Background Uncomplicated bloodstream infections (uBSI) are common and often receive prolonged courses of intravenous (IV) antibiotics, increasing risk for catheter-associated complications and hospitalization costs. β-hemolytic Streptococcus spp. are a common cause of BSI and have reliable susceptibility to many oral antibiotics. Clinically improving patients without persistent BSI and a controlled source of infection are candidates for oral antimicrobial therapy (OAT) but despite anecdotal practice, there are few studies affirming the practice of OAT for gram-positive uBSI. We evaluated IV to OAT transitions for treating β-hemolytic streptococcal uBSI. Methods This retrospective cohort study included patients >18 years old hospitalized between 1/1/2013 and 12/31/2019 diagnosed with uBSI due to β-hemolytic Streptococcus. Patients were excluded if BSI was due to endovascular, central nervous, or bone/joint infection without source control. We compared outcomes in patients treated with IV only to those transitioned to OAT including: 30-day mortality, antimicrobial therapy, BSI relapse, 30-day rehospitalization, adverse drug events, and reversion to IV therapy. Fisher’s exact test was used for categorical variables; Mann-Whitney test and independent t-test for continuous variables. Results A total of 238 Streptococcus BSI (of 321 BSI screened) were included (83 excluded as complicated, pediatric, or outpatient). OAT was used in 153 (64%). Cohort demographics were similar (table 1). Infectious disease (ID) consultation was not statistically associated with OAT transition; in fact, ID consults tended to use less OAT (66% IV vs. 54% OAT p=0.10). Hospital length of stay was statistically shortened in the OAT cohort with a median of 5 (interquartile range 4) vs. 7.5 (10.5) (p< 0.0001). Patients transitioned to OAT were more likely to finish their antibiotic course outpatient (93 vs. 61% p< 0.001). Thirty-day mortality was decreased in the OAT cohort (2% vs. 13% p< 0.0001). Adverse events were not statistically significant between the groups. Conclusion Opportunities exist to modify practice management of uBSI. For β-hemolytic Streptococcus uBSI, OAT was associated with decreased length of stay without adverse clinical outcomes. Disclosures Bryan T. Alexander, PharmD, BCIDP, AAHIVP, Astellas Pharma: Advisor/Consultant Trevor C. Van Schooneveld, MD, bioMerieux: Advisor/Consultant|bioMerieux: Grant/Research Support|Insmed: Grant/Research Support|Merck: Grant/Research Support|Thermo-Fischer: Advisor/Consultant Jasmine R. Marcelin, MD, Pfizer (Grant reviewer): Honoraria.

Background Antibiotic overuse increases healthcare cost and promotes antimicrobial resistance. People with HIV (PWH) who develop acute respiratory infections (ARI) may be assumed “higher risk,” compared with non-PWH, but comparative antibiotic use evaluations have not been performed. Methods This observational, single-center study compared antibiotic prescribing in independent clinical encounters for PWH and non-PWH diagnosed with ARI in outpatient clinical practices using ICD 10 codes between January 1, 2014 and April 30, 2018. Fisher’s exact test compared categorical variables with antibiotic prescribing patterns. Results There were 209 patients in the PWH cohort vs. 398 patients in the non-PWH cohort. PWH had median CD4+ count of 610 cells/mm3 with 91% on antiretroviral therapy and 78% were virally suppressed. Thirty-seven percent of all visits resulted in an antibiotic prescription, 89% were inappropriate. Antibiotics were prescribed more frequently in non-PWH (35% PWH vs. 40% non-PWH; p 0.172) and managed according to guidelines more often in PWH (37% PWH vs. 30% non-PWH; p 0.039). Antibiotics were prescribed appropriately most frequently in PWH managed by HIV clinicians (29% PWH managed by HIV clinician vs. 12% PWH managed by non-HIV clinician vs. 8% non-PWH p 0.010). HIV clinicians prescribed antibiotics for a mean duration of 5.9 days vs. PWH managed by a non-HIV clinician for 9.1 days vs. non-PWH for 7.6 days (p <0.0001). Conclusion Outpatient antibiotic overuse remains prevalent among patients evaluated for ARI. We found less frequent inappropriate antibiotic use in PWH. Prescriber specialty, rather than HIV diagnosis, was related to appropriateness of antimicrobial prescribing.

BackgroundAntibiotic overuse is widespread, increasing healthcare cost and promoting antimicrobial resistance. People with HIV (PWH) who develop URIs may be assumed “higher risk,” compared with non-PWH, but comparative antibiotic use evaluations have not been performed. We evaluated antibiotic prescribing patterns for URI diagnoses (cough, sinusitis, bronchitis, and cold) in PWH and non-PWH.MethodsThis was an observational, single-center study comparing PWH and non-PWH diagnosed with URI (using ICD 10 codes for URI syndromes: cough, sinusitis, bronchitis, and cold) between January 1, 2014 and April 30, 2018. Patients were empaneled in an outpatient primary care clinic or specialty care clinic in one healthcare system. Appropriateness of antibiotic prescribing was defined based on published guidelines. Fisher’s exact test compared categorical variables with antibiotic prescribing patterns. Each encounter was considered an independent event.ResultsThe two groups (PWH and non-PWH) were similar, with 34% of subjects in both groups being female. PWH had median CD4+ count of 610 cells/mm3 with 91% on antiretrovirals and 77% with HIV RNA < 20 copies/mL. Overall, 37% of visits resulted in antibiotic prescriptions, 92% of which were inappropriate (discordant with guidelines). Antibiotics were prescribed slightly more frequently in non-PWH (40% vs. 33%, P = 0.056; Figure 1) and inappropriate more often in non-PWH (37% vs. 30%, P = 0.029). Over 20% of PWH antibiotic prescriptions were too long, and 22% of non-PWH received the wrong drug (Figure 2; P = 0.011). 47% of the non-PWH receiving antibiotics for URI had private insurance (compared with other payers; P < 0.0001) vs. 33% in PWH (P = 0.32) (Figure 3).ConclusionOutpatient antibiotic overuse remains prevalent among patients evaluated for URIs. This is the first study, to our knowledge, comparing antibiotic use for URIs in PWH compared with non-PWH. Counterintuitively, we found less-frequent inappropriate antibiotic use in PWH. We speculate that PWH are more likely to be evaluated by infectious disease/HIV specialists, possibly explaining the lower rate of antibiotic prescriptions for URIs in this population. Future analyses will evaluate the association between provider specialty and inappropriate antibiotic use. Disclosures All Authors: No reported Disclosures.

Background No established guidelines exist regarding the role of oral antibiotic therapy (OAT) to treat uncomplicated bloodstream infections (uBSIs) and practices may vary depending on clinician specialty and experience. Methods An IRB-exempt web-based survey was emailed to Nebraska Medicine clinicians caring for hospitalized patients, and widely disseminated using social media. The survey was open access and once disseminated on social media, it was impossible to ascertain the total number of individuals who received the survey. Chi-squared analysis for categorical data was conducted to evaluate the association between responses and demographic groups. Results Of 275 survey responses, 51% were via social media, and 94% originated in the United States. Two-thirds of respondents were physicians, 16% pharmacists, and infectious diseases clinicians (IDC) represented 71% of respondents. The syndromes where most were comfortable using OAT routinely for uBSI were urinary tract infection (92%), pneumonia (82%), pyelonephritis (82%), and skin/soft tissue infections (69%). IDC were more comfortable routinely using OAT to treat uBSIs associated with vertebral osteomyelitis and prosthetic joint infections than non-infectious diseases clinicians (NIDC), but NIDC were more likely to report comfort with routine use of OAT to treat uBSIs associated with meningitis and skin/soft tissue infections. IDC were more likely to report comfort with routine use of OAT for uBSIs due to Enterobacteriaceae and gram-positive anaerobes, while NIDC were more likely to be comfortable with routinely using OAT to treat uBSIs associated with S. aureus, coagulase-negative staphylococci and gram-positive bacilli. In one clinical vignette of S. aureus uBSI due to debrided abscess, 11% of IDC would be comfortable using OAT vs 28% of NIDC; IDC were more likely to report routinely repeating blood cultures (99% vs 83%, p&lt; 0.05). Figure 1: Clinician comfort using oral antibiotic therapy to treat uncomplicated bacteremia due to specific syndromes Figure 2: Clinician comfort using oral antibiotic therapy to treat uncomplicated bacteremia due to specific organisms Conclusion Considerable variation in comfort using OAT for uBSIs among IDC vs NIDC exists, highlighting opportunities for IDC to continue to demonstrate their value in clinical practice. Understanding the reasons for variability may be helpful in creating best practice guidelines to standardize decision making. Disclosures All Authors: No reported disclosures