Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Patients with a reported β-lactam allergy (BLA) are often given alternative perioperative antibiotic prophylaxis, increasing risk of surgical site infections (SSIs), acute kidney injury (AKI), and Clostridioides difficile infection (CDI). The purpose of this study was to implement and evaluate a pharmacist-led BLA clarification interview service in the preoperative setting. Methods A pharmacist performed BLA clarification telephone interviews before elective procedures from November 2018 to March 2019. On the basis of allergy history and a decision algorithm, first-line preoperative antibiotics, alternative antibiotics, or allergy testing referral was recommended. The pharmacist intervention (PI) group was compared to a standard of care (SOC) group who underwent surgery from November 2017 to March 2018. Results Eighty-seven patients were included, with 50 (57%) and 37 (43%) in the SOC and PI groups, respectively. The most common surgeries included orthopedic surgery in 41 patients (47%) and neurosurgery in 17 patients (20%). In the PI group, all BLA labels were updated after interview. Twenty-three patients were referred for allergy testing, 12 of the 23 (52%) completed BLA testing, and penicillin allergies were removed for 9 of the 12 patients. Overall, 28 of the 37 (76%) pharmacy antibiotic recommendations were accepted. Cefazolin use significantly increased from 28% to 65% after the intervention (P = 0.001). SSI occurred in 5 (10%) patients in the SOC group and no patients in the PI group (P = 0.051). All of these SSIs were associated with alternative antibiotics. Incidence of AKI and CDI was similar between the groups. No allergic reactions occurred in either group. Conclusion Implementation of a pharmacy-driven BLA reconciliation significantly increased β-lactam preoperative use without negative safety outcomes.

Background Outpatient parenteral antimicrobial therapy (OPAT) has challenges: venous access complications, cost, and non-adherence. Venous line preservation is an added concern for patients on hemodialysis (HD). While ertapenem is dosed 500 mg daily post-HD, there is limited data on dosing it as 1 gm thrice weekly. This study compares disposition and outcome in patients treated with these two regimens. Methods IRB approved, retrospective cohort study. Inclusion: adult patients on intermittent HD, admitted 6/1/20 to 7/31/21, and discharged with ertapenem either with daily (daily group) or thrice weekly (TIW group) dosing. Data were reported using descriptive statistics and bivariate analysis. Primary endpoints: discharge delay after medical stability. Secondary endpoints: efficacy (readmissions, alterations in antibiotics, and mortality) and safety (line or drug – related adverse events including line infection and seizure). Results 33 patients included: 10 daily and 23 TIW. Baseline characteristics were similar. Median (IQR) age: 57 (48-64) daily and 63 (47-70) TIW, P=0.552. Both groups had a high median Charlson index (IQR): 5 (4-5) daily and 4 (2-5) TIW, P=0.287. Primary reason for ertapenem use was infection from extended-spectrum beta lactamase producing organism: 60% daily and 52% TIW. The TIW group had significantly fewer lines placed (80% daily vs. 22% TIW, p=0.05). Median (IQR) length of stay in days was similar: 7 (6–15) daily and 8 (6-8) TIW, P=0.773. Discharge delays were similar (10% daily vs 9% TIW, P=1.0). Most patients were discharged home (60%). More patients received ertapenem at the dialysis center or infusion clinic in the TIW group (78% TIW vs 30% daily, P=0.016). There was no difference in safety and efficacy endpoints including readmission, mortality, alternation in antibiotics, and line infection. Conclusion In this study’s cohort, ertapenem thrice weekly dosing led to a decrease in line placement without compromising efficacy and safety. Disclosures All Authors: No reported disclosures.

BackgroundPatients with reported β-lactam allergies (BLA) are often given alternative perioperative antibiotic prophylaxis, increasing risk of surgical site infections (SSI), acute kidney injury (AKI), and Clostridioides difficile infection (CDI). The purpose of this study was to implement and evaluate a pharmacist-led BLA clarification interview in the preoperative setting.MethodsThis single-center, IRB-approved, quasi-experimental study compared surgical patients with a BLA between November 2017 and March 2018 (pre-intervention) vs. November 2018 and March2019. From November 2018 to March 2019, a pharmacist performed BLA clarification phone interviews for patients scheduled for a surgical procedure. Based on the allergy history and decision algorithm, first-line antibiotics, alternative antibiotics, or an allergy testing referral were recommended and documented in the EHR. The allergy label was updated as well. The primary outcome was the use of β-lactams preoperatively. Secondary outcomes included 30-day SSI and CDI, AKI, allergic reactions, allergy labels updated or removed, time to incision, and vancomycin doses administered.Results87 patients were included in the study; 50 (57%) and 37 (43%) in the pre- and post-group, respectively. Most common surgeries: orthopedic 41 (47%), neurosurgery 17 (20%). In the post-group, all EHR BLA labels were updated after interview. 23 patients were referred for allergy testing, 12 (52%) completed BLA testing, and 7 BLA allergies were removed. 76% of pharmacy antibiotic recommendations were accepted (figure). Cefazolin use significantly increased from 28% to 65% post-intervention, P = 0.001; vancomycin use also increased from 19 (38%) to 22 (59%), P = 0.047. Time to incision decreased by a median of 8 minutes (P = 0.484). SSI occurred in 5 (10%) patients in the pre-group only, P = 0.051. All of these were associated with alternative antibiotics. Incidence of AKI and CDI were similar between the groups (P > 0.05). No allergic reactions occurred in either group.ConclusionClarifying reported BLA in the perioperative setting significantly increased β-lactam preoperative use without negative clinical sequelae. Disclosures All authors: No reported disclosures.

The liver plays a major role in drug metabolism. Liver transplantation impacts the intrinsic metabolic capability and extrahepatic mechanisms of drug disposition and elimination. Different levels of inflammation and oxidative stress during transplantation, the process of liver regeneration, and the characteristics of the graft alter the amount of functional hepatocytes and activity of liver enzymes. Binding of drugs to plasma proteins is affected by the hyperbilirubinemia status and abnormal synthesis of albumin and alpha‐1‐acid glycoproteins. Postoperative intensive care complications such as biliary, circulatory, and cardiac also impact drug distribution. Renally eliminated antimicrobials commonly present reduced clearance due to hepatorenal syndrome and the use of nephrotoxic immunosuppressants. In addition, liver transplantation recipients are particularly susceptible to multidrug‐resistant infections due to frequent manipulation, multiple hospitalizations, invasive devices, and frequent use of empiric broad‐spectrum therapy. The selection of appropriate anti‐infective therapy must consider the pathophysiological changes after transplantation that impact the pharmacokinetics and pharmacodynamics of antibiotics and antifungal drugs.

Background Eravacycline (ERV) is a fluorocycline with in vitro activity against Clostridioides difficile infection (CDI). The purpose of this study was to evaluate the usage of ERV in the management of CDI. Methods IRB-approved, retrospective case series in a health system that added ERV to formulary in 9/2019. All patients between 9/2019 and 2/2020 treated with adjunctive ERV for > 24 hours for severe, recurrent, or fulminant CDI were included. Exclusion criteria: pregnant, age < 18 years. Primary outcome: all-cause mortality at 30 days (d) from start of ERV. Secondary outcomes: clinical cure, colectomy, and recurrence within 30 d. Data was reported using descriptive statistics and measures of central tendency. Results 14 patients included: severe (4, 29%), recurrent (4, 29%), and fulminant CDI (6, 43%) (table 1). Infectious diseases consult: 14/14, median time to consult 1 (1, 2) d. Surgery consult: 1 severe and 5 fulminant CDI cases, median time to consult 1 (1, 3) d. Prior to ERV initiation, 10 patients were on oral vancomycin (PO VAN) and intravenous metronidazole (IV MTZ), one was on PO VAN, two were on IV MTZ, and one was on no CDI therapy. After ERV was initiated, six patients were on ERV, PO VAN, and IV MTZ combination and eight patients were on ERV and PO VAN concurrently. The reason for using ERV was fulminant CDI (6, 42.8%), severe CDI (4, 29%), unable to tolerate other CDI medications (3, 21%), refractory CDI (3, 21%), and recurrent CDI (1, 7%). Time to eravacycline initiation 1.5 d (1, 3.75) with median duration of 6 d (4.5, 7.75). 30-day all-cause mortality 2 (14%), all were in-hospital; 1 (7%) hospice. Clinical cure occurred in 12 (86%). Two (14%) required colectomy; one received surgery on the same day of CDI diagnosis and ERV initiation and the other had surgery 4 days before ERV initiation. Two patients with recurrent CDI received fecal microbiota transplant outpatient, one of which also received bezlotoxumab. Zero recurrences and one readmission within 30 d. Table 1.Patient demographics, severity, and clinical outcomes Conclusion ERV appears to be a potential adjunctive therapy for severe, recurrent, or fulminant CDI. Prospective studies are needed to further investigate the safety and efficacy of ERV in serious CDI. Disclosures All Authors: No reported disclosures.