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Topic Significance & Study Purpose/Background/Rationale: Allogeneic hematopoietic stem cell transplant (HSCT) patients are at high risk for infection during the pre-engraftment period. Current guidelines recommend fluoroquinolone prophylaxis for adults with anticipated neutropenia >6 days. This study was performed to determine optimal timing and antibiotic prophylaxis regimen for myeloablative allogeneic HSCT recipients. Methods, Intervention, & Analysis: An IRB-approved, singleinstitution retrospective study assessed patients undergoing myeloablative allogeneic HSCT with total body irradiation (TBI) between 3/2011 and 5/2016. Patients were grouped by antibiotic prophylaxis regimen. Early prophylaxis was defined as ciprofloxacin/metronidazole initiated in the first half of the preparative regimen. Late prophylaxis was defined as ciprofloxacin/metronidazole initiated in the latter half of the preparative regimen or on day of stem cell infusion. Ciprofloxacin-only early prophylaxis was defined as ciprofloxacin initiated in the first half of the preparative regimen. Neutropenia onset was defined as early (before Day −1), average (Day −1 to +1), or late (after Day +1). Microbiology results were reviewed from preparative regimen onset through 30 days post-transplant. Multiple logistic regression models compared effects of prophylaxis regimens adjusting for sex, Hematopoietic Cell Transplantation-Specific Comorbidity Index, Karnofsky performance status (KPS), prior BSI, and neutropenia onset. Findings & Interpretation: One hundred twenty-six patients met inclusion criteria (46 early, 50 late, 30 early ciprofloxacin-only prophylaxis). Groups did not differ significantly by sex, age, disease, KPS, allograft type, C. difficile history, BSI history, or neutropenia onset. Multiple logistic regression revealed significant differences in gram negative BSI and C. difficile infection rates. Gram negative BSI were less frequent with early versus late prophylaxis (adjusted OR .15, 95% CI .02-.78) and with early ciprofloxacin-only versus late prophylaxis (adjusted OR .12, 95% CI .006-.81). C. difficile infections were less frequent with early versus late prophylaxis (adjusted OR .13, 95% CI .02-.57) and early versus early ciprofloxacin-only prophylaxis (adjusted OR .18, 95% CI .02-.99). Total and Gram positive BSI rates did not differ significantly by prophylaxis regimen. Discussion & Implications: In this study, early prophylaxis with ciprofloxacin was associated with decreased Gram negative BSI. Metronidazole incorporation into early prophylaxis was associated with decreased C. difficile infection. These data support earlier antibiotic prophylaxis initiation with a fluoroquinolone and metronidazole.

Topic Significance & Study Purpose/Background/Rationale: Delayed discharge negatively impacts patients, staff, hospitals and their interrelationships. Within an NCI-designated Cancer Center in the Southwest United States, an inpatient stem cell transplant (SCT) unit observed discharge delays that can impede patient throughput and access to care. To streamline the process, an interprofessional team collaborated to identify discharge barriers, implement process flow changes and develop standardized teaching tools to improve time of discharge among hospitalized SCT patients. Methods, Intervention, & Analysis: An interprofessional nurse-led team consisting of SCT nurse leaders, advanced practice registered nurses (APRN) representing the medical team, and clinical pharmacists collaboratively identified several opportunities for workflow improvement, including: (a) streamlining nursing and APRN discharge education to reduce duplicity (b) integrating discharge teaching by APRNs and clinical pharmacists during the rounding period rather than after rounds, which was often in the afternoon; (c) improving communication between nurses and medical teams, insuring timely administration of electrolytes, blood product replacements and/or antibiotics. The initiatives included 1. Creating standardized discharge teaching materials for autologous and mobilization patients by consolidating APRN and nursing discharge teachings. This enabled APRNs to delegate their discharge teachings to nurses and provided free time for APRNs to assist clinical pharmacists in medication reconciliation and teaching. Clinical Nurse Leaders (CNLs) collaborated with APRNs to educate nursing staff about these changes. 2. APRNs serve as liaison to communicate anticipated discharges with CNLs on a daily basis, and conduct teaching prior to discharge. 3. APRNs collaborate with CNLs and nursing informatics to develop "day of discharge orders". This would prompt nurses to draw labs at midnight instead of 4 am and initiate necessary replacements sooner. Findings & Interpretation: After 3 months of the initiative, the units have seen average discharge time improve from 3:00 PM to 2:00 PM. Discharge teaching tools are incorporated into the electronic health record (EHR), readily available to nurses, and printable along with other discharge materials. "Day of discharge orders" are currently available in the EHR. Discussion & Implications: Proactive planning and care coordination can improve time of discharge. Enhancing our practices and leveraging resources such as the EHR can support more efficient discharge processes that lead to improved throughput and efficiency.

Introduction: While hematopoietic stem cell transplantation (HSCT) has great therapeutic potential, intensive conditioning regimens and variability in time to stem cell engraftment result in a period of pancytopenia and immunosuppression in which patients are vulnerable to infection. Bloodstream infections (BSIs) occur in 20-45% of inpatient autologous and allogeneic transplant patients, leading to prolonged hospitalization and increased mortality. One method of infection prevention is daily application of the antiseptic chlorhexidine gluconate (CHG). Daily CHG bathing, either with a CHG wash or with application of CHG-impregnated cloths, has been shown to reduce the incidence of all-cause hospital-acquired BSIs in critically ill patients, such as those in the ICU, though very few studies include HSCT patients. Methods: We conducted an observational cohort study to assess the impact of daily CHG bathing on the rate of BSIs among adults undergoing inpatient HSCT at the Duke University Medical Center. Patients were included if they were admitted for pre-transplant conditioning and inpatient monitoring for allogeneic or autologous HSCT from January 2016 through December 2018. CHG bathing was instituted in January 2017 for all patients admitted to the inpatient HSCT unit using 2% CHG-impregnated cloths (SAGE™), providing one year of data with no CHG bathing and two years of data with bathing. Patients were tracked from admission until unit discharge, transfer, or first infection. Laboratory-confirmed bloodstream infections (LCBI), central-line associated bloodstream infections (CLABSI), and mucosal barrier injury laboratory-confirmed bloodstream infections (MBI-LCBI) were determined per CDC/NHSN definitions. An additional variable of "clinically-significant infection" was recorded; this included both laboratory-confirmed BSIs and infections deemed significant by the treatment team but that did not meet CDC/NHSN criteria. For example, patients that were febrile, hypotensive, and treated with antibiotics, but with only one positive culture of a common commensal were deemed to have a clinically-significant BSI. Because not all patients adhered to CHG, patients were grouped into four categories by rate of daily CHG usage: High (>75%), Medium (50-75%), Low (1-49%), and None (0%). Baseline characteristics and clinical outcomes between groups were compared via ANOVA, Chi-squared test, or Cochran-Armitage two-sided trend test. Multivariate analysis using the Fine-Grey subdistribution hazard model was conducted to compare time to all infection variables, accounting for the effects of CHG usage, antibiotic prophylaxis regimen, and type of transplant. Results: We evaluated 192 patients hospitalized for HSCT, including 118 (62%) allogeneic transplants and 74 (38%) autologous transplants. Of these, 25 (13%) had high CHG usage, 33 (17%) medium, 45 (23%) low, and 89 (46%) none. Demographics and transplant characteristics were evenly matched between the CHG usage groups with the exception that high usage groups were more likely to receive levofloxacin for antibiotic prophylaxis (p=0.003). Increased CHG usage was significantly associated with decreased incidence of clinically-significant infection (p=0.006), CLABSI (p=0.04), and MBI-LCBI (p=0.002) (Table 1). Multivariate analysis did not demonstrate a significant contribution of antibiotic prophylaxis regimen. No significant difference was found between CHG usage groups in median days to stem cell engraftment, incidence of febrile neutropenia or C. difficile infection, or rashes requiring medical treatment. There were no rashes attributable to CHG usage. Among patients who were VRE rectal swab negative on admission, there was a significant trend toward lower rates of VRE acquisition with increasing CHG usage (High CHG 13.6% vs No CHG 25.3%, p=0.02). Discussion: Increased CHG usage is associated with a significant trend toward lower rates of clinically-significant infection, CLABSI, MBI-LCBI, and VRE colonization in adult inpatients undergoing HSCT. Effects are most strongly seen at >75% daily CHG usage. There were no adverse effects due to CHG application. The significant decrease in MBI-LCBI with topical CHG suggests an interaction between the skin microbial environment and enteric organisms. Therefore, further research exploring the effects of CHG on the skin and gut microbiota is warranted. Disclosures Gasparetto: BMS: Consultancy, Honoraria, Other: Travel, accommodations, or other expenses paid or reimbursed ; Janssen: Consultancy, Honoraria, Other: Travel, accommodations, or other expenses paid or reimbursed ; Celgene: Consultancy, Honoraria, Other: Travel, accommodations, or other expenses paid or reimbursed . Horwitz:Abbvie Inc: Membership on an entity's Board of Directors or advisory committees. Rizzieri:Celgene, Gilead, Seattle Genetics, Stemline: Other: Speaker; AbbVie, Agios, AROG, Bayer, Celgene, Gilead, Jazz, Novartis, Pfizer, Sanofi, Seattle Genetics, Stemline, Teva: Other: Advisory Board; AROG, Bayer, Celgene, Celltron, Mustang, Pfizer, Seattle Genetics, Stemline: Consultancy; Stemline: Research Funding. Sung:Novartis: Research Funding; Merck: Research Funding; Seres: Research Funding.