Infective endocarditis and vertebral osteomyelitis are rare infections, most commonly caused by methicillin-sensitive Staphylococcus aureus (MSSA). The eustachian valve is an embryological remnant of the inferior vena cava that has the potential to harbor a nidus leading to infective endocarditis. Eustachian valve endocarditis has been documented in the literature on less than 50 occasions and has yet to be documented in the presence of concomitant vertebral osteomyelitis. In this case, we present a 43-year-old African American male presenting with vertebral osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA). Persistent bacteremia prompted the identification of a vegetative growth on a eustachian valve remnant. This case helps mend the gap in the literature by documenting the treatment considerations in a patient with eustachian valve endocarditis in the presence of osteomyelitis caused by MRSA.
Background Outpatient Parenteral Antimicrobial Therapy (OPAT) programs aim to facilitate early discharge and improve patient care; however, rates of readmission remain high. After discharge, safe monitoring and follow-up is logistically heterogenous and prone to error. We aimed to utilize a Six Sigma framework to evaluate our OPAT process and define opportunities for improvement in patient care. Methods A define, measure, analyze, improve, control (DMAIC) approach was used by a multidisciplinary group to evaluate errors and opportunities in the OPAT discharge process (Fig 1). Baseline analysis of 6-months of OPAT discharges revealed an all cause 30-day readmission rate of 19.7%, and less than half of all patients (45%) were seen in the infectious diseases (ID) clinic within 28-days. The group created a process map and identified potential opportunities for error and heterogeneity in the process. A define, measure, analyze, improve, control (DMAIC) approach was used by a multidisciplinary group to evaluate errors and opportunities in the OPAT discharge process Results Process mapping revealed process heterogeneity depending on patient discharge location (Fig 2). Reliability of ordering labs and transporting patients to appointments varied by location (Skilled nursing facility (SNF) versus home infusion, etc.). Furthermore, the OPAT note was not included in the discharge summary and the process was reliant on an ID team member emailing the clinic to request follow-up. An Ishikawa diagram identified numerous factors contributing to OPAT related adverse events (Fig 3). Main opportunities for improvement included (1) the OPAT note, (2) delegation of laboratory ordering for monitoring patient after discharge, (3) patient follow-up scheduling and monitoring, and (4) skilled nursing facility (SNF) communication and expectations. Interventions resulting included working with information technology to update the OPAT note to include appointment dates, attaching OPAT note to discharge summary, and bridging communication and ensuring task completion by delegating certain reliable SNFs as centers of excellence. Process mapping revealed significant process heterogeneity depending on patient discharge location, that the OPAT note was not included in the discharge summary, and the process was heavily reliant on an ID team member emailing the clinic to request follow-up and ensure future laboratory tracking. An Ishikawa diagram identified numerous factors contributing to OPAT related adverse events including numerous system and individual factors Conclusion The DMAIC approach was useful in identifying opportunities to improve transitions of care in patients discharged on OPAT and developing interventions for targeted process improvement. Other centers may use a similar strategy to analyze and improve the care of OPAT patients. Disclosures All Authors: No reported disclosures.
Background The coronavirus disease 2019 (COVID-19) pandemic dramatically affected the delivery of healthcare. Patients discharged on outpatient parenteral antibiotic therapy (OPAT) require clinic follow-up and laboratory monitoring which is a logistical challenge to standardize across discharge locations. We sought to investigate how COVID-19 impacted patients discharged with OPAT at an academic medical center. Primary objectives included 30-day readmission rates and ID clinic follow-up before and during COVID-19. Secondary outcomes included whether suspected infection type, antimicrobial selection and discharge location differed between the two cohorts. Baseline Patient Characteristics & Outcomes between pre-COVID-19 and COVID-19 cohorts Methods Patients discharged on OPAT were evaluated in two 3-month cohorts from Oct-Dec 2019 (pre-COVID-19) and compared to Oct-Dec 2020 (COVID)-19. Demographics, infection type, discharge location, therapy characteristics, and outcomes were compared retrospectively (Fig 1). Statistical analysis was performed using Chi-square and Wilcoxon rank-Sum test with p< 0.05 considered statistically significant. Suspected Infectious Source among the two cohorts Results A total of 316 pre-COVID patients were discharged with OPAT compared to 263 COVID-19 patients. Table 1 shows the comparison of OPAT characteristics between 2019 and 2020. There were significantly more patients discharged home and fewer patients discharged to facilities in COVID-19 group(p=0.001 and p=0.011, respectively). LOS, ID clinic follow-up, and 30-day readmission did not differ between groups. Reasons for readmission were similar (Fig 1). Antimicrobial prescribing was generally similar except for more vancomycin prescribed in the COVID-19 group (12.5% versus 7.3%, p=0.033). Suspected source of infection did not differ between groups (Fig 2), nor did isolation of pseudomonas, MRSA, or drug resistant organisms (Table 2). Conclusion Sources of infection and antimicrobial classes were generally similar despite decrease in elective procedures during a COVID-19 related winter surge. Rates of readmission and clinic follow did not differ, however, patients discharged with OPAT post-COVID were more likely to go home versus a facility. Further analysis of this difference may help determine best practices to facilitate improved monitoring and clinic follow-up among OPAT patients. Disclosures All Authors: No reported disclosures.
Background: Penicillin allergies are frequently reported and are associated with adverse clinical and antimicrobial stewardship outcomes. Allergy delabeling, either by patient history or skin testing and oral challenge can facilitate removal of penicillin allergy label. However, penicillinallergies are often reinstated in the medical record and data is limited about how and why this occurs. In our center, the departments of allergy and infectious diseases utilize an allergist nurse practitioner for penicillin allergy delabeling. We investigated the prevalence of penicillin allergy reinstatement following removal and associated factors thereof. Methods: We performed a retrospective observational study of patients who previously had penicillin allergy removed by the allergist nurse practitioner between August 2020 and May 2021 (250 days). Patients were followed for a minimum of 8 months and up to 16 months after penicillin allergy removal. We then assessed whether the allergy was reinstated. Clinical characteristics were compared between patients with penicillin allergy reinstated and not reinstated using the χ2 and Mann-Whitney U test. The primary end point was prevalence of penicillin allergy reinstatement following removal. Results: During the study period, 81 patients had penicillin allergy removed, but it was later reinstated in 19 patients (23%) (Fig 1). Median time to reinstatement was 94 days. Allergies were reinstated most frequently by nurses (53%) and medical assistants (37%). Reinstatement occurred in both outpatient (53%) and inpatient (47%) settings. In 18 of 19 cases, there was no acknowledgment that a prior assessment had determined the patient was not allergic to penicillin. Only 1 patient experienced a reaction prompting reinstatement of penicillin allergy. Once the allergy was redocumented, it was subsequently mentioned in a median of 17 notes per patient. Comorbidities did not differ between patients with allergy reinstated versus those without (Table 1). Patients with penicillin allergy reinstated were more often originally delabeled via history rather than skin test followed by oral challenge and were more likely to have been readmitted subsequently. Conclusions: Penicillin allergies were redocumented in almost one-quarter of patients, most frequently by a nonphysician team member and without acknowledgement of prior removal. Patients who undergo skin testing may be less likely to continue to report a penicillin allergy to medical staff compared to those whose allergy is removed based on history. Increased interactions with the healthcare system may have contributed to having the allergy reinstated.Funding: NoneDisclosures: None
Neuroleptic malignant syndrome (NMS) is a rare and life-threatening emergency. The condition is largely iatrogenic and is often precipitated by medications such as antipsychotics. First-generation antipsychotics are more likely to cause NMS than second-generation antipsychotics. The literature lacks an objective measure for NMS diagnosis. Instead, the diagnosis relies largely on the recognition of characteristic symptoms in the presence of an inciting medication. Additional challenges exist with concomitant disease processes and toxicities that may distort the clinical picture. Here, we report a case of a 44-year-old Caucasian man who presented with atypical NMS in the setting of quetiapine overdose. The patient remained uncharacteristically afebrile throughout his admission. Although the patient recovered, extended delays in identification and management can contribute to an increased risk of morbidity and mortality.
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