Background Telemedicine (TM) programs can be implemented to deliver specialty care through virtual platforms and overcome geographic/resource constraints. Few data exist to describe outcomes associated with TM-based infectious diseases (ID) management. The purpose of this study was to compare outcomes associated with TM and on-site standard of care (SOC) ID consultation after implementation of an antimicrobial stewardship (AMS)-led S. aureus bacteremia (SAB) bundle. Methods A retrospective cohort study was conducted on the effects of a SAB bundle comparing ID consult delivery (SOC or TM) at 10 US hospitals within Atrium Health in adult patients admitted September 2016 through December 2017. Type of ID consult provided was based on admitting hospital; no hospital had both modalities. Bundle components included: (1) ID consult, (2) appropriate antibiotics, (3) repeat blood cultures until clearance, (4) echocardiogram obtainment, and (5) appropriate antibiotic duration. AMS facilitated bundle initiation and compliance. The primary outcome was bundle adherence between groups. Differences in clinical outcomes were also assessed. Results We evaluated 738 patients with SAB (576 with SOC, 162 with TM ID). No differences were observed in overall bundle adherence (SOC 86% vs TM 89%, p = 0.33). Additionally, no significant differences resulted between groups for hospital mortality, 30-day SAB-related readmission, persistent bacteremia, and culture clearance. Groups did not differ in 30-day mortality when controlling for demographics, bacteremia source, and physiological measures with multivariable logistic regression. Conclusion Our findings provide evidence to support effective use of TM ID consultation and AMS-led care bundles for SAB management in resource-limited settings.
BackgroundTelemedicine (TM) programs have been effectively implemented to deliver specialty care through virtual platforms to overcome geographic and resource constraints. Yet, few data exist to describe outcomes associated with TM-based management of patients with infectious diseases (ID). The purpose of this study was to compare adherence and other outcomes associated with TM and on-site (SOC) ID consultation (IDC) implementation strategies of an antimicrobial stewardship (ASP)-led S. aureus bacteremia (SAB) bundle.MethodsWe launched an SAB bundle at 10 acute care hospitals in the metro Charlotte, NC area in September 2016 for adult patients admitted with SAB and conducted a retrospective cohort study using data collected through 2017. Bundle components included (1) mandatory IDC, (2) appropriate antibiotics within 24 hours of S. aureus speciation, (3) repeat blood cultures at least every 72 hours until clearance, (4) obtainment of an echocardiogram, and (5) appropriate duration of intravenous antibiotic therapy based on SAB severity. ASP facilitated bundle initiation and assisted with compliance for all patients. The primary outcome was bundle adherence. Secondary outcomes included time to culture clearance and persistent SAB (i.e., positive blood cultures for >7 days). We used Wilcoxon rank-sum and chi-squared tests to compare outcomes.ResultsWe evaluated 872 patients with SAB during the study interval. After excluding 126 patients (prematurely discharged or died/transitioned to comfort care within 48 hours of S. aureus speciation), we analyzed 583 SOC and 163 TM group patients. There were no differences observed in overall SAB bundle adherence (SOC 86% vs. TM 88%, P = 0.52), or its individual components. No differences were found in time to culture clearance (median days: SOC = 2.9 vs. TM = 2.8, P = 0.96) and persistent SAB (SOC 11% vs. TM 11%, P = 0.77).ConclusionOur findings provide preliminary evidence to support TM-based strategies for IDC and ASP-led care bundles in resource-limited settings. Future analyses will compare mortality and hospital readmission outcomes. Disclosures All authors: No reported disclosures.
Background Background:: Immune modulation in patients with clinical features suggestive of a cytokine release syndrome (CRS) has become a pharmacologic target for potential treatment of COVID-19 and prevention of ARDS. Tocilizumab is an IL-6 receptor blocker FDA-approved for chimeric antigen receptor (CAR) T cell-induced severe or life-threatening CRS. The objective of this study was to describe clinical outcomes associated with tocilizumab compared with those not receiving tocilizumab in critically ill patients with severe COVID-19. Methods Methods: Retrospective case series of 49 adult patients admitted to an intensive care unit with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients receiving tocilizumab were compared with those not receiving tocilizumab. The primary outcome was clinical improvement (decrease in supplemental oxygen requirement, discharge from ICU, or live discharge from hospital). Secondary endpoints included mortality and frequency of extubation. All comparative endpoints were assessed at 2 weeks after ICU admission. Results Results: 49 patients were identified with SARS-CoV-2 who were admitted to an ICU, 16 received tocilizumab. Baseline characteristics were similar; most were African American males with comorbidities such as obesity, cardiovascular disease, and diabetes. The time from symptom onset to positive test and subsequent intubation were similar (4 and 7 days, respectively). 75% received one dose (all received 8 mg/kg). The median time from symptom onset to tocilizumab administration was 11 days. In patients receiving tocilizumab compared with those not receiving tocilizumab, there were similar rates of clinical improvement (44% versus 61%, p=0.27), extubation (31% versus 45%, p=0.60), and mortality (18% versus 19%, p >0.99, respectively). 81% of the tocilizumab group had resolution of fever and 75% had improvement in C-reactive protein levels. Conclusion Conclusion: In this study of patients with progressed disease, outcomes were similar regardless of receipt of tocilizumab. Randomized controlled trials are needed to assess the impact of earlier administration and identify clinical characteristics to assist with selection of appropriate patients who may benefit from tocilizumab. Disclosures All Authors: No reported disclosures
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