Cryptococcus neoformans is a fungal pathogen associated with advanced HIV disease and other disorders associated with immune dysfunction. The pulmonary and the central nervous system are the most common manifestations of the disease. Localised osteomyelitis as the sole manifestation of extrapulmonary disease is rare. Herein, we present five cases of Cryptococcus osteomyelitis as the only manifestation of extrapulmonary disease. We also identified 84 additional cases of isolated cryptococcal osteomyelitis in the literature. Using these data, we have made some general recommendations regarding an approach to treatment of this uncommon clinical entity.

Background Telemedicine (TM) programs can be implemented to deliver specialty care through virtual platforms and overcome geographic/resource constraints. Few data exist to describe outcomes associated with TM-based infectious diseases (ID) management. The purpose of this study was to compare outcomes associated with TM and on-site standard of care (SOC) ID consultation after implementation of an antimicrobial stewardship (AMS)-led S. aureus bacteremia (SAB) bundle. Methods A retrospective cohort study was conducted on the effects of a SAB bundle comparing ID consult delivery (SOC or TM) at 10 US hospitals within Atrium Health in adult patients admitted September 2016 through December 2017. Type of ID consult provided was based on admitting hospital; no hospital had both modalities. Bundle components included: (1) ID consult, (2) appropriate antibiotics, (3) repeat blood cultures until clearance, (4) echocardiogram obtainment, and (5) appropriate antibiotic duration. AMS facilitated bundle initiation and compliance. The primary outcome was bundle adherence between groups. Differences in clinical outcomes were also assessed. Results We evaluated 738 patients with SAB (576 with SOC, 162 with TM ID). No differences were observed in overall bundle adherence (SOC 86% vs TM 89%, p = 0.33). Additionally, no significant differences resulted between groups for hospital mortality, 30-day SAB-related readmission, persistent bacteremia, and culture clearance. Groups did not differ in 30-day mortality when controlling for demographics, bacteremia source, and physiological measures with multivariable logistic regression. Conclusion Our findings provide evidence to support effective use of TM ID consultation and AMS-led care bundles for SAB management in resource-limited settings.

BackgroundTelemedicine (TM) programs have been effectively implemented to deliver specialty care through virtual platforms to overcome geographic and resource constraints. Yet, few data exist to describe outcomes associated with TM-based management of patients with infectious diseases (ID). The purpose of this study was to compare adherence and other outcomes associated with TM and on-site (SOC) ID consultation (IDC) implementation strategies of an antimicrobial stewardship (ASP)-led S. aureus bacteremia (SAB) bundle.MethodsWe launched an SAB bundle at 10 acute care hospitals in the metro Charlotte, NC area in September 2016 for adult patients admitted with SAB and conducted a retrospective cohort study using data collected through 2017. Bundle components included (1) mandatory IDC, (2) appropriate antibiotics within 24 hours of S. aureus speciation, (3) repeat blood cultures at least every 72 hours until clearance, (4) obtainment of an echocardiogram, and (5) appropriate duration of intravenous antibiotic therapy based on SAB severity. ASP facilitated bundle initiation and assisted with compliance for all patients. The primary outcome was bundle adherence. Secondary outcomes included time to culture clearance and persistent SAB (i.e., positive blood cultures for >7 days). We used Wilcoxon rank-sum and chi-squared tests to compare outcomes.ResultsWe evaluated 872 patients with SAB during the study interval. After excluding 126 patients (prematurely discharged or died/transitioned to comfort care within 48 hours of S. aureus speciation), we analyzed 583 SOC and 163 TM group patients. There were no differences observed in overall SAB bundle adherence (SOC 86% vs. TM 88%, P = 0.52), or its individual components. No differences were found in time to culture clearance (median days: SOC = 2.9 vs. TM = 2.8, P = 0.96) and persistent SAB (SOC 11% vs. TM 11%, P = 0.77).ConclusionOur findings provide preliminary evidence to support TM-based strategies for IDC and ASP-led care bundles in resource-limited settings. Future analyses will compare mortality and hospital readmission outcomes. Disclosures All authors: No reported disclosures.

BackgroundAt least 30% of antibiotics prescribed in the ambulatory setting are unnecessary, including high rates of overuse for acute respiratory infections (ARI). We designed and evaluated whether a multifaceted outpatient stewardship program leveraging multidisciplinary stakeholder engagement, education tools, and an innovative prescribing dashboard decreased antibiotic prescribing in ARI.MethodsIn November 2017, the Carolinas HealthCare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN) launched an antibiotic awareness campaign in over 150 ambulatory practices in the Charlotte metropolitan area, reaching over one million patients. The campaign included online and in-person tools for patients and providers, targeted education at meetings, and social and mass media exposure. In March 2018, a provider level prescribing dashboard was introduced to target inappropriate antibiotic prescribing in ARI (acute sinusitis, nonsuppurative otitis media, nonbacterial pharyngitis, URI, cough, allergy, and influenza). Data were collected for family medicine (FM), internal medicine (IM), urgent care (UC) and pediatric medicine (PM); 10% and 20% relative reduction targets (years 2019 and 2020, respectively) were set for each service line. We compared pre (April 2016–March 2018) vs. post (April 2018–March 2019) intervention prescribing rates (calculated as the number of encounters with antibiotics vs. total) as rate ratios and used segmented regression models to assess change over time.ResultsThere were 1,001,335 pre and 448,390 post-intervention encounters. Postintervention prescribing rates (antibiotics per 100 encounters) decreased for all service lines, FM (49.4 to 39.3), IM (49.7 to 41.2), UC (49.8 to 44.4), and PM (40.6 to 36.1) vs. pre-intervention (all rate ratios, P ≤ 0.01). All service lines met the target 2019 10% reduction goals. Post-implementation, FM and IM showed immediate decreases in prescribing (figure). After an initial increase, UC showed a significant month-to-month decrease (figure).ConclusionIntegration of a prescribing dashboard within a multifaceted antibiotic awareness campaign reduced inappropriate outpatient antibiotic prescribing for ARI and achieved interim targets consistent with 2020 reduction goals. Disclosures All Authors: No reported Disclosures.

BackgroundEmergency department (ED) providers frequently use fluoroquinolones (FQs) as first-line therapy for common infections in discharged patients. In 2016 the FDA issued a warning against FQ use for three common conditions: cystitis, bronchitis, and sinusitis. This study evaluated the effect of an electronic health record (EHR) clinical decision support alert followed by targeted provider education on FQ prescribing in the ED.MethodsWe performed a nonrandomized, single arm, pre–post study of FQ prescribing in target indications before (November 2015–October 2016) and after (January 2017–December 2017) implementation of an EHR alert at 19 hospital-based and free-standing EDs in the Charlotte NC area. Providers were alerted when a patient was discharged from the ED on an FQ with a target diagnosis (infections identified as being inappropriate for FQ) without additional exclusions (e.g., penicillin allergy) (Figure 1). Initial provider education on appropriate FQ use accompanied EHR alert implementation at all 19 participating EDs in November 2016. Targeted follow-up education was delivered in August 2017. We compared overall FQ prescribing rates in pre- vs. post-alert intervals using chi-squared tests. We compared FQ prescription volume following alert failure by indication for high alert failure diagnoses (ICD10 codes with ≥75 alerts) in Q1 2017 vs. Q4 2017.ResultsTarget population ED discharges remained stable pre- and post-alert implementation (n = 37,975; n = 37,731). FQ prescribing decreased 53% from pre (n = 13,796, 36%) to post alert (n = 7,289, 19%; P < 0.01). While total orders avoided after alert firing remained low, the total prescriptions (i.e., alert overrides) dropped from 789 in January 2017 to 397 in December 2017 (Figure 2). The largest decrease was observed after repeat provider education in August 2017. Diagnosis categories with high volume alert failures decreased from 15 unique ICD10 diagnosis (n = 1,534 prescriptions) in Q1 2017 to 3 (diverticulitis, pneumonia, gastroenteritis/colitis; n = 419 prescriptions) in Q4 2017.ConclusionEffective EHR alert implementation combined with timely and targeted provider education on appropriate prescribing reduces inappropriate ED provider FQ prescribing by more than 50%. Disclosures L. Davidson, Duke Endowment: Grant Investigator, Grant recipient