Background Daptomycin pulmonary eosinophilia (DPE) has been well described in case reports and reporting from the Food and Drug Administration. We report 3 eosinophilic syndromes associated with daptomycin use. Methods This is a retrospective review of all patients who received daptomycin (inpatient or outpatient) from 2010 to 2020 at the Veterans Affairs Portland Healthcare System. Patients who developed DPE while receiving daptomycin were evaluated to determine risk factors. Data collected included daptomycin dose and duration, body mass index, creatinine clearance, and peripheral eosinophilia. Results Of 330 patients who received daptomycin, 81.5% developed a peripheral eosinophilia, with 109 (33%) developing peripheral eosinophilia ≥5%. Fifty-one (16%) met criteria for DPE. Primary DPE occurred in 38 of the 51 patients with a median 26 days of treatment, and 49% had peripheral eosinophilia ≥5%. Re-exposure DPE occurred in the other 13 patients and occurred a median of 3 days after initiation of daptomycin. The presence of an elevated peripheral eosinophilia of ≥5% during daptomycin usage was significantly associated with primary (odds ratio [OR], 2.23; 95% CI, 1.2–4.09; P = .008) and re-exposure DPE (OR, 12; 95% CI, 1.6–103; P = .003). All patients recovered after withdrawal of daptomycin without complications. Conclusions There are 3 daptomycin eosinophilic syndromes: peripheral eosinophilia, primary DPE occurring about 4 weeks into therapy, and re-exposure DPE. Elevated peripheral eosinophilia ≥5% was a risk factor for both primary and re-exposure DPE, but still identified about half the cases. Peripheral eosinophilia should be carefully monitored during daptomycin treatment, and clinicians should be aware that prior eosinophilia may predict an acute pulmonary reaction upon daptomycin re-exposure.

BackgroundDaptomycin pulmonary eosinophilia (DPE) has been described as a rare event. Since the Food and Drug Administration (FDA) first described the syndrome which occurs about 3 weeks after starting the drug, it continues to be a miss diagnosed. Most outpatient antibiotic treatment (OPAT) programs focus on screening for CPK elevations. We describe an unusual increase in DPE at our center including acute reactions on re-exposure to daptomycin.MethodsRetrospective review from local VA pharmacy and OPAT database of adverse drug events (ADE) with daptomycin from 2010 to April 2018. Data evaluated include, age, gender, weight, body mass index (BMI), daptomycin dosing, indication for use, duration of therapy, time to symptom onset, Creatinine clearance, white cell count (WCC), %eosinophilia (%eos), admission to intensive care unit (ICU), and clinical outcomes or interventions.ResultsThere were 363 unique initiations of Daptomycin in the time period. There were 17 DPE (5%) and 3 CPK (0.6%) events in that time period. The medians for all DPE was; Age 68 years (range 55–95), BMI 29 m/kg2 (range 21–49.5), daptomycin dose 500 mg (>7 mg/kg), baseline CrCl 35.5 mL/minute, eosinophilia at onset of DPE 9% (8–44%), and duration of therapy to onset was 21 days (1–33). All recovered on removal of daptomycin, but 5 patients required adjunctive corticosteroid therapy. Four patients had a severe and novel hyperacute DPE within 48 hours of a new initiation of daptomycin therapy. All 4 patients had prior exposure to daptomycin in the last 12 months. They presented with hypoxic respiratory failure, abnormal chest x-rays and/or CT chest scans, with preceding systemic fevers and fatigue after the first dose. All had low grade %eos (3–5%) on prior use, and all recovered rapidly with discontinuation of daptomycin.ConclusionDPE may be underreported and is associated with doses of 500 mg or >7 mg/kg, with CrCl <35 mL/minute and older age. Of concern are the new cases of hyperacute DPE within 48 hours of re-exposure to daptomycin that we have seen, who had prior low-grade eosinophilia. Close monitoring of these factors may be warranted in at risk individuals.Disclosures All authors: No reported disclosures.

Gait speed (GS), 30-second chair stand test (CST), timed up and go test (TUG), and step test (ST) have been validated for face-to-face assessment (F2F) but not for virtual testing (VT). This study examined reproducibility and acceptability of GS, CST, TUG, and ST for VT. Three student physical therapists administered GS, CST, TUG, and ST to 52 healthy participants in F2F and VT formats. Participants' experience and acceptability of VT were captured via a survey. Reproducibility of these measures for VT was assessed using intraclass correlation coefficient (ICC), where ICC &#62; 0.75 and &#62; 0.90 indicated good and excellent reliability. Paired <i>t</i>-tests examined whether the scores differed in VT versus F2F. Interview responses were coded for convergence of information for acceptability of VT and audiovisual communication during VT. Scores for GS (ICC &#61; 0.83), CST (ICC &#61; 0.87), TUG (ICC &#61; 0.95), and ST (ICC &#61; 0.93) obtained in VT were reproducible with F2F. However, <i>t</i>-tests revealed that the VT scores were statistically different (<i>P</i> &#60; 0.0001) for all measures, with exception of GS (<i>P</i> &#61; 0.14), where performance was superior in F2F testing. Thematic analysis suggested high level of acceptability with VT but unanimous preference for F2F assessment. Results indicate that scores for GS, CST, TUG, and ST obtained via VT are reproducible with F2F, albeit superior performance was observed in F2F. Participants found VT acceptable but indicated preference for F2F. We caution clinicians that the established norms for F2F for these measures should not be used and different normative values for these measures may be required for VT.

BackgroundRegional spread of multidrug-resistant organisms (MDROs), including carbapenem-resistant Enterobacteriaceae (CRE), can occur when carriers present unbeknownst to healthcare facilities and thereby delay appropriate infection control interventions. Herein, we describe pilot implementation of a novel national system that automatically alerts local facility staff to newly admitted patients with any history of CRE or methicillin-resistant Staphylococcus aureus (MRSA) in VA.MethodsFrom December 2016 to November 2017, we implemented the alert system in 10 VA medical centers. The system continually monitors the VA Corporate Data Warehouse for new facility admissions nationwide among patients with archived CRE and MRSA data. When such admissions occur, an alert is emailed to Infection Prevention personnel at the local facility. During implementation, we upgraded to a faster, more accurate report, “MDRO Tracker”, that provided alerts within 4 hours of admission. We evaluated system utility in three ways: (1) assessing user data and feedback; (2) comparing a dataset identifying all unique patients harboring CRE and MRSA to the subset of patients whose most recent positive result was identified at a different VA facility; and (3) enrolling a convenience sample of CRE and MRSA patients to validate system accuracy and assess whether the new system or existing infrastructure identified the MDRO first. IRB approval was obtained at each site.ResultsThe number of users increased over time and are shown in Figure 1. User feedback data are shown in Figure 2; 71/256 (28%) responses indicated that alert data were new and/or timely. Of all CRE- and MRSA-positive patients identified during the study period, 11/101 (11%) and 214/2,390 (9%), respectively, had positive MDRO results originating from a different VA facility. Of the 61 CRE and 1,720 MRSA patients enrolled by research staff, 21% (n = 13) of CRE and 7% (n = 71) of MRSA cases were first identified by the automated system. ConclusionThis pilot implementation of a novel automated MDRO alert system shows feasibility and potential for substantial utility of such a system. Further refinement and expanded β-testing of the system is underway.Disclosures M. A. Gelman, Cepheid: Speaker, Speaking Fee.

Objectives: Surgical site infections (SSI) after lower extremity amputations range between 20% and 40%. Staphylococcus aureus is the predominant organism. We sought to determine if preoperative anterior nares decolonization with povidone-iodine (PI) reduced the rate of SSI at our institution.Methods: We performed a single-institution retrospective review of patients undergoing above knee amputation, below knee amputation, or complete transmetatarsal amputation. Outcomes were examined before and after institution of a policy of administering PI to nares immediately preoperatively. Outcomes measured included preoperative and postoperative MRSA colonization status, SSI, and mortality.Results: We examined 100 patients; 71 patients were treated before the institution of the PI decolonization protocol and 29 patients were treated after. Fifty-three percent underwent below knee amputation, 13% underwent above knee amputation, and 35% underwent transmetatarsal amputation. Between patient groups who did and did not receive PI, there was no difference in preoperative methicillin-resistant S aureus (MRSA) status (18% vs 11%; P ¼ .52). PI decolonization did not result in a significant difference in postoperative MRSA decolonization (17% vs 15%; P ¼ .75) and 54% of MRSA positive patients undergoing decolonization continued to test positive for MRSA postoperatively. There was no difference between the PI and control groups in overall SSI before or after 30 days (31% vs 27%; P ¼ .82), SSI requiring antibiotics within or after 30 days (31% vs 25% [P ¼ .62]; 28% vs 32% [P ¼ .81]), or in SSI requiring procedural intervention before or after 30 days (3% vs 13% [P ¼ .27]; 17% vs 27% [P ¼ .44]). There was no difference in all-cause mortality within or after 30 days (12% vs 9% [P ¼ .70]; 33% vs 35% [P ¼ .48]). There were no deaths attributable to sepsis within 30 days in either treatment group. However, there were significantly more sepsis-related mortalities after 30 days in the group that received PI versus the group that did not (33% vs 3%; P ¼ .003). Of the patients with sepsis-related mortality, 33% were MRSA colonized. Of those who did not die of sepsis-related mortality, 15% were MRSA colonized. (P ¼ .172).Conclusions: At our institution, preoperative decolonization with PI did not seem to reduce nares MRSA colonization and did not reduce SSI. However, PI was found to have an association with increased sepsisrelated mortality after 30 days. More investigation is needed regarding the use and resistance profile of PI for decolonization for patients undergoing major amputation.