A 44-year-old female presented with a 3-month history of headache, dizziness, nausea, and vomiting. Her past medical history was significant for long-standing intravenous drug abuse. Shortly after admission, the patient became hypertensive and febrile, with fever as high as 38.8°C. The lumbar puncture profile supported an infectious process; however multiple cultures of blood and cerebrospinal fluid (CSF) did not initially show growth of organisms. Finally after 9 days of incubation, a CSF culture showed evidence of a few colonies of Candida albicans. To confirm the diagnosis, preserved CSF from that sample was tested for (1→3)-β-d-glucan, showing levels >500pg/ml. This report illustrates a rare complication of intravenous drug use in an immunocompetent patient and demonstrates the utility of (1→3)-β-d-glucan testing in possible Candida meningitis.

Background As the population in the United States ages, the number of people who will require a joint arthroplasty is expected to rise dramatically. The most serious complication of this surgery is prosthetic joint infection (PJI) which can lead to long-term morbidity and even mortality. Biofilms play a major role in these infections, and studies have suggested that tigecycline may work better than other antimicrobials in the setting of biofilms. In this study, we examined our institution’s experience with using tigecycline to treat PJI.Methods This was a retrospective review of all adult patients with PJI treated at West Virginia University from January 2008 to March 2016 who received tigecycline for 50% or greater of the treatment course. Demographic data, rationale for tigecycline use, type of surgery, microbiologic data, outcome and complications were assessed. Failure was defined as need to return to the operating room for an infectious complication or persistent drainage from the joint.ResultsIn total, 34 patients met inclusion criteria. The median age was 65 years, and 62% of the patients were female. The most common reason for tigecycline use was empiric therapy, but other reasons included antimicrobial allergies and resistant organisms. The antimicrobial was used as frontline therapy in 29 cases (85%), and the mean duration of tigecycline therapy was 38 days. The most common organisms isolated were methicillin resistant Staphylococcus aureus (n = 7), coagulase negative Staphylococci (n = 5), and Enterococcus species (n = 4), but 12 cases (35%) were culture negative. Treatment success was documented for 21 cases (62%); though, there was limited follow-up (2 months or less) in four of the successful cases. Nausea and vomiting was the most common adverse event, occurring in three patients.Conclusion Tigecycline is a glycylcycline approved for use in a variety of infections including intra-abdominal and skin soft-tissue infections, but little is known about its use in the treatment of PJI. We found that tigecycline is well tolerated even when given for 6 weeks duration. Twenty-one of the 34 patients (62%) met our definition of successful treatment outcome with tigecycline. More studies are needed to assess tigecycline’s use in the treatment of PJI.Disclosures All authors: No reported disclosures.

Background Literature shows early intravenous (IV) to oral (PO) antimicrobial transition for infective endocarditis (IE) and bone and joint infection (BJI) is noninferior to prolonged IV antimicrobial therapy. COVID-19 pandemic peaks resulted in critical shortages of staffed hospital beds spurring innovation. Outpatient parenteral antimicrobial therapy (OPAT), a well-established program using prolonged IV antimicrobials, faces challenges such as infusion resource needs and social circumstance limitations. Complex outpatient antimicrobial therapy (COpAT) uses PO in place of IV antimicrobials. We hypothesized rapid adoption of COpAT would decrease hospital length of stay and open beds while retaining satisfactory clinical outcomes. Methods COpAT protocols (Image 1) and guidelines by infection type and isolated organism (Image 2) were created. Hospitalized patients including persons who inject drugs (PWID) were evaluated for IV to PO antimicrobial transition by an infectious diseases (ID) physician and then followed by an ID physician-pharmacist team. Demographic, ID, and clinical outcome data for the first 100 COpAT patients between December 2020 and February 2022 were obtained by retrospective chart review. Image 1.COpAT Inpatient and Outpatient Protocols Image 2. COpAT Guidelines by Infection Type and Isolated Organism MSSA = methicillin-susceptible Staphylococcus aureus; MRSA = methicillin-resistant Staphylococcus aureus; spp. = species; TMP/SMX = trimethoprim-sulfamethoxazole; DS = double strength; SSTI = skin and soft tissue infection; CAP = community-acquired pneumonia Results PWID accounted for 78% of COpAT patients. BJI followed by mixed infection (IE and BJI) was most prevalent (Image 3) with bacteremia in 53% of cases. Staphylococcus aureus was most frequently isolated (Image 4). Oral linezolid and fluoroquinolones, often in combination, were most commonly used. IV and PO antimicrobials were taken for a median 28 and 14 days, respectively. The COpAT program saved 1425 IV antimicrobial and 1363 hospital days. Assuming daily inpatient cost of $2050, cost avoided was $2,794,150. COpAT patients participated in ID follow-up and adhered to PO antimicrobials with low 30-day readmission rates (Image 5). Image 3.Infection TypeImage 4.Isolated Organism CoNS = coagulase-negative staphylococci Image 5.Clinical Outcomes Conclusion In a sample of 100 COpAT patients including PWID, IV to PO antimicrobial transition safely saved hospital days and mitigated critical bed shortages during pandemic peaks. A successful COpAT program requires a multidisciplinary group: close ID physician-pharmacist collaboration extending to OPAT and antimicrobial stewardship teams. With a COpAT program in place, even earlier IV to PO antimicrobial transitions should be studied. Disclosures All Authors: No reported disclosures.

Background Antimicrobial stewardship (AMS) committees ensure appropriate antimicrobial utilization. One stewardship intervention is to evaluate the delivery model of high-cost antimicrobials to better utilize resources and mitigate expenses. We analyzed the total medication waste and costs of high-cost antimicrobials, specifically daptomycin, ertapenem, amphotericin, and micafungin, at our institution and propose innovative cost-savings changes at a systems level. Methods This retrospective study consisted of 263 patients. All patients were at least 18 years old who was admitted to our academic institution from January 2020 to April 2021 and received daptomycin, ertapenem, amphotericin, or micafungin. Demographics, daily medication dosage, total doses received, the date and time of the start of the medication, last administered dose, and discontinued order were recorded. Results The daptomycin cohort consisted of 143 patients with 46.2% females and average age of 56.3 years. In this group, 145.3 vials were wasted which equated to a loss of &22,630. The ertapenem group had 53 patients with 62.3% females and a mean age of 62.3 years. There were 24 vials wasted with a calculated loss of &1080. The amphotericin cohort had 32 patients with an average age of 52.2 years and 43.8% females. There were 189 vials wasted with a loss of &46,116. The micafungin group had 35 patients with 42.9% females and average age of 60.4 years. This group had 12 vials wasted with a loss of &2052. Conclusion Each antimicrobial has a specific formulation protocol. Daptomycin and ertapenem formulation occurs in the early morning. Amphotericin formulation occurs 2 hours prior to medication use. Micafungin formulation occurs at the time the order label prints. These medications were more often administered in the late morning to early afternoon timeframe. The order to discontinue the medications also occurred at the same interval. One reason could be due to decisions made on morning rounds from primary teams and specialty input. These orders would then be placed after rounds. A cost-saving method would be to batch and change the formulation time for all antimicrobials to later in the afternoon, which would not only prevent waste, but also allow the AMS team to effectively audit appropriate antimicrobial use. Disclosures All Authors: No reported disclosures

A 30-year-old female who is 34 weeks pregnant was admitted with a 3 day history of fever associated with rigors, chills, nausea, and vomiting. Her blood pressure was normal; there was no tachycardia with fever. On admission, her white blood cell count was 4.4×10 3 /µL with 3% bands and 74% neutrophils, hemoglobin was 11.0 g/dL, and platelet count was 63x10 9 /L Human immunodeficiency virus testing was negative. On day 2 of admission, she developed a fever of 38.8°C resulting in fetal bradycardia, thus prompting an emergent cesarean section. A healthy male infant was delivered. The hematoxylin and eosin stained preparation of the placenta is shown in Figure 1. What is your diagnosis?