Pharmacokinetic (PK) and pharmacodynamic (PD) variability in special populations can impact antimicrobial efficacy and safety. This review highlights the importance of PK/PD optimization in patients known to have altered PK, including those with obesity, cystic fibrosis, renal dysfunction, critical illness, transplantation, pregnancy, and/or significant burns. Historically, PK/PD data are underrepresented in these populations, leading to suboptimal dosing recommendations and increased risks of therapeutic failure or toxicity. Herein, we discuss key physiological alterations affecting antimicrobial PK/PD, regulatory challenges, and currently available solutions. To bridge these knowledge gaps, we advocate for broader patient inclusion in clinical trials, improved PK modeling, real-world data collection, and increased investment in precision dosing strategies. Addressing these issues has the potential to enhance patient outcomes, reduce antimicrobial resistance, and improve infectious diseases management. This review serves as a call to action for researchers, clinicians, and policymakers to prioritize PK/PD research in special patient populations.

Abstract Background The U.S. Centers for Disease Control and Prevention, through the National Healthcare Safety Network (NHSN), developed antimicrobial utilization (AU) metrics for hospital reporting and benchmarking. We applied this framework, using a modified NHSN definition of inpatient AU, to identify factors associated with antimicrobial use among solid organ transplant (SOT) recipients. Methods We conducted a retrospective single-center cohort study of first adult SOT recipients from 2010 to 2019. Inpatient AU during the first six months post-transplant was calculated as facility-wide days of therapy (DOT) per 1000 patient-days using a modified NHSN definition. Organ-specific multiple linear regression identified baseline characteristics associated with AU. Results Among 1845 recipients (293 heart, 531 kidney, 426 liver, 595 lung), AU varied by organ: heart 560, kidney 285, liver 622, lung 1111 DOT/1000 patient-days. In heart recipients, pretransplant infection requiring intravenous (IV) antibiotics and longer ischemic time were associated with higher AU, while transplant year, A-blood group, and medical condition at transplant predicted lower AU. In lung recipients, ischemic time increased AU, whereas age and lung allocation score decreased AU. In liver recipients, only the transplant year was associated with lower AU. In kidney recipients, ischemic time was associated with increased AU, while transplant year, functional status, and insurance type were associated with lower AU. Conclusion AU in the first six months post-SOT was substantial and varied by organ type, with specific baseline characteristics influencing its use. Applying AU metrics to SOT populations can inform targeted antimicrobial stewardship interventions.

Background:Patients discharged from emergency departments (ED) with antibiotics for common infections often receive unnecessarily prolonged durations, representing a target for transition of care (TOC) antimicrobial stewardship intervention. Methods:This study aimed to evaluate the effectiveness of TOC pharmacists' review on decreasing the duration of discharge oral antibiotics in patients discharged from the ED at an academic medical center. Pharmacist interventions were guided by an antibiotic duration of therapy guidance focused on respiratory, urinary, and skin infections developed and implemented by the antimicrobial stewardship program. Pharmacist interventions from January 27, 2023, to December 29, 2023, were analyzed to quantify the total number of antibiotic days saved and the percentage of provider acceptance. Results:The ED TOC pharmacists reviewed a total of 157 oral antibiotic prescriptions. 86.6% percent of the reviews required pharmacist interventions. The most common indications for the discharge antibiotics were urinary tract infections (50.0%) and skin infections (23.4%). The total number of antibiotic days saved was 155 days with the provider acceptance rate of 76.5%. In 21% of cases, providers did not count the antibiotic doses administered in the ED, contributing to unnecessarily prolonged duration. 10.2% of patients re-presented to the ED while 6.4% of patients were hospitalized within 30 days of index ED discharge. Conclusion:The transitions of care pharmacist-led intervention was successful in optimizing the duration of discharge oral antibiotics in the ED utilizing prospective audit and feedback based on institutional guidance. The ED represents a high-yield setting for TOC-directed antimicrobial stewardship.

Purpose: Pharmacist-led initiatives providing optimization of medications during transitions of care (TOC) have shown to have a positive impact on prescribing practices and patient outcomes. This study aims to evaluate the role and impact of TOC pharmacist review of outpatient parenteral antimicrobial therapy (OPAT) prescriptions prior to hospital discharge.Methods: In a retrospective chart review, patients with OPAT prescriptions between November 1, 2022 and January 31, 2023 were evaluated using prescription-specific and intervention-specific data points. Prescription-specific data points included intravenous antimicrobials prescribed, indication, prescribing team, and time from OPAT prescription to TOC pharmacist review. Intervention-specific data points included antimicrobial optimization (dose/frequency, duration, and other), prescription clarification, and laboratory monitoring.Results: Of the 137 OPAT prescriptions evaluated, 67 required intervention by TOC pharmacists (48.9%). The General Infectious Disease Consult team placed 71.5% of OPAT prescriptions and required interventions less frequently (42.9%) compared to the other teams. Antimicrobial optimization interventions accounted for 54.2% of interventions, which were primarily related to medication dose and frequency.Conclusion: The TOC pharmacists can play a key role in the evaluation of OPAT prescriptions at hospital discharge. This intervention demonstrated how TOC pharmacists can effectively collaborate with the OPAT team, which builds on prior evidence of the role and value of pharmacists in the transitional care setting.

Background: Complicated intra-abdominal infections (cIAIs) require a combined tactic, of source control and antimicrobial therapy. This study aimed to evaluate the safety and efficacy of oral step-down antimicrobial therapy in cIAIs after initial intravenous (IV) antimicrobial therapy. Methods: This retrospective cohort study included hospitalized adult patients diagnosed with a cIAI who received more than seven days of IV therapy from March 2017 to October 2021. Exclusion criteria included primary/peritoneal dialysis-related peritonitis, necrotizing pancreatitis, fistulizing inflammatory bowel disease, or upper gastrointestinal tract infection. Patients were assigned into two groups: IV-only or oral step-down therapy. The primary outcome was infection recurrence, defined as re-initiation of antimicrobial agents after a treatment-free period of more than or equal to three days. Secondary outcomes included treatment escalation, repeat source control procedure, treatment-related complications, and all-cause mortality. Results: The cohort consisted of 248 patients (199 IV-only and 49 oral step-down). Patients receiving IV-only therapy had a shorter median antimicrobial duration than the oral step-down group (13 vs. 23 d; p <0.0001). Infection recurrence occurred in 26 (13.1%) and 6 (12.2%) patients in the IV-only and oral step-down groups, respectively (p = 0.88). Treatment escalation, repeat source control, and 28-day mortality were similar between groups. Oral step-down therapy resulted in more adverse drug events (10.2% vs. 3.0%; p = 0.04). Discussion: Transition to oral step-down after initial IV therapy had a similar rate of infection recurrence as IV-only therapy but was associated with a longer duration of antimicrobial therapy and an increased rate of adverse drug reactions. Larger randomized non-inferiority studies are needed to confirm this approach.

Pharmacists and physicians play key roles in antimicrobial stewardship. This commentary on a case describes these health professionals' need to collaborate to optimize therapeutic use of antimicrobials in clinical settings. Prescription preauthorization is one antimicrobial stewardship strategy that can meet with some physicians' frustration and generate conflict between pharmacists and prescribing physicians, particularly when pharmacists make alternative treatment recommendations. This commentary considers interprofessional tension concerning prescription preauthorization and suggests strategies for navigating such conflict.

OBJECTIVE:The purpose of this study is to investigate predictors of pressure injury (PrI) outcomes at one year after discharge for Veterans with spinal cord injury (SCI) hospitalized with a Stage 3 or 4 PrI. DESIGN/SETTING/PARTICIPANTS:This is a retrospective medical record review from one VA Health Care System SCI unit. Participants were Veterans with traumatic or non-traumatic SCI admitted with one Stage 3 or 4 pelvic PrI treated medically (e.g. without flap surgery). Logistic models were used to select the significant predictors of PrI healing outcomes. OUTCOME MEASURE:One year after discharge wound outcomes (healed vs non-healed) for Veterans with SCI hospitalized with a Stage 3 or 4 PrI. RESULTS:A total of 62 hospitalizations were included for analyses resulting in 33 healed and 29 non-healed PrIs. Three significant predictors of non-healed PrI outcomes included use of pressure mapping during hospitalization, greater PrI depth, and usage of alginate dressings. Two significant predictors of healed PrI outcomes included the use of animal-based tissue and hydrocolloid dressings. Area under curve of this logistic regression model was 79.98%. CONCLUSION:The clinical decision of having a patient pressure mapped predicts that the PrI may not heal at one year of discharge. Pressure mapping protocol correlated with another variable that could not serve as a predictor by itself, including using powered pressure relief techniques. The three PrI treatment predictors may represent characteristics of the PrI itself, rather than the efficacy of the product. Further investigation on these clinical decision-making factors is warranted to ensure efficient and cost-effective treatment strategies for individuals with SCI hospitalized with PrIs.

Abstract Background Oral abstract presentations (OAP) at national meetings are high visibility opportunities. However, there has not been a formal process for coaching presenters and providing feedback at IDWeek. We led a pilot project pairing ID-trained medical educators with OA presenters for feedback prior to and at IDWeek. Methods A link in IDWeek 2022 OAP acceptances invited presenters to participate in the OAP coaching pilot program (CPP). The link requested demographics, availability of local mentors to provide feedback, and areas of desired feedback for the OAP. Coaches were primarily solicited from the IDSA Med Ed Community of Practice Workgroups to give feedback pre-IDWeek, attend the IDWeek OAP, and provide feedback after. An anonymous survey was sent to presenters and coaches 8 days post-IDWeek. Results 38 presenters (median of 1 (IQR 0, 4) prior national OAP) requested to participate, despite 71% already having feedback available (table 1). Due to coaching pool limitations, presenters with no prior national OAPs and/or without local feedback were prioritized for the CPP. 22 (85%) and 18 (69%) of the 26 coaches and presenters responded to the post-IDWeek survey, respectively (table 2). Presenters and coaches largely overlapped regarding the types of feedback requested and delivered before and at IDWeek (table 3). Presenter qualitative comments highlighted the value provided in improving OAP visual display, delivery, clarity for those unfamiliar with the work, and the presenter’s confidence. Coaches described appreciation for the opportunity to practice providing feedback and feelings of pride and fulfillment in the improvements noted following the feedback. Both presenters and coaches commented on the benefit of meeting new colleagues and building networks. 94% of presenters and 91% of coaches reported professional/personal benefit from the CPP.Table 1:Characteristics of presenters requesting and selected to participate in the IDWeek Oral Abstract Coaching Pilot ProgramTable 2:Demographics of presenters and coaches in the IDWeek Oral Abstract Coaching Pilot ProgramTable 3:Results of IDWeek Oral Abstract Coaching Pilot Program evaluation survey Conclusion This OAP CPP was highly successful, with > 90% of presenters and coaches reporting professional/personal benefit and interest in participating again. In the future, a coach’s guide will be incorporated to increase feedback effectiveness across the desired OAP topics and to augment expansion of the pool of potential coaches. We hope coaching targeting these early career presenters can enhance engagement and recruitment into ID. Disclosures James B. Cutrell, MD, IDSA: stipend as Deputy Editor for Open Forum Infectious Diseases

Beta-lactam antibiotics are first-line for most infections during pregnancy and delivery. We assessed outcomes of proactive screening and referral from an obstetrics (OB) clinic for penicillin allergy evaluation.

The Infectious Diseases Society of America (IDSA) has set clear priorities in recent years to promote inclusion, diversity, access, and equity (IDA&E) in infectious disease (ID) clinical practice, medical education, and research. The IDSA IDA&E Task Force was launched in 2018 to ensure implementation of these principles. The IDSA Training Program Directors Committee met in 2021 and discussed IDA&E best practices as they pertain to the education of ID fellows. Committee members sought to develop specific goals and strategies related to recruitment, clinical training, didactics, and faculty development. This article represents a presentation of ideas brought forth at the meeting in those spheres and is meant to serve as a reference document for ID training program directors seeking guidance in this area.

ABSTRACT Objectives Outpatient parenteral antimicrobial therapy (OPAT) use has increased significantly as it provides safe and reliable administration of long-term antimicrobials for severe infections. Benefits of OPAT include fewer antibiotic or line-related complications, increased patient satisfaction, shorter hospitalizations, and lower costs. Although OPAT programs carefully screen patients for eligibility and safety prior to enrollment, complications can occur. There is a paucity of studies identifying predictors of clinical outcomes in OPAT patients. Here, we seek to identify baseline predictors of OPAT outcomes utilizing machine learning methodologies. Methods We used electronic health record data from patients treated with OPAT between February 2019 and June 2022 at a large academic tertiary care hospital in Dallas, Texas. Three primary outcomes were examined: 1) clinical improvement at 30 days without evidence of reinfection; 2) patient actively being followed at 30 days; and 3) occurrence of any adverse event while on OPAT. Potential predictors were determined a priori , including demographic and clinical characteristics, OPAT setting, intravenous line type, and antimicrobials administered. Three classifiers were used to predict each outcome: logistic regression, random forest, and extreme gradient boosting (XGBoost). Model performance was measured using AUC, F1, and accuracy scores. Results We included 664 unique patients in the study, of whom 57% were male. At 30 days, clinical improvement was present in 78% of patients. Two-thirds of patients (67%) were actively followed at 30 days, and 30% experienced an adverse event while on OPAT. The XGBoost model performed best for predicting treatment success (average AUC = 0.873), with significant predictors including ID consultation and the use of vancomycin. The logistic regression model was best for predicting adverse outcomes (average AUC = 0.710). Risk factors for adverse outcomes included management in the home setting and the use of vancomycin, daptomycin, or piperacillin-tazobactam. Conclusion Outcomes of patients undergoing OPAT can be predicted with the use of easily-obtainable clinical and demographic factors. Patients requiring certain antimicrobial therapies, such as vancomycin or daptomycin, may derive less benefit from early hospital discharge and OPAT.

COVID-19 is associated with acute myocardial injury in hospitalized patients, and those with abnormal troponin lev-els are at higher risk for death.1 Medical comorbidities such as advanced age, cardiovascular disease (CVD), hyperten-sion, and the severity of COVID-19 infection have been associated with elevated troponin in retrospective analyses.2,3 The primary aim of the study was to prospec-tively determine the association of cardiac injury measured by high-sensitivity troponin and the phenotype of cardiac injury, as determined in contrast-enhanced cardiac mag-netic resonance (CMR) imaging.

Abstract Background Complicated intra-abdominal infections (cIAIs) require a combined strategy of source control and antimicrobial therapy. Guidelines recommend initial intravenous (IV) therapy with oral step-down therapy following source control. Due to limited data supporting this strategy, we aimed to evaluate the safety and efficacy of oral step-down antimicrobial therapy in cIAIs after initial IV antimicrobial therapy. Methods This retrospective cohort study included hospitalized patients ≥ 18 years of age diagnosed with a cIAI who received > 7 days of IV therapy during index hospitalization at quaternary hospital from March 2017 to October 2021. Patients were excluded for primary or peritoneal dialysis-related peritonitis, necrotizing pancreatitis, fistulizing inflammatory bowel disease, or upper gastrointestinal tract infection; repeat hospitalization during study period; or transfer from another facility after > 24 hours of care. Patients were assigned into two treatment groups: IV-only or oral step-down therapy. The primary outcome was infection recurrence defined as re-initiation of antimicrobials after a treatment-free period of ≥ 3 days. Secondary outcomes included treatment escalation, repeat source control procedure, treatment-related complications, and all-cause mortality. Results The cohort consisted of 248 patients (199 IV-only and 49 oral step-down). Baseline, infection, and treatment characteristics were similar between groups, except for gender, length of stay, and overall treatment duration (Table 1). Patients receiving IV-only therapy had a shorter median antimicrobial duration than the oral step-down group (13 vs. 23 days; P < 0.001). Infection recurrence occurred in 26 (13.1%) and six (12.2%) patients in the IV-only and oral step-down groups, respectively (P = 0.88). Treatment escalation, repeat source control, and 28-day mortality were similar between groups (Table 1). Oral step-down therapy resulted in more adverse drug events (10.2% vs. 3.0%; P = 0.04). Table 1: Baseline and infection-related characteristics for IV only and oral step-down therapy groups aDefined as: solid organ transplant, hematopoietic stem cell transplant within the last 1 year, long-term high-dose steroids (prednisone >10 mg, or equivalent, for ≥2 weeks), concomitant immunosuppressive medication, or HIV (CD4 count <200 cells/µL) bOther antimicrobials included cephalexin, cefpodoxime, doxycycline, fluconazole, and sulfamethoxazole-trimethoprim cAdverse drug events included dermatologic reactions, gastrointestinal upset, nausea/vomiting, diarrhea, fatigue, thrombocytopenia, and acute kidney injury Conclusion Transition to oral step-down after initial IV antimicrobial therapy may be an alternative strategy for the management of cIAIs; however, larger non-inferiority studies are warranted to confirm the safety and efficacy of this approach. Disclosures James Sanders, PhD, PharmD, Merck & Co., Inc.: Grant/Research Support|Shionogi Inc.: Grant/Research Support Sara Hennessy, M.D., Boston Scientific: Advisor/Consultant Sara Hennessy, M.D., Boston Scientific: Advisor/Consultant.

Abstract Background Many abstracts are submitted to scientific meetings each year. Scholarly work benefits from peer review, yet specific feedback from abstract reviewers is rarely given to authors. Here reviewers provided feedback to all authors who submitted Medical Education abstracts to IDWeek 2021. Methods All IDWeek 2021 abstract reviewers for the Medical Education category were invited to an abstract review instructional webinar and were asked to provide feedback on each assigned abstract in a free text box on the review website. Each submitting author was sent this feedback when informed of their abstract disposition. In October 2021, these authors were sent an email containing a link to a survey soliciting their perspectives on the feedback; the survey included demographic questions and Likert scale questions. Descriptive data analysis was performed. All 10 reviewers participated in one of two virtual, semi-structured focus groups about their experience. Two authors conducted thematic analysis on transcripts. Results Among abstract authors, 18/26 (69%) responded to the survey. All respondents found the feedback helpful. Twelve (67%) incorporated the feedback into their IDWeek presentations. All 14 submitters who plan to write a manuscript intend to incorporate the feedback into that work. Most (94%) would want to receive feedback on future abstract submissions (Figure); all wish other scientific meetings would provide feedback on abstracts. Among reviewers, common themes included that they (1) provided more attentive reviews due to a sense of responsibility to provide thoughtful feedback, (2) found the work rewarding, (3) improved their abstract-reviewing skills, (4) planned to use this experience to help trainees write better abstracts, and (5) felt this activity built community within IDSA. While providing feedback required more time than past reviews, all would volunteer to provide feedback in the future. Conclusion Authors who submitted Medical Education abstracts to IDWeek valued abstract feedback and used it to strengthen their presentations; reviewers found it to be a positive experience and would do it again. IDSA and other societies should consider providing feedback for all abstract categories. Disclosures All Authors: No reported disclosures.

PURPOSE:Utilization of rapid diagnostic testing alongside intensive antimicrobial stewardship interventions improves patient outcomes. We sought to determine the clinical impact of a rapid blood culture identification (BCID) panel in an established Antimicrobial Stewardship Program (ASP) with limited personnel resources.METHODS:A single center retrospective pre- and post-intervention cohort study was performed following the implementation of a BCID panel on patients admitted with at least 1 positive blood culture during the study period. The primary outcome was time to optimal therapy from blood culture collection. Secondary outcomes included days of therapy (DOT), length of stay, and 30-day mortality and readmission rates.RESULTS:277 patients were screened with 180 patients included, with 82 patients in the pre-BCID and 98 in the post-BCID arms. Median time to optimal therapy was 73.8 hours (IQR; 1.1-79.6) in the pre-BCID arm and 34.7 hours (IQR; 10.9-71.6) in the post-BCID arm (p ≤ 0.001). Median DOT for vancomycin was 4 and 3 days (p ≤ 0.001), and for piperacillin-tazobactam was 3.5 and 2 days (p ≤ 0.007), for the pre-BCID and post-BCID arms, respectively. Median length of hospitalization was decreased from 11 to 9 days (p = 0.031). No significant change in 30-day readmission rate was noted, with a trend toward lower mortality (12% vs 5%; p = 0.086).CONCLUSION:Introduction of BCID into the daily workflow resulted in a significant reduction in time to optimal therapy for bloodstream infections and DOT for select broad-spectrum antibiotics, highlighting the potential benefits of rapid diagnostics even in settings with limited personnel resources.

Social media platforms have revolutionized how we consume information, along with how to effectively present communication, education, and advocacy efforts. There is profound value in leveraging social media within these aspects for the field of infectious diseases, for divisions and individual clinicians. Herein, we provide the rationale to incorporate social media as a key competency for infectious diseases training and specific guidance on aspects of education and strategic development of new accounts critical for success.

BACKGROUND:Journal clubs have been an enduring mainstay of medical education, and hosting these on social media platforms can expand accessibility and engagement. We describe the creation and impact of #IDJClub, an infectious diseases (ID) Twitter journal club.METHODS:We launched #IDJClub in October 2019. Using the account @IDJClub, an ID physician leads a 1-hour open-access Twitter discussion of a recent publication. All participants use the hashtag #IDJClub. Sessions started monthly, but increased due to demand during the coronavirus disease 2019 (COVID-19) pandemic. We used Symplur 's Healthcare Hashtag project to track engagement of #IDJClub per 60-minute discussion plus the following 30 minutes to capture ongoing conversations. We also conducted an online anonymous survey using Likert scales and open-ended questions to assess educational impact.RESULTS:In its first 20 months, 31 journal clubs were held, with medians of 42 (interquartile range [IQR], 28.5-60) participants and 312 (IQR, 205-427.5) tweets per session. 134 participants completed the survey, of whom 39% were ID physicians, 19% pharmacists, 13% ID fellows, and 10% medical residents. Most agreed or strongly agreed that #IDJClub provided clinically useful knowledge (95%), increased personal confidence in independent literature appraisal (72%), and was more educational than traditional journal clubs (72%). The format addressed several barriers to traditional journal club participation such as lack of access, subject experts, and time.CONCLUSIONS:#IDJClub is an effective virtual journal club, providing an engaging, open-access tool for critical literature appraisal that overcomes several barriers to traditional journal club participations while fostering connectedness within the global ID community.