Background Serious bacterial infections associated with substance use often result in long hospitalizations, premature discharges, and high costs. Out-of-hospital treatment options in people with substance use disorder (SUD) are often limited. Methods We describe a novel multidisciplinary and interprofessional care conference, “OPTIONS-DC,” to identify treatment options agreeable to both patients and providers using the frameworks of harm reduction and patient-centered care. We retrospectively reviewed charts of patients who had an OPTIONS-DC between February 2018 and July 2019 and used content analysis to understand the conferences’ effects on antibiotic treatment options. Results Fifty patients had an OPTIONS-DC during the study window. Forty-two (84%) had some intravenous (IV) substance use and 44 (88%) had an active substance use disorder. Participants’ primary substances included opioids (65%) or methamphetamines (28%). On average, conferences lasted 28 min. OPTIONS-DC providers recommended out-of-hospital antibiotic treatment options for 34 (68%) of patients. OPTIONS-DC recommended first line therapy of IV antibiotics for 35 (70%) patients, long-acting injectable antibiotics for 14 (28%), and oral therapy for 1 (2%). 35 (70%) patients that had an OPTIONS-DC completed an antibiotic course and 6 (12%) left the hospital prematurely. OPTIONS-DC expanded treatment options by exposing and contextualizing SUD, psychosocial risk and protective factors; incorporating patient preferences; and allowing providers to tailor antibiotic and SUD recommendations. Conclusions OPTIONS-DC is a feasible intervention that allows providers to integrate principles of harm reduction and offer patient-centered choices among patients needing prolonged antibiotic treatment.

IntroductionInhaled marijuana has been infrequently identified as a potential risk factor for the development of spontaneous pneumomediastinum (SPM), a rare finding of free air in the mediastinum likely caused by barotrauma during breathing manoeuvres. The mechanism of inhalation drug use is often not ascertained by physicians, thus little is known about how different smoking techniques precipitate pulmonary injury. We aimed to evaluate the frequency of marijuana use in patients with non-traumatic pneumomediastinum over a 12-month period, identifying additional relevant clinical features or risk factors, and determining the extent to which clinicians record smoking techniques.MethodsWe performed a retrospective chart review over a 1-year period, identifying patients presenting to the hospital with a diagnosis of pneumomediastinum in the absence of trauma, malignancy or iatrogenic cause.ResultsWe identified 21 cases, 14 of which (66.7%) were associated with marijuana use, average age was 22.5 years (range 18–30), with male predominance (64.2%). Daily or more use was reported in 50% of cases. Concurrent risk factors including vomiting (57.1%) and coughing (42.9%) were commonly present. The mechanism of smoking was described in only two cases (14.3%).DiscussionInhaled marijuana may be an underappreciated risk factor for the development of SPM, caused by air leakage around the bronchovascular sheaths during successive inhalation through a high-resistance smoking apparatus or forced exhalation against a closed glottis. Physicians should be aware of this association in order to provide appropriate counselling. Further research is needed to direct the safe use of smoking devices and techniques.

Respiratory failure due to SARS-CoV-2 has caused widespread mortality, creating an urgent need for effective treatments and a long-term need for antivirals for future emergent coronaviruses. Pharmacotherapy for respiratory viruses has largely been unsuccessful with the exception of early treatment of influenza viruses, which shortens symptom duration and prevents infection in close contacts. Under the rapidly evolving circumstances of the COVID-19 pandemic, most clinical trials of experimental treatments in the United States have focused on later stages of the disease process. Worldwide, the clinical studies of the most impactful drugs, remdesivir and dexamethasone in ACTT-1, RECOVERY, and Solidarity, have studied hospitalized patients. Less than half of clinical trials in the U.S. have investigated oral agents, and the majority have taken place in hospitals at a disease stage where the viral load is already decreasing. The limited success of treatments for respiratory viruses and the viral dynamics of COVID-19 suggest that an antiviral therapy with the greatest impact against pandemic coronaviruses would be orally administered, well-tolerated, target a highly conserved viral protein or host-coronavirus interaction and could be used effectively throughout the world, including resource-poor settings. We examine the treatment of respiratory viral infections and current clinical trials for COVID-19 to provide a framework for effective antiviral therapy and prevention of future emergent coronaviruses and call attention to the need for continued preclinical drug discovery.

BackgroundInfectious complications in people with substance use disorders (SUD) are rising, and while outpatient parenteral antimicrobial therapy (OPAT) is widely used in the general population, OPAT failure rates in SUD are high. Due to perceived PICC risks and OPAT safety, serious infections in people with SUD at our institution often resulted in hospitalization for the duration of treatment. Prolonged inpatient treatment is difficult to tolerate and increases healthcare costs. Our OPAT and addiction medicine teams initiated multidisciplinary discharge planning conferences (OPTIONS-DC) for inpatients with SUD requiring prolonged antimicrobials. The goal was to prioritize patient preferences regarding OPAT setting while incorporating harm-reduction principles. The goal of this study is to assess the impact and outcomes of the OPTIONS-DC.MethodsWe prospectively recorded comprehensive notes at OPTIONS-DC and retrospectively performed chart review for conferences held from February 2018 to March 2019.We performed a content analysis of OPTIONS-DC notes and patient records to identify ways that OPTIONS-DC modified care plans and prioritized patient preferences.ResultsThirty-one conferences were held during the study period. Twenty-eight patients reported substance use within 90 days, 24 used intravenous substances, 12 were homeless, 24 had a mental health diagnosis, and 20 started medication-assisted treatment during hospitalization (Table 1). For 16 patients the conference altered the definitive treatment plan to align with patient preferences while emphasizing safety, and 13 of those were changed to an outpatient setting. A total of 10 patients had a decreased length of stay, with a total of 238 hospital days saved overall. OPAT was planned at discharge for 15 patients, 11 of whom completed their OPAT course. Overall, 21/31 (68%) completed their recommended antimicrobial course and 3 were lost to follow-up.ConclusionA multidisciplinary conference that prioritizes patient preferences and uses harm reduction strategies to optimize infection treatment plans is feasible and effective. The OPTIONS-DC model has potential to expand treatment options for infections in SUD, reduce hospital days, and may serve as an example for other institutions. Disclosures All authors: No reported disclosures.

BackgroundOutpatient parenteral antimicrobial therapy (OPAT), widely used for serious infections, has high failure rates in people with substances use disorders (SUD)1–2. At our institution, completing therapy in the hospital was previously the best option for high-risk patients; but long hospital stays are often unacceptable to patients and costly. To improve outcomes, our Infectious Diseases division, OPAT program, and Improving Addiction Care Team (IMPACT) developed and implemented a novel multidisciplinary conference (OPTIONS-DC) for inpatients with SUD requiring prolonged antibiotics. This study describes the conference development, tool, and initial experience.MethodsFrom June 2017 to June 2018, diverse stakeholders collaboratively created and implemented a structured conference to discuss treatment options that balance medical efficacy, patient preferences, and feasibility using harm-reduction principles. After 10 months of hospital-wide implementation, we elicited provider feedback and performed a content analysis of OPTIONS-DC notes and patient records to evaluate the impact.ResultsThe goal of conference development was prioritizing patient preferences and engaging multidisciplinary input. One RN facilitates the conference using the tool (Figure 1) to elicit input from the relevant providers. The tool systematically addresses components that may predict treatment success (i.e., working phone) while emphasizing patient preference and harm reduction. The IMPACT social work PICC safety assessment informs risks for IV access. Antibiotic recommendations are not a binary of optimal/suboptimal choices for the infection but options that best fit patient context. The average conference length was 28 minutes (IQR 21). Preliminary data shows good clinical outcomes and savings to inpatient days and cost. Initial feedback suggests the model was positively experienced by medical providers (Figure 2) and supported patient preferences.ConclusionA multidisciplinary patient-centered conference that prioritizes patient preference and uses harm-reduction principles for this high-risk population is practical, effective, and positively experienced by providers. This model may serve as a roadmap for other institutions. Disclosures All authors: No reported disclosures.

BackgroundCurrent Infectious Disease Society of America guidelines recommend anti-methicillin-resistant Staphylococcus aureus(MRSA) agents for treatment of community-acquired pneumonia (CAP) only in specific high-risk patients. There are limited data on duration of vancomycin use that is appropriate in hospitalized patients with CAP. The objective of this study was to evaluate the use of vancomycin for CAP among inpatients.MethodsWe conducted a retrospective cohort study of inpatients at Oregon Health and Science University Hospital from August 1st, 2017 to July 31st, 2018 who received IV vancomycin and had a pneumonia encounter ICD-9 diagnosis code. Patients with hospital or ventilator-associated pneumonia were excluded. Appropriate therapy was defined as empiric therapy with known risk-factors, concordant therapy with no de-escalation option, or concurrent sepsis or febrile neutropenia. Vancomycin appropriateness was assessed based on medical history and microbiology for both empiric and definitive therapy. We characterized patients receiving inappropriate therapy and calculated the proportion of inappropriate days of therapy (DOT).ResultsWe identified 52 patients with CAP who were treated with vancomycin for a median of 2 DOT (Interquartile Range (IQR): 1–3). Approximately 21% (11/52) of patients had risk factors warranting vancomycin empiric therapy and 42% (22/52) had concurrent sepsis. Nine CAP patients received inappropriate courses of vancomycin, median of 1 day (IQR: 1–2.25) of inappropriate therapy. The most common reason for classifying use as inappropriate was a positive culture for organisms other than MRSA. Patients receiving inappropriate therapy were more frequently transferred from another hospital (44% vs. 30%, P = 0.22). Overall, 16% (20/125) of vancomycin DOT were inappropriate.ConclusionIn our study,CAP patients accounted for a small number of pneumonia patients who received vancomycin. The median inappropriate DOT was relatively short, possibly indicating that identification and de-escalation was performed quickly. Further work is required to determine the impact of these findings on patients.Disclosures All authors: No reported disclosures.

BackgroundAssessing appropriateness of hospital antibiotic use is typically a labor-intensive task for antimicrobial stewardship teams and relies heavily on clinician judgement rather than a systematic process. Vancomycin is a frequently used agent that is a common stewardship target. We developed an algorithm to automatically classify the appropriateness of vancomycin days of therapy (DOTs) based upon electronic health record data.MethodsWe constructed a retrospective cohort of Oregon Health and Science University (OHSU) Hospital and Doernbecher Children’s Hospital patients admitted August 1, 2017 to July 31, 2018 receiving vancomycin. Data were collected on demographic, encounter, pharmacy, microbiology, and surgery data. An electronic algorithm was applied to classify vancomycin DOTs as appropriate, inappropriate, or indeterminate. Inappropriate use was defined as any case in which there was an opportunity for de-escalation as identified using microbiology data, ICD-10 codes, and procedure codes.ResultsWe included 4,231 encounters; 493 (12%) were pediatric patients. Our algorithm automatically classified 59%, 3%, and 38% of encounters as having either appropriate, inappropriate, or indeterminate DOTs, respectively. Forty-four percent of all encounters received no more than a 24-hour course of vancomycin and were considered appropriate empiric therapy; half of these were attributed to surgical prophylaxis. Nine percent of all encounters had vancomycin administered within 3 days of a blood, sputum or tissue culture in which either a methicillin-resistant Staphylococcus species or an ampicillin-resistant, vancomycin-susceptible Enterococcus species was isolated and were classified as appropriate. Six percent of all encounters had cultures in which only Gram-negatives, fungi, or yeast were isolated and were therefore considered appropriate in the empiric period (≤48 hours) but inappropriate thereafter.ConclusionAutomated assessments of antibiotic appropriateness could facilitate more informed antimicrobial stewardship initiatives and serve as a valuable stewardship metric. Characterization of indeterminate vancomycin use may inform increased automated classification. Further effort is needed to validate these assessments.Disclosures All authors: No reported disclosures.

Background: Probiotics are protective against Clostridioides difficile infection and antibiotic-associated diarrhea, and they may decrease risk of infections following complex abdominal surgeries. Infectious risks associated with probiotic use are not well described in the literature. We describe probiotic use among patients with bloodstream infections (BSIs) due to organisms typically found in probiotics. Methods: Patients with positive blood cultures with Lactobacillus spp, Saccharomyces spp, and Bifidobacterium spp at our large academic hospital from October 2016 through October 2019 were identified using Theradoc, a clinical surveillance tool. Clinical data and orders for probiotics, including probiotic capsules, probiotic yogurt, and kefir, were extracted from the electronic medical record. Cases were considered distinct if the cultures were collected 7 or more days apart. True infections were defined as positive cultures which were treated with antimicrobials and had provider documentation outlining clinical relevance of culture data. Results: Among 26 distinct episodes of BSI, 16 (62%) were considered true infections. The remaining 10 cases were interpreted as contaminants or of unclear significance. Of the 16 cases representing true infection in 14 patients, 6 (38%) had received probiotics in the hospital in the preceding month. Among these patients, 5 had Lactobacillus bacteremia and had received Lactobacillus capsules, probiotic yogurt, and/or kefir. One patient had Saccharomyces fungemia following receipt of probiotic yogurt and kefir. All 6 patients with BSI possibly related to probiotic use had an antecedent gastrointestinal procedure or surgery within a month of the BSI, and 2 had intra-abdominal abscesses from which the same organism was cultured. Of the 16 true BSIs, 9 occurred in immunocompromised hosts, but antecedent probiotic use was confirmed in only 1 of these cases. Two episodes caused by different organisms occurred within the same month; all other episodes were >60 days apart. Conclusions: In our retrospective review of BSIs with organisms typically found in probiotics over a 3-year period at a large academic hospital, more than one-third of those with clinically relevant BSIs had antecedent probiotic use within the hospital. All patients with infections possibly related to probiotic use had recent gastrointestinal procedures or surgery, raising concern for probiotic use following interventions that increase the risk for gastrointestinal tract leakage or translocation. Further research is necessary to assess the risk of bloodstream infection in postoperative patients treated with probiotics.Funding: NoneDisclosures: None