Objectives: To address the importation of multi-drug-resistant organisms (MDROs) when a colonized or infected patient is transferred from another VA facility, the Veterans Health Administration (VHA) launched the Inpatient Pathogen Tracker (IPT) in 2020. IPT tracks MDRO-infected/colonized patients and alerts MDRO Program Coordinators (MPCs) and Infection Preventionists (IPs) when such patients are admitted to their facility to facilitate rapid identification and isolation of infected/colonized patients. IPT usage has been low during initial rollout (32.5%). The VHA and the CARRIAGE QUERI Program developed targeted implementation strategies to increase utilization of IPT’s second iteration, VA Bug Alert (VABA). Methods: Familiarity with IPT was assessed via pre-education survey (3/2022). All sites received standard VABA implementation including: 1) adaptation of VABA features based on end-user feedback (completed 4/2022), 2) development and delivery of an educational module regarding the revised tool (completed 4/2022), and 3) internal facilitation from the VHA MDRO Program Office (ongoing) (see Figure for all key timepoints). Intent to register for VABA was assessed via post-education survey (4-5/2022). Sites (125 eligible) not registered for VABA by 6/1/2022 were randomly assigned to receive one of two conditions from 6/2022–8/2022: continued standard implementation alone or enhanced implementation. Enhanced implementation added the following to standard implementation: 1) audit and feedback reports and 2) external facilitation, including interviews and education about VABA. We compared the number of sites with ≥1 MPC/IP registered for VABA to-date between implementation conditions. Results: Pre-education survey. 168 MPC/IPs across 117 sites responded (94% of eligible sites). Among respondents, 25% had used IPT, 35.1% were familiar with but had not used IPT, and 39.9% were unfamiliar with IPT. Post-education survey. 93 MPC/IPs across 80 sites responded (59% of eligible sites). Of these, 81.7% said they planned to register for VABA, 4.3% said they would not register, and 14.0% said they were unsure. Post-6/1/2022 Registrations. By 6/1/2022, 71% of sites had ≥1 registered VABA user. Of the 28 unregistered sites eligible for enhanced implementation, thirteen were assigned to receive enhanced implementation, and fifteen were assigned to receive continued standard implementation. Eight sites in the enhanced implementation condition (61.5%) registered for VABA. Seven standard-implementation-only sites (46.7%) registered. The number of registered sites did not significantly differ by implementation condition (Fisher’s exact p=0.476). Conclusions: Standard and enhanced implementation were equally effective at encouraging VABA registration, suggesting that allocating resources to enhanced implementation may not be necessary.

Disclosures: None.

Among 108 (0.05% of cohort) US veterans with a Clostridioides difficile infection (CDI) within 30 days of a dental antibiotic prescription, 80% of patients received guideline-discordant antibiotics. Half had chronic gastrointestinal illness potentially exacerbating their CDI risk. More efforts are needed to improve antibiotic stewardship.

We assessed trends in treatment of patients with CRE from 2012 through 2018. We detected decreased utilization of aminoglycosides and colistin and increased utilization in extended-spectrum cephalosporins and ceftazidime-avibactam. We found significant uptake of ceftazidime-avibactam, a newly approved antibiotic, to treat CRE infections.

Background: Gram-negative bacteria cause a variety of hospital-associated infections (HAIs). Of concern is Pseudomonas aeruginosa, which is a leading cause of HAIs. Early and adequate therapy of P. aeruginosa blood stream infection (BSI) is associated with decreased mortality. Additionally, infectious disease consultation has also shown to improve health outcomes, streamline care, and decrease costs. Therefore, the goal of this study was to describe treatment of P. aeruginosa BSI and impact of infectious disease consultations on health outcomes. Methods: In this retrospective cohort study, we analyzed national VA medical, encounter, pharmacy, microbiology, and laboratory data from January 1, 2012 to December 31, 2018. The cohort included all hospitalized adult veterans (aged ≥18 years) who had a positive blood culture for P. aeruginosa. Only the first P. aeruginosa blood culture per patient was included, and duplicate cultures within 30 days were removed. Treatment was identified within −2 to +5 days of the culture date. Multidrug-resistant (MDR) cultures were identified based on resistance to at least 1 agent in at least 3 or more antimicrobial categories tested. Multivariable logistic regression models were fit to assess infectious disease consultations and adequate treatment on in-hospital mortality and 30-day mortality. Results: In total, 3,256 patients had a BSI with P. aeruginosa, of which 386 (11.5%) were MDR. Most of these patients were male (97.5%), >65 years of age (70.9%), and non-Hispanic white (63.8%). Also, 784 patients (23.3%) died during hospitalization and 870 (25.8%) died within 30 days of their culture. In multivariable regression models, infectious disease consultations were associated with decreased odds of in-hospital mortality (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.53–0.77) and 30-day mortality (OR, 0.56, 95% CI, 0.48–0.67) even after adjusting for age, race, care setting, Charlson score, and prior healthcare exposures. Furthermore, inadequate definitive treatment was associated with increased odds of in-hospital mortality (OR, 2.77; 95% CI, 1.35–5.69) and 30-day mortality (OR, 2.37; 95% CI, 1.18–4.79), even after adjusting for age, Charlson score, care setting, and prior healthcare exposures. In addition, carbapenem treatment was associated with increased odds of in-hospital mortality (OR, 1.38; 95% CI, 1.12–1.70) and 30-day mortality (OR, 1.49; 95% CI, 1.22–1.81), whereas fluoroquinolone treatment was associated with lower odds of in-hospital mortality (OR, 0.49; 95% CI, 0.41–0.59) and 30-day mortality (OR, 0.60; 95% CI, 0.50–0.71). Finally, extended-spectrum cephalosporin was also associated with lower odds of in-hospital mortality (OR, 0.82; 95% CI, 0.68–0.98). Conclusions: Use of infectious disease consultations and any adequate definitive treatment for those with P. aeruginosa BSI lowered odds of in-hospital and 30-day mortality. Early consultation with infectious disease physicians regarding adequate treatment has direct positive impact on clinical outcomes for patients with P. aeruginosa BSI.

Funding: No

Disclosures: None

Background: Infections caused by Acinetobacter spp are often healthcare acquired and associated with high mortality. Extensively drug-resistant (XDR) Acinetobacter are nonsusceptible to at least 1 agent in all but 2 or fewer antibiotic classes. Few of the new antibiotics targeting multidrug-resistant gram-negative bacteria are effective against XDR Acinetobacter. Recent national guidelines for treatment of resistant gram-negative infections do not include Acinetobacter, leaving a knowledge gap in best practices. Methods: This retrospective cohort study included microbiology, clinical, and pharmacy data from all patients hospitalized between 2012 and 2018 at any Veterans’ Affairs medical center who had cultures that grew XDR Acinetobacter spp. Bivariate unadjusted analyses compared clinical outcomes by monotherapy versus combination therapy. Using mixed-effects ordinal logistic regression, propensity score–adjusted models accounting for severity of illness and other variables associated with treatment were fit to compare outcomes. Results: Of 11,546 patients with 15,364 cultures that grew Acinetobacter spp, 408 patients (3.5%) had 666 cultures (4.3%) with XDR Acinetobacter. Moreover, 276 of these patients (67.6%) had gram-negative targeted antibiotic treatment within −2 to +5 days from the culture. Furthermore, 118 patients (42.8%) received monotherapy, most commonly piperacillin-tazobactam (n = 54, 45.7%) or an anti-Pseudomonas cephalosporin (n = 21, 17.8%). Also, 158 (57.2%) patients received combination therapy, most commonly a carbapenem (n = 93, 58.9%) and/or polymyxin (n = 68, 43.0%). Moreover, 41 patients (25.9%) received both a carbapenem and polymyxin. In both unadjusted and adjusted analyses, there were no significant differences in the odds of 30-day mortality (aOR, 1.43; 95% CI, 0.86–2.38) or 1-year mortality (aOR, 1.04; 95% CI, 0.68–1.60) between combination therapy and monotherapy groups. Among 264 patients (96%) whose cultures occurred during an inpatient or long-term care admission, unadjusted analyses showed increased odds of in-hospital mortality (OR, 1.89; 95% CI, 1.08–3.29) and longer postculture length of stay in the combination therapy group: median, 23 days (IQR, 11–57) versus 14 days (IQR, 7–32) (P = .02). However, with propensity score adjustment, these associations were no longer significant. Furthermore, there was no significant difference in odds of 90-day readmission between groups in either unadjusted or adjusted analyses (aOR, 1.20; 95% CI, 0.74–1.95). Conclusions: In this large national cohort of patients with XDR Acinetobacter cultures, more patients received combination therapy than monotherapy, and carbapenems and polymyxins were the most-used classes. However, there were no significant differences in outcomes between patients receiving combination therapy and monotherapy, suggesting lack of clinical benefit to the common practice of treating XDR Acinetobacter infections with multiple antibiotics. Further research is needed to determine optimal treatment strategies for this pathogen.

Funding: No

Disclosures: None

This is an epidemiological study of carbapenem-resistant Enterobacteriaceae (CRE) in Veterans’ Affairs medical centers (VAMCs). In 2017, almost 75% of VAMCs had at least 1 CRE case. We observed substantial geographic variability, with more cases in urban, complex facilities. This supports the benefit of tailoring infection control strategies to facility characteristics.

Background: Ceftolozane-tazobactam (C/T) and ceftazidime-avibactam (C/A) are new β-lactam/β-lactamase combination antibiotics that were approved by the FDA in 2014 and 2015, respectively, to treat complicated intra-abdominal and urinary tract infections. They are commonly used to treat multidrug-resistant Pseudomonas aeruginosa (MDRPA) and carbapenem-resistant Enterobacteriaceae (CRE) infections at any site. Both medications are also often used as salvage therapy when empiric therapy has failed or when the infectious organism tests resistant to all other available antibiotics. The purpose of this review is to present the clinical experience and reported clinical success rates of C/T and C/A. Methods: PubMed, EMBASE, and Google Scholar were searched from January 1, 2013, through October 1, 2019, for publications detailing clinical experience with C/T and C/A in patients with CRE and MDRPA infections. Included study designs were extended cases series and clinical observational studies. Information on infection type, bacterial agent, salvage therapy uses, clinical success, and resistance development during treatment were abstracted. Meta-regression analysis was used to determine the pooled effectiveness of C/T and C/A among included studies. Results: The literature search returned 1,645 publications. After exclusion criteria were applied, 16 publications representing 769 patients were retained. The study population was mostly male (pooled average, 62%). The major comorbidities represented in the pooled population were solid organ transplantation (20.0%), kidney disease (19.5%), cardiovascular disease (15.3%), and diabetes (15.3%). Pneumonia was the predominant infection type (41.4%) and MDRPA was the pathogen most frequently evaluated (57.7%). The pooled clinical success rate was 70.2% (95% CI, 64.5%–75.3%). Also, 10 studies explicitly evaluated C/A or C/T as salvage therapy. The pooled clinical success rate for salvage therapy studies was 75.2% (95% CI, 69.7%–80.0%). Development of resistance to C/T or C/A during or after treatment was reported for 2.0% of the population. Conclusion: Overall, these medications have a high clinical success rate in patients with severe and complicated infections and limited treatment options. Pooled clinical success rates were high (70.2%) and the medications were particularly effective as salvage therapy. Resistance rates were low, although this could have been biased by the small percentage of studies that reported on this outcome. More longitudinal studies comparing the effectiveness of C/T and C/A against other antibiotic regimens are needed.

Funding: None

Disclosures: None

Background: Infections caused by Acinetobacter spp are often healthcare acquired, difficult to treat, and associated with high mortality. Extensively drug-resistant (XDR) Acinetobacter are nonsusceptible to at least 1 agent in all but 2 or fewer antimicrobial classes. Epidemiologic and outcome data for XDR Acinetobacter are limited and have largely been reported outside the United States. This national cohort study describes epidemiology, clinical characteristics, and outcomes for patients with XDR Acinetobacter in VA health care. Methods: This was a retrospective cohort study including microbiology and clinical data from all patients hospitalized between 2012 and 2018 at any VA medical center who had cultures that grew XDR Acinetobacter spp. Performance and reporting of bacterial speciation and antibiotic susceptibility testing were performed by each VA laboratory according to their protocol. Descriptive statistics were used to summarize data. Results: Of 11,541 unique patients with 15,358 cultures that grew Acinetobacter spp during the study period, 410 (3.6%) patients had 670 (4.4%) cultures that grew XDR Acinetobacter. Mean age was 68 years (SD, 12.2 years) and the median Charlson comorbidity index was 3 (IQR, 1–5). The greatest proportion of isolates were from the respiratory tract (n = 235, 35%) followed by urine (n = 184, 28%). The South had the greatest proportion of patients with XDR Acinetobacter (n = 162, 40%); almost all patients were seen at urban VA medical centers (n = 406, 99%). Most patients (n = 335, 82%) had had antibiotic exposure in the prior 90 days, most commonly vancomycin (n = 238, 65%) and third- or fourth-generation cephalosporins (n = 155, 38%). Most patients (n = 334, 81%) also had a hospital or long-term care admission in the prior 90 days. Fig. 1 shows antibiotic susceptibilities of XDR Acinetobacter isolates; polymyxins, tigecycline, and minocycline demonstrated the highest susceptibility. In-hospital mortality occurred in 90 patients (22%), 30-day mortality in 97 patients (24%), and 1-year mortality in 198 patients (48%). Of 93 patients, 23% were readmitted to the hospital within 90 days. Conclusions: Providers should maintain a heightened suspicion for infection with XDR Acinetobacter spp in older patients seen at urban medical centers who have had recent healthcare and antibiotic exposures, particularly if they have respiratory or urinary tract infections. Isolation of XDR Acinetobacter is associated with high in-hospital and 30-day mortality. New antibiotics targeting MDR gram-negative bacteria generally lack activity against Acinetobacter, leaving polymyxins, tigecycline, and minocycline as the only limited treatment options. Therefore, novel antibiotics for XDR Acinetobacter are urgently needed.

Funding: None

Disclosures: None

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are gram-negative bacteria resistant to at least 1 carbapenem and are associated with high mortality (50%). Carbapenemase-producing CRE (CP-CRE) are particularly serious because they are more likely to transmit carbapenem resistance genes to other gram-negative bacteria and they are resistant to all carbapenem antibiotics. Few studies have evaluated risk factors associated with CP-CRE colonization. The goal of this study was to determine the risk factors associated with CP-CRE colonization in a cohort of US veterans. Methods: We conducted a retrospective cohort study of patients seen at VA medical centers between 2013 and 2018 who had positive cultures for CRE from any site, defined by resistance to at least 1 of the following carbapenems: imipenem, meropenem, doripenem, or ertapenem. CP-CRE was defined via antibiotic sensitivity data that coded the culture as being ‘carbapenemase producing,’ being ‘Hodge test positive,’ or ‘KPC producing.’ Only the first positive culture for CRE was included. Patient demographics (year of culture, age, sex, race, major comorbidities, infectious organism, culture site, inpatient status, and CP-CRE status) and facility demographics (rurality, geographic region, and facility complexity) were collected. Bivariate analysis and multiple logistic regression were performed to determine variables associated with CP-CRE versus non–CP-CRE. Results: In total, 3,322 patients were identified with a positive CRE culture: 546 (16.4%) with CP-CRE and 2,776 (83.63%) with non–CP-CRE. Most patients were men (95%) and were older (mean age, 71; SD, 12.5) and were diagnosed at a high-complexity VA medical center (65%). Most of the cultures were urine (63%), followed by sputum (13%), and blood (7%). Most were from inpatients (46%), followed by outpatients (42%), and long-term care facilities (12%). Multivariable analysis showed the following variables to be associated with CP-CRE positive cultures: congestive heart failure (P = .0136), African American (P = .0760), Klebsiella spp (P < .0001), GI cancers (P = .0087), culture collected in 2017 (P = .0004), and culture collected in 2018 (P < .0001). There were also significant differences CP-CRE frequencies by geographic region (P < .001). Discussion: CP-CRE diagnoses are relatively rare; however, the serious complications associated make them important infections to investigate. In our analysis, we found that congestive heart failure and gastric cancer were comorbidities strongly associated with CP-CRE. In 2017, the VA formalized their CP-CRE definition, which led to more accurate reporting. Conclusions: After the guideline was implemented, CP-CRE detection dramatically increased in noncontinental US facilities. More work should be done in the future to determine the different risk factors between non–CP-CRE and CP-CRE infections.

Funding: None

Disclosures: None