Background Accelerate Pheno blood culture detection system (AXDX) provides identification (ID) and antimicrobial susceptibility testing (AST) results within 8h of blood culture growth. Limited data exists regarding its clinical impact. Other rapid platforms coupled with antimicrobial stewardship program (ASP) real-time notification (RTN) have shown improved length of stay (LOS) in bacteremia Methods A single-center, quasi-experimental study of adult bacteremic inpatients before/after AXDX implementation was conducted comparing clinical outcomes from 1 historical and 2 intervention cohorts (AXDX and AXDX+RTN). Primary outcome was LOS. Results Of 830 bacteremic episodes, 188 (77%) of 245 historical and 308 (155 AXDX, 153 AXDX+RTN; 65%) of 585 intervention episodes were included. Median LOS was shorter with AXDX (6.3d) and AXDX+RTN (6.7d) compared to historical (8.1d; P=0.001). Achievement of optimal therapy (AOT) was more frequent (93.6% and 95.4%) and median time to optimal therapy (TTOT) was faster (1.3d and 1.4d) in AXDX and AXDX+RTN compared to historical (84.6%, P≤0.001 and 2.4d; P≤0.001) respectively. Median antimicrobial days of therapy (DOT) was shorter in both intervention arms compared to historical (6d each vs 7d; P=0.011). Median LOS benefit was most pronounced in patients with coagulase negative Staphylococcus bacteremia (5.5d and 4.5d vs 7.2d; P=0.003) in AXDX, AXDX+RTN, and historical cohorts respectively. Conclusions LOS, AOT, TTOT, and total DOT significantly improved after AXDX implementation. Addition of RTN did not show further improvement over AXDX and an already active ASP. These results suggest AXDX can be integrated into healthcare systems with an active ASP even without the resources to include RTN.

Background and Purpose: Doxorubicin (DOX) is a risk factor for arm lymphedema in breast cancer patients. We reported that DOX opens ryanodine receptors (RYRs) to enact “calcium leak,” which disrupts the rhythmic contractions of lymph vessels (LVs) to attenuate lymph flow. Here, we evaluated whether dantrolene, a clinically available RYR1 subtype antagonist, prevents the detrimental effects of DOX on lymphatic function.Experimental Approach: Isolated rat mesenteric LVs were cannulated, pressurized (4–5 mm Hg) and equilibrated in physiological salt solution and Fura-2AM. Video microscopy recorded changes in diameter and Fura-2AM fluorescence tracked cytosolic free calcium ([Ca2+i]). High-speed in vivo microscopy assessed mesenteric lymph flow in anesthetized rats. Flow cytometry evaluated RYR1 expression in freshly isolated mesenteric lymphatic muscle cells (LMCs).Key Results: DOX (10 μmol/L) increased resting [Ca2+i] by 17.5 ± 3.7% in isolated LVs (n = 11). The rise in [Ca2+i] was prevented by dantrolene (3 μmol/L; n = 10). A single rapid infusion of DOX (10 mg/kg i.v.) reduced positive volumetric lymph flow to 29.7 ± 10.8% (n = 7) of baseline in mesenteric LVs in vivo. In contrast, flow in LVs superfused with dantrolene (10 μmol/L) only decreased to 76.3 ± 14.0% (n = 7) of baseline in response to DOX infusion. Subsequently, expression of the RYR1 subtype protein as the presumed dantrolene binding site was confirm in isolated mesenteric LMCs by flow cytometry.Conclusion and Implications: We conclude that dantrolene attenuates the acute impairment of lymph flow by DOX and suggest that its prophylactic use in patients subjected to DOX chemotherapy may lower lymphedema risk.

BackgroundAccelerate Pheno™ blood culture detection system (AXDX) provides identification (ID) and antimicrobial susceptibility testing (AST) within 8 hours of growth in blood culture. We previously reported length of stay (LOS), time to optimal therapy (TTOT), and antibiotic days of therapy (DOT) decrease following AXDX implementation alongside an active antimicrobial stewardship program (ASP). It is unclear whether real-time notification (RTN) of results further improves these variables.MethodsA single-center, quasi-experimental before/after study of adult bacteremic inpatients was performed after implementation of AXDX. A 2017 historical cohort was compared with two 2018 intervention cohorts. Intervention-1: AXDX performed 24/7 with results reviewed by providers or ASP as part of their normal workflow. Intervention 2: AXDX performed 24/7 with RTN to ASP 7 days per week 9a-5p and overnight results called to ASP at 9a. Interventions 1 and 2 were utilized on an alternating weekly basis during the study (February 2018–September 2018). Historical ID/AST were performed using VITEK® MS and VITEK®2. Exclusion criteria included polymicrobial or off-panel isolates, prior positive culture, and patients not admitted at the time of AST. Clinical outcomes were compared with Wilcoxon rank-sum and χ 2 analysis.Results540 (83%) of 650 positive cultures performed on AXDX had on-panel organisms. 308 (57%) of these cultures and 188 (77%) of 244 reviewed historical cultures met inclusion criteria. Baseline illness severity and identified pathogens were similar between cohorts. Clinical outcomes and antimicrobial DOT are reported in Tables 1 and 2.ConclusionFollowing our implementation of AXDX, clinical outcomes including LOS, TTOT, total DOT, BGN DOT, and frequency of achieving optimal therapy were significantly improved compared with a historical cohort. Addition of RTN for AXDX results in the setting of an already active ASP did not further improve these metrics. However, compared with historical arm, AXDX with RTN did significantly impact specific subsets of antibiotic use while AXDX alone did not. This may be due to earlier vancomycin de-escalation. These results support the benefit of integration of AXDX into healthcare systems with an active ASP even without the resources to include real-time notification. Disclosures All authors: No reported disclosures.

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BackgroundKetamine has garnered increased interest for its promising applications in chronic pain treatment, particularly in cases where conventional therapies have proven insufficient. Nevertheless, despite its potential advantages, ketamine remains classified as a third-line medication for pain management. While there are well-documented reactions to ketamine such as hypertension and tachycardia, not much is known about its relationship to cortisol. In this case report, we explicate the administration of ketamine in a patient presenting with atypical facial pain, examining its multifaceted effects on cortisol levels and concurrent pain management.Case presentationA patient with a history of Cushing’s disease underwent multiple resections of a pituitary tumor. Afterwards, the patient began experiencing a burning-like pain on the left side of the face. The discomfort was initially treated with a variety of neuromodulatory and anti-inflammatory medications, which caused intolerable side effects and were not effective for pain. As a final recourse, we initiated a regimen of oral compounded ketamine at 5–10 mg three times daily as needed. The patient exhibited marked amelioration in their pain symptoms; however, there was an elevation in their baseline cortisol. In view of the potential risk of inducing Cushing’s syndrome, the administration of daily ketamine was discontinued.ConclusionWhile ketamine is primarily known to control pain through the antagonization of N-methyl-D-aspartate receptors, its effects on cortisol may also contribute to its analgesic properties. Physicians should be aware of the potential for these interactions, particularly when treating patients with a predisposition to hormonal imbalances.