are frequently implicated in necrotizing soft-tissue infections (NSTIs). Clindamycin administration may improve outcomes in patients with serious streptococcal infections. However, clindamycin resistance is growing worldwide, and resistance patterns in NSTIs and their impact on outcomes are unknown. Methods Between 2015 and 2018, patients with NSTI at a quaternary referral center were followed up for the outcomes of death, limb loss, and streptococcal toxic shock syndrome. Surgical wound cultures and resistance data were obtained within 48 hours of admission as part of routine care. Risk ratios for the association between these outcomes and the presence of β-hemolytic streptococci or clindamycin-resistant β-hemolytic streptococci were calculated using log-binomial regression, controlling for age, transfer status, and injection drug use–related etiology. Results Of 445 NSTIs identified, 85% had surgical wound cultures within 48 hours of admission. β-Hemolytic streptococci grew in 31%, and clindamycin resistance was observed in 31% of cultures. The presence of β-hemolytic streptococci was associated with greater risk of amputation (risk ratio, 1.80; 95% confidence interval, 1.07–3.01), as was the presence of clindamycin resistance among β-hemolytic streptococci infections (1.86; 1.10–3.16). Conclusions β-Hemolytic streptococci are highly prevalent in NSTIs, and in our population clindamycin resistance was more common than previously described. Greater risk of limb loss among patients with β-hemolytic streptococci—particularly clindamycin-resistant strains—may portend a more locally aggressive disease process or may represent preexisting patient characteristics that predispose to both infection and limb loss. Regardless, these findings may inform antibiotic selection and surgical management to maximize the potential for limb salvage.

Background Inappropriate testing for Clostridioides difficile leads to overdiagnosis of C difficile infection (CDI). We determined the effect of a computerized clinical decision support (CCDS) order set on C difficile polymerase chain reaction (PCR) test utilization and clinical outcomes. Methods This study is an interrupted time series analysis comparing C difficile PCR test utilization, hospital-onset CDI (HO-CDI) rates, and clinical outcomes before and after implementation of a CCDS order set at 2 academic medical centers: University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC). Results Compared with the 20-month preintervention period, during the 12-month postimplementation of the CCDS order set, there was an immediate and sustained reduction in C difficile PCR test utilization rates at both hospitals (HMC, −28.2% [95% confidence interval {CI}, −43.0% to −9.4%], P = .005; UWMC, −27.4%, [95% CI, −37.5% to −15.6%], P, Implementation of a computerized clinical decision support (CCDS) order set significantly reduced C difficile PCR test utilization rates and was not associated with an increase in severe CDI or CDI-related complications including ICU transfer, 30-day mortality, and toxic megacolon.

Background The Infectious Diseases Society of America (IDSA) has supported the development of the Core and Advanced Antimicrobial Stewardship (AS) Curricula for fellows to ensure the future ID workforce is effectively prepared to practice, participate in and lead AS efforts in health care institutions. The Core AS Curriculum is currently available; the Advanced AS Curriculum pilot will begin July, 2020. Methods IDSA formed the AS Curriculum Workgroup, comprised of leaders in AS and medical education from institutions across the country, to lead the AS Curricula development process. The workgroup conducted two surveys of ID Fellowship Program Directors, one in 2016 for the core curriculum and a second in 2018 for the advanced curriculum, to assess existing AS educational resources and determine needs for additional AS educational and evaluation resources. The workgroup used the evaluation data to inform the content, delivery methods, and assessment tools for the curricula. The Core AS Curriculum is designed to provide fellows foundational knowledge and skills in AS. The Advanced AS Curriculum is designed to provide fellows the knowledge and skills to become leaders in AS. The Core AS Curriculum was piloted by 56 ID Fellowship Programs in 2018 and then made broadly available via IDSA Academy in 2019. Pilot data will be used to improve future iterations of the curriculum. The Advanced AS Curriculum pilot will begin in 2020 and will be broadly available in 2021. Results The curricular packages contain a variety of training resources including eLearning modules, lectures slides, case-based questions, videos, reading materials, pocket cards, group-based learning, role play exercises and simulations. The modules can be taught by faculty to fellows or conducted as a self-directed learning experience. Program directors and fellows who participated in the Core AS Curriculum pilot reported that their fellowship program was significantly more effective in teaching multiple key stewardship content areas (Table). Table. Conclusion Evaluation data from programs who piloted the Core AS Curriculum indicate that this blended learning experience is an effective method for teaching AS and in providing educational and assessment tools for ID fellowship programs. The Advanced AS Curriculum will be similarly evaluated. Disclosures Julie Ann Justo, PharmD, MS, BCPS-AQ ID, bioMerieux (Speaker’s Bureau)TRC Healthcare (Speaker’s Bureau)

Background In an effort to support stewardship endeavors, the MITIGATE (a Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings) Toolkit was published in 2018, aiming to reduce unnecessary antibiotics for viral respiratory tract infections (RTIs). At the University of Washington, we have incorporated strategies from this toolkit at our urgent care clinics. This study aims to address solutions to some of the challenges we experienced. Challenges and Solutions Methods This was a retrospective observational study conducted at Valley Medical Center (Sept 2019-Mar 2020) and the University of Washington (Jan 2019-Feb 2020) urgent care clinics. Patients were identified through ICD-10 diagnosis codes included in the MITIGATE toolkit. The primary outcome was identifying challenges and solutions developed during this process. Results We encountered five challenges during our roll-out of MITIGATE. First, using both ICD-9 and ICD-10 codes can lead to inaccurate data collection. Second, technical support for coding a complex data set is essential and should be accounted for prior to beginning stewardship interventions of this scale. Third, unintentional incorrect diagnosis selection was common and may require reeducation of prescribers on proper selection. Fourth, focusing on singular issues rather than multiple outcomes is more feasible and can offer several opportunities for stewardship interventions. Lastly, changing prescribing behavior can cause unintended tension during implementation. Modifying benchmarks measured, allowing for bi-directional feedback, and identifying provider champions can help maintain open communication. Conclusion Resources such as the MITIGATE toolkit are helpful to implement standardized data driven stewardship interventions. We have experienced some challenges including a complex data build, errors with diagnostic coding, providing constructive feedback while maintaining positive stewardship relationships, and choosing feasible outcomes to measure. We present solutions to these challenges with the aim to provide guidance to those who are considering using this toolkit for outpatient stewardship interventions. Disclosures All Authors: No reported disclosures

Background In an effort to combat antimicrobial resistance and adverse drug events, The Joint Commission mandated expansion of antimicrobial stewardship programs into ambulatory healthcare settings Jan 2020. The most common diagnoses resulting in inappropriate antimicrobial prescribing are respiratory infections. This study aimed to assess the rate of antibiotic prescribing for viral respiratory tract infections within six urgent care clinics affiliated with University of Washington Medicine health system in Seattle, WA. Methods This was a retrospective observational study from Jan 2019-Feb 2020. We used the MITIGATE toolkit; a resource that meets CDC’s core elements for outpatient stewardship. Patients were identified based upon pre-specified ICD-10 codes for viral respiratory infections. The primary outcome was the rate of unnecessary antimicrobial prescriptions for acute viral respiratory infections. Secondary outcomes evaluated inappropriate prescribing practices based on antibiotic selection, diagnosis, and age. Results Of 7,313 patients (6078 adults and 1235 pediatric) included, 23% were inappropriately prescribed antibiotics. The most common antibiotics inappropriately prescribed were azithromycin (62%), amoxicillin (13%), and doxycycline (13%). Fluoroquinolone (FQ) utilization was low (2%). Bronchitis (61%) and nonsuppurative otitis media (NSOM) (24%) were the most common viral diagnoses for which antibiotics were prescribed. Overall, unnecessary prescribing was lower in pediatrics than adults at 13% and 25%, respectively (p< 0.001). Adults were more often prescribed antibiotics inappropriately for bronchitis and NSOM compared to pediatrics (p=0.0013). Conclusion Inappropriate prescribing practices across six urgent care clinics varied based upon age and diagnosis. Azithromycin is most often inappropriately prescribed but the low rate of FQ prescribing is encouraging. The lower rate of unnecessary prescribing in pediatrics is promising although there is room for improvement as 1 in 8 children were unnecessarily prescribed antibiotics. These findings support the need for antibiotic stewardship in the outpatient setting, targeting areas for azithromycin use and therapeutic management of bronchitis. Disclosures All Authors: No reported disclosures

Background Following a meropenem shortage, we implemented a post-prescription review with feedback (PPRF) in November 2015 with mandatory infectious disease (ID) consultation for all meropenem and imipenem courses > 72 hours. Providers were made aware of the policy via an electronic alert at the time of ordering. Methods A retrospective study was conducted at the University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC) to evaluate the impact of the policy on antimicrobial consumption and clinical outcomes pre- and post-intervention during a 6-year period. Antimicrobial use was tracked using days of therapy (DOT) per 1,000 patient-days, and data were analyzed by an interrupted time series. Results There were 4,066 and 2,552 patients in the pre- and post-intervention periods, respectively. Meropenem and imipenem use remained steady until the intervention, when a marked reduction in DOT/1,000 patient-days occurred at both hospitals (UWMC: percentage change -72.1%, (95% CI -76.6, -66.9), P < 0.001; HMC: percentage change -43.6%, (95% CI -59.9, -20.7), P = 0.001). Notably, although the intervention did not address antibiotic use until 72 hours after initiation, there was a significant decline in meropenem and imipenem initiation (“first starts”) in the post-intervention period, with a 64.9% reduction (95% CI 58.7, 70.2; P < 0.001) at UWMC and 44.7% reduction (95% CI 28.1, 57.4; P < 0.001) at HMC. Meropenem and Imipenem DOT (January 2013 – November 2019) Conclusion Mandatory ID consultation and PPRF for meropenem and imipenem beyond 72 hours resulted in a significant and sustained reduction in the use of these antibiotics and notably impacted their up-front usage. Disclosures All Authors: No reported disclosures

We retrospectively evaluated off-label use of dalbavancin as secondary therapy in 32 patients with serious Staphylococcus aureus infections (endocarditis, osteomyelitis, septic thrombophlebitis, epidural infection) who were also persons who use drugs. The majority of patients (56%) had a clinical response to treatment. Only 1 patient who completed the intended dalbavancin course experienced a treatment failure.

Background Critical access hospitals (CAH), defined as those with 25 or fewer beds and/or located in rural settings, may have difficulty implementing core elements of antimicrobial stewardship (CES) due to limited human resources, expertise, and funding. A 2015 National Healthcare Safety Network (NHSN) hospital survey found only 26% of CAH reported implementing all 7 CES compared with 50% of larger hospitals across the United States. The University of Washington Tele-Antimicrobial Stewardship Program (UW TASP) was developed through partnership with the University of Washington for hospitals lacking stewardship resources. The state department of health (DOH) provided funding to allow CAH to participate. Methods In January 2017, CAH were recruited to join UW TASP and participate in weekly 60 minute audiovisual conference calls led by an interdisciplinary team of infectious diseases physicians, pharmacists and microbiologists. Each session included a 15-minute didactic on stewardship topics followed by a discussion of case studies presented by participating hospitals. UW TASP faculty visited CAH to foster a collegial relationship between teams. Using hospital-reported metrics from the NHSN hospital survey reported in year 2016–2018 for years 2015–2017, we compared CES implementation by CAH participating in UW TASP (TASP CAH) in 2017 (n = 17) to those not participating (non-TASP CAH) (n = 22). Results TASP CAH reported increased implementation of all 7 CES from 29% (2015) to 59% (2016) before joining TASP to 76% (2017) after joining TASP (Figure 1). Non-TASP CAH reported implementation increased from 32% (2015) to 45% (2016) to 59% (2017). By the end of 2017, TASP CAH also succeeded in implementing individual CES to a greater degree than did non-TASP CAH (Table 1). Conclusion TASP CAH reported more successful implementation of CES than did non-TASP CAH. Improved CES implementation in TASP CAH may in part be due to differences in baseline hospital characteristics; however, expertise and support provided by UW TASP likely contributed. The use of telehealth mentoring increased antimicrobial stewardship in this resource-limited setting. Disclosures All authors: No reported disclosures.

Background Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one-third of this usage is considered unnecessary. Multiple tools have emerged to evaluate antibiotic prescribing in ambulatory settings. The toolkits, MITIGATE and Choosing Wisely, have been funded by the Centers for Disease Control and Prevention and promoted by the American Board of Internal Medicine, respectively, but use different reporting criteria. Notably, the target rate of antibiotic prescribing in the MITIGATE framework is zero, whereas the target rate for Choosing Wisely is not zero because it includes diagnoses for which an antibiotic may be appropriate. We compared both to evaluate prescribing in primary care and specialty clinics, urgent care, and the emergency department. Methods This was a single-center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. The primary outcome was rate of inappropriate antibiotic prescribing overall and in each of the individual settings. Results Between March 2018 and April 2019, 42,650 patient visits met MITIGATE inclusion criteria and 11% received an antibiotic unnecessarily. In the same time-period, 23,366 patient visits met Choosing Wisely inclusion criteria and 17% received an antibiotic unnecessarily. Within the MITIGATE framework, inappropriate prescribing was highest in the ED (17%), followed by primary care (12%), urgent care (10%), and specialty care (5%). Choosing Wisely, inappropriate prescribing was highest in primary care (23%), followed by urgent care (15%), and specialty care (8%). The ED was not included in the Choosing Wisely technical specifications. The top coded diagnosis in both frameworks was acute respiratory infection, unspecified. Conclusion Rates of inappropriate antibiotic prescribing varied widely depending upon the toolkit used. Inappropriate antibiotic prescribing in primary care by Choosing Wisely framework was double that of MITIGATE. Careful consideration of the differences and goals of using these toolkits is needed both on the local level for individual provider feedback and more broadly, when comparing prescribing rates between institutions. Disclosures All authors: No reported disclosures.

Background Serious staphylococcal infections require prolonged courses of intravenous (IV) antibiotics. Weekly IV dalbavancin is an alternative to more frequent IV antimicrobial dosing for homeless patients or persons who inject drugs (PWID), for whom creating a treatment plan can be challenging. We examined the clinical outcomes in patients who were treated with dalbavancin compared with a similar population treated with alternative antibiotics. Methods We identified 18 patients who received dalbavancin from June 1, 2015 to December 31, 2016 using pharmacy records and 89 patients receiving IV antibiotics for similar infections treated at Harborview Medical Center from January 1, 2015 to May 31, 2015, before dalbavancin was available. Medical records were reviewed, and patient demographics, length of stay (LOS), readmission, and outcomes were abstracted using REDCap, linked to the University of Washington’s Clinical Data Repository. Results Basic demographics in Table 1. The types of infections are in Figure 1. Clinical cure rates were similar between the two groups (Figure 2) although 21% and 28% of the patients were lost to follow-up in the pre and post dalbavancin period. Among the subgroup of PWID, those who received dalbavancin had higher rates of clinical cure (64.7% vs. 29.4%, P = 0.01), a trend toward decreased LOS (11.4 ± 5.8 vs. 20.2 ± 15.1 days, P = 0.04), and fewer 30-day readmissions (0% vs. 29.4%, P = 0.02) (Figure 2). Fewer PWID in the dalbavancin group were lost to follow-up (23.5% vs. 70.6%). Conclusion Patients treated with dalbavancin had similar outcomes compared with patients treated in the pre-dalbavancin time period. Among PWID, dalbavancin use led to significantly improved outcomes including a higher clinical cure rate, lower readmission rate, and shorter hospital LOS, which offset the cost of the drug. Dalbavancin is an option for the treatment of serious staphylococcal infections in selected patients. Disclosures All authors: No reported disclosures.

Importance Identifying infectious causes of subacute or chronic meningitis can be challenging. Enhanced, unbiased diagnostic approaches are needed. Objective To present a case series of patients with diagnostically challenging subacute or chronic meningitis using metagenomic next-generation sequencing (mNGS) of cerebrospinal fluid (CSF) supported by a statistical framework generated from mNGS of control samples from the environment and from patients who were noninfectious. Design, Setting, and Participants In this case series, mNGS data obtained from the CSF of 94 patients with noninfectious neuroinflammatory disorders and from 24 water and reagent control samples were used to develop and implement a weighted scoring metric based onzscores at the species and genus levels for both nucleotide and protein alignments to prioritize and rank the mNGS results. Total RNA was extracted for mNGS from the CSF of 7 participants with subacute or chronic meningitis who were recruited between September 2013 and March 2017 as part of a multicenter study of mNGS pathogen discovery among patients with suspected neuroinflammatory conditions. The neurologic infections identified by mNGS in these 7 participants represented a diverse array of pathogens. The patients were referred from the University of California, San Francisco Medical Center (n = 2), Zuckerberg San Francisco General Hospital and Trauma Center (n = 2), Cleveland Clinic (n = 1), University of Washington (n = 1), and Kaiser Permanente (n = 1). A weightedzscore was used to filter out environmental contaminants and facilitate efficient data triage and analysis. Main Outcomes and Measures Pathogens identified by mNGS and the ability of a statistical model to prioritize, rank, and simplify mNGS results. Results The 7 participants ranged in age from 10 to 55 years, and 3 (43%) were female. A parasitic worm (Taenia solium, in 2 participants), a virus (HIV-1), and 4 fungi (Cryptococcus neoformans,Aspergillus oryzae,Histoplasma capsulatum, andCandida dubliniensis) were identified among the 7 participants by using mNGS. Evaluating mNGS data with a weightedzscore–based scoring algorithm reduced the reported microbial taxa by a mean of 87% (range, 41%-99%) when taxa with a combined score of 0 or less were removed, effectively separating bona fide pathogen sequences from spurious environmental sequences so that, in each case, the causative pathogen was found within the top 2 scoring microbes identified using the algorithm. Conclusions and Relevance Diverse microbial pathogens were identified by mNGS in the CSF of patients with diagnostically challenging subacute or chronic meningitis, including a case of subarachnoid neurocysticercosis that defied diagnosis for 1 year, the first reported case of CNS vasculitis caused byAspergillus oryzae, and the fourth reported case ofC dubliniensismeningitis. Prioritizing metagenomic data with a scoring algorithm greatly clarified data interpretation and highlighted the problem of attributing biological significance to organisms present in control samples used for metagenomic sequencing studies.

Cause-of-death data for many developing countries are not available. Information on deaths in hospital by cause is available in many low- and middle-income countries but is not a representative sample of deaths in the population. We propose a method to estimate population cause-specific mortality fractions (CSMFs) using data already collected in many middle-income and some low-income developing nations, yet rarely used: in-hospital death records.For a given cause of death, a community's hospital deaths are equal to total community deaths multiplied by the proportion of deaths occurring in hospital. If we can estimate the proportion dying in hospital, we can estimate the proportion dying in the population using deaths in hospital. We propose to estimate the proportion of deaths for an age, sex, and cause group that die in hospital from the subset of the population where vital registration systems function or from another population. We evaluated our method using nearly complete vital registration (VR) data from Mexico 1998-2005, which records whether a death occurred in a hospital. In this validation test, we used 45 disease categories. We validated our method in two ways: nationally and between communities. First, we investigated how the method's accuracy changes as we decrease the amount of Mexican VR used to estimate the proportion of each age, sex, and cause group dying in hospital. Decreasing VR data used for this first step from 100% to 9% produces only a 12% maximum relative error between estimated and true CSMFs. Even if Mexico collected full VR information only in its capital city with 9% of its population, our estimation method would produce an average relative error in CSMFs across the 45 causes of just over 10%. Second, we used VR data for the capital zone (Distrito Federal and Estado de Mexico) and estimated CSMFs for the three lowest-development states. Our estimation method gave an average relative error of 20%, 23%, and 31% for Guerrero, Chiapas, and Oaxaca, respectively.Where accurate International Classification of Diseases (ICD)-coded cause-of-death data are available for deaths in hospital and for VR covering a subset of the population, we demonstrated that population CSMFs can be estimated with low average error. In addition, we showed in the case of Mexico that this method can substantially reduce error from biased hospital data, even when applied to areas with widely different levels of development. For countries with ICD-coded deaths in hospital, this method potentially allows the use of existing data to inform health policy.

Since 2001, Mexico has been designing, legislating, and implementing a major health-system reform. A key component was the creation of Seguro Popular, which is intended to expand insurance coverage over seven years to uninsured people, nearly half the total population at the start of 2001. The reform included five actions: legislation of entitlement per family affiliated which, with full implementation, will increase public spending on health by 0.8-1.0% of gross domestic product; creation of explicit benefits packages; allocation of monies to decentralised state ministries of health in proportion to number of families affiliated; division of federal resources flowing to states into separate funds for personal and non-personal health services; and creation of a fund to protect families against catastrophic health expenditures. Using the WHO health-systems framework, a wide range of datasets to assess the effect of this reform on different dimensions of the health system was used. Key findings include: affiliation is preferentially reaching the poor and the marginalised communities; federal non-social security expenditure in real per-head terms increased by 38% from 2000 to 2005; equity of public-health expenditure across states improved; Seguro Popular affilates used more inpatient and outpatient services than uninsured people; effective coverage of 11 interventions has improved between 2000 and 2005-06; inequalities in effective coverage across states and wealth deciles has decreased over this period; catastrophic expenditures for Seguro Popular affiliates are lower than for uninsured people even though use of services has increased. We present some lessons for Mexico based on this interim evaluation and explore implications for other countries considering health reforms.

Summary Absence of financial protection in health is a recently diagnosed "disease" of health systems. The most obvious symptom is that families face economic ruin and poverty as a consequence of financing their health care. Mexico was one of the first countries to diagnose the problem, attribute it to lack of financial protection, and propose systemic therapy through health reform. In this article we assess how Mexico turned evidence on catastrophic and impoverishing health spending into a catalyst for institutional renovation through the reform that created Seguro Popular (Popular Health Insurance). We present 15-year trends on the evolution of catastrophic and impoverishing health spending, including evidence on how the situation is improving. The results of the Mexican experience suggest an important role for the organisation and financing of the health system in reducing impoverishment and protecting households during periods of individual and collective financial crisis.

Absence of financial protection in health is a recently diagnosed “disease” of health systems. The most obvious symptom is that families face economic ruin and poverty as a consequence of financing their health care. Mexico was one of the first countries to diagnose the problem, attribute it to lack of financial protection, and propose systemic therapy through health reform. In this article we assess how Mexico turned evidence on catastrophic and impoverishing health spending into a catalyst for institutional renovation through the reform that created Seguro Popular de Salud (Popular Health Insurance). We present 15-year trends on the evolution of catastrophic and impoverishing health spending, including evidence on how the situation is improving. The results of the Mexican experience suggest an important role for the organisation and financing of the health system in reducing impoverishment and protecting households during periods of individual and collective financial crisis.