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Background Preliminary data from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia patients indicate that a cytokine storm may increase morbidity and mortality. Tocilizumab (anti-IL-6R) is approved by the Food and Drug Administration for treatment of cytokine storm associated with chimeric antigen receptor T-cell therapy. Here we examined compassionate use of tocilizumab in patients with SARS-CoV-2 pneumonia. Methods We report on a single-center study of tocilizumab in hospitalized patients with SARS-CoV-2 pneumonia. All patients had confirmed SARS-CoV-2 pneumonia and oxygen saturations Results Twenty-seven SARS-CoV-2 pneumonia patients received one 400 mg dose of tocilizumab. Interleukin (IL)-6 was the predominant cytokine detected at tocilizumab treatment. Significant reductions in temperature and CRP were seen post-tocilizumab. However, 4 patients did not show rapid CRP declines, of whom 3 had poorer outcomes. Oxygen and vasopressor requirements diminished over the first week post-tocilizumab. Twenty-two patients required mechanical ventilation; at last follow-up, 16 were extubated. Adverse events and serious adverse events were minimal, but 2 deaths (7.4%) occurred that were felt unrelated to tocilizumab. Conclusions Compared to published reports on the morbidity and mortality associated with SARS-CoV-2, tocilizumab appears to offer benefits in reducing inflammation, oxygen requirements, vasopressor support, and mortality. The rationale for tocilizumab treatment is supported by detection of IL-6 in pathogenic levels in all patients. Additional doses of tocilizumab may be needed for those showing slow declines in CRP. Proof of efficacy awaits randomized, placebo-controlled clinical trials.

“Mid-Term Break” (1966) is one of Seamus Heaney’s (1939–2015) best-known poems, and although criticism has justly focused on biography,1 diction, and tone,2 it has not emphasized the Christian remn...

IntroductionMore than 93,000 cases of coronavirus disease (COVID-19) have been reported worldwide. We describe the epidemiology, clinical course, and virologic characteristics of the first 12 U.S. patients with COVID-19.MethodsWe collected demographic, exposure, and clinical information from 12 patients confirmed by CDC during January 20–February 5, 2020 to have COVID-19. Respiratory, stool, serum, and urine specimens were submitted for SARS-CoV-2 rRT-PCR testing, virus culture, and whole genome sequencing.ResultsAmong the 12 patients, median age was 53 years (range: 21–68); 8 were male, 10 had traveled to China, and two were contacts of patients in this series. Commonly reported signs and symptoms at illness onset were fever (n=7) and cough (n=8). Seven patients were hospitalized with radiographic evidence of pneumonia and demonstrated clinical or laboratory signs of worsening during the second week of illness. Three were treated with the investigational antiviral remdesivir. All patients had SARS-CoV-2 RNA detected in respiratory specimens, typically for 2–3 weeks after illness onset, with lowest rRT-PCR Ct values often detected in the first week. SARS-CoV-2 RNA was detected after reported symptom resolution in seven patients. SARS-CoV-2 was cultured from respiratory specimens, and SARS-CoV-2 RNA was detected in stool from 7/10 patients.ConclusionsIn 12 patients with mild to moderately severe illness, SARS-CoV-2 RNA and viable virus were detected early, and prolonged RNA detection suggests the window for diagnosis is long. Hospitalized patients showed signs of worsening in the second week after illness onset.

Background Recent data has shown a transition to oral (PO) antibiotics (ABX) for definitive treatment of uncomplicated bacteremia has similar efficacy compared to continuation of intravenous (IV) ABX, and reduces hospital length of stay (LOS). The purpose of this study was to evaluate the safety and efficacy of an antimicrobial stewardship pharmacist-driven, IV to PO ABX transition in clinically stable patients with uncomplicated bacteremia, and to determine the impact on hospital LOS. Methods This was a prospective, interventional study with concurrent controls, conducted at Cedars-Sinai Medical Center between November 2019 and April 2020. For patient recruitment, a report of all positive inpatient blood cultures was reviewed daily. For patients meeting study criteria, the treating provider was contacted to recommend an IV to PO ABX transition. The treating provider was responsible for making the final determination on ABX therapy. Patients continuing IV ABX served as the comparator group to those transitioning to PO. The primary outcome of interest was a composite of: 30-day, all-cause mortality, 30-day readmission due to infectious- or ABX-related complications, or 30-day recurrent infection with the same organism recovered. The second outcome of interest was overall hospital LOS and hospital LOS after the definitive ABX regimen was established. Results A total of 117 patients were evaluated; 69 patients met criteria for inclusion in the study (46 PO ABX / 23 IV ABX). Overall, baseline characteristics were similar between the groups. No difference was observed in the 30-day composite outcome (1 in each group), but the median, overall hospital LOS was three days shorter in the PO group. Furthermore, hospital LOS after the definitive ABX regimen was established was four days shorter in the PO group. Based on the differences in hospital LOS observed, the intervention was estimated to have resulted in approximately $819,200 cost-avoidance during the study period. Conclusion Similar to prior studies, our findings support the safety and effectiveness of an IV to PO ABX transition in clinically stable patients with uncomplicated bacteremia. Antimicrobial stewardship pharmacists can be leveraged to facilitate such a transition. Disclosures All Authors: No reported disclosures

In patients with β-lactam allergies, administration of non–β-lactam surgical prophylaxis is associated with increased risk of infection. Although many patients self-report β-lactam allergies, most are unconfirmed or mislabeled. A quality improvement process, utilizing a structured β-lactam allergy tool, was implemented to improve the utilization of preferred β-lactam surgical prophylaxis.

Purpose: To raise awareness of cefotetan-induced hemolytic anemia, a known rare but serious side effect that occurred in 5 patients at our medical center. Summary: Five cases of cefotetan-induced hemolytic anemia, which presented over the period of a single year at our center, are described. In each case, hemolytic anemia was confirmed by testing for the presence of anti-cefotetan antibodies. Each case occurred approximately 1 to 2 weeks following exposure to the drug. All five patients survived. A brief review of drug-induced immune hemolytic anemia (DIIHA) is also discussed. Conclusion: DIIHA may be difficult to distinguish from other causes of hemolytic anemia, but should be included in the differential in patients exposed to medications associated with DIIHA. Once suspected, antibody testing should be performed, and once diagnosed, further exposure should be avoided.

Background As an 886-bed tertiary care hospital with both teaching and private physician groups, Cedars-Sinai Medical Center has a unique opportunity to incorporate antimicrobial stewardship pharmacist (ASP) rounds with both a general medicine teaching service (TS) as well as a non-teaching hospitalist group (NTH). The impact of ASP rounds on antimicrobial (ABX) utilization and notable differences in clinical outcomes associated with both rounding models were evaluated. Methods An ASP was incorporated into existing teaching rounds for TS and disposition planning rounds for NTH. ASP-TS and ASP-NTH rounds both occurred once daily on weekdays with facetime of 3-4 hours per day for TS and 0.5-1 hour per day for NTH. Metrics included ASP recommendations and acceptance rates, total ASP time, ABX utilization, and clinical outcomes. Chi-squared and the Student’s t-test were used as appropriate. Results Between November 2016 to April 2017, ASPs reviewed 3184 NTH patients and 1322 TS patients. More opportunities for ASP intervention were identified with TS (40% vs. 26%, P < 0.001). Overall recommendation acceptance rates were higher for TS compared with NTH (95% vs. 79%, P < 0.001). Total recommendations identified per ASP-hour were higher for NTH vs. TS (1.76 vs. 0.93). ASP recommendations targeting ABX de-escalation, unnecessary use of fluoroquinolones, and treatment of asymptomatic bacteriuria were similar for both groups. Compared with baseline rates, ASP rounds were associated with a significant reduction (-6%, P = 0.01) in ABX days-of-therapy (DOT) for NTH but not for TS (-1%, P = 0.6). Anti-Pseudomonal (PSA) DOT significantly declined in both NTH (-11%, P = 0.04) and TS (-22%, P = 0.02). No significant changes in mortality, length of stay, and 30-day readmission rates were observed for either group. Conclusion ASP rounds identified ample opportunities for improvement in ABX utilization in both NTH and TS models. Rounds were associated with a significant reduction in anti-PSA DOT for both models and a significant reduction in overall ABX DOT for NTH group. Although NTH provided a higher patient volume and allowed for more interventions per ASP-hour compared with the TS model, acceptance rates were lower, which may reflect a shorter amount of time spent on patient discussions. Disclosures All authors: No reported disclosures.

How new computing techniques become adopted by academic and government users is not well understood. The papers and discussion in this session will explore the mix of human, organizational, and technical considerations which confront anyone who hopes to offer and develop the use of innovative computer services.