136. Impact of an OPAT Pharmacist on Guideline Adherence and Clinical Outcomes

Abstract Background Outpatient parenteral antibiotic therapy (OPAT) provides select patients a cost-effective alternative to completing intravenous (IV) antibiotic therapy outside the hospital. The Infectious Diseases Society of America (IDSA) OPAT practice guidelines and handbook recommend weekly laboratory monitoring and timely follow-up for OPAT patients. An analysis at VA Palo Alto Healthcare System (VAPAHCS) conducted prior to pharmacist involvement demonstrated that IDSA recommendations were not routinely followed, leading to a clinical cure rate of 62.7%. This led to the implementation of an OPAT pharmacist in 2019. This analysis aims to determine the impact of a pharmacist-managed OPAT program at VAPAHCS. Methods This comparative, retrospective analysis included patients who received OPAT at VAPAHCS between October 1, 2019 and September 30, 2020 and those who received OPAT in a prior analysis. Primary outcomes included rates of adherence to IDSA recommendations on follow-up visits and weekly lab monitoring during OPAT. Secondary outcomes included rates of clinical cure, 90-day readmission, and adverse events or complications. Data was analyzed using Fisher’s exact test and independent t-test. Results This analysis included 74 patients and 76 total OPAT episodes. Bacteremia was the most common diagnosis (n=35, 38.0%), and the most common organism was methicillin-susceptible Staphylococcus aureus (MSSA) (n=23, 29.9%). With respect to guideline adherence pre- and post- pharmacist-managed OPAT, 31.3% versus 93.4% of patients had follow-up within 7 to 14 days of discharge (p< 0.001). Rates of weekly lab monitoring of CBC, BMP, and LFTs pre-pharmacist were 63.2%, 63.3%, and 49.5%, respectively, compared to post-pharmacist rates of 93.0%, 92.1%, and 83.6%, respectively. Clinical cure rates were 62.7% pre-pharmacist and 89.6% post-pharmacist (p< 0.001). More adverse drug reactions were identified in the post-pharmacist period, of which 30% required pharmacist intervention. Figure 1. Weekly Laboratory Monitoring of Antimicrobials (%) Figure 2. Adherence to IDSA Guideline Follow-up Recommendation Figure 3. Rates of Clinical Cure Conclusion Pharmacist involvement in OPAT significantly increased IDSA guideline adherence to lab monitoring and follow-up visits, and clinical cure rates. Identification of adverse drug reactions prompting pharmacist intervention further highlights the importance of follow-up in OPAT patients. Disclosures All Authors: No reported disclosures

. Quarterly risk-adjusted rates of A) lactate testing, B) anti-MRSA antibiotic administration, and C) anti-Pseudomonal beta-lactam antibiotic administration within 24 hours of hospital presentation for patients with suspected sepsis before and after SEP-1 implementation in Q4 2015.
All models included time (in quarters), an indicator of the post-SEP-1 implementation period (starting Q12016, to allow for evaluation of an immediate policy effect), and a two-way interaction term to assess whether SEP-1 implementation resulted in a change in trend. When data suggested no change in trend, models were also fit without this interaction term; this yielded a significant association for an immediate level change in lactate testing (OR 1.34 [95% CI 1.04-1.74]) but not antibiotic utilization. All analyses were adjusted for patient severity of illness and baseline characteristics including age, sex, race, initial vital signs (systolic blood pressure, temperature, respiratory rate, heart rate), and initial laboratory results (creatinine, platelet count, bilirubin, white blood cell count) if done within 24 hours. Figure 2. Quarterly risk-adjusted outcomes of patients with suspected sepsis before and after SEP-1 implementation in Q4 2015: A) In-hospital death or discharge to hospice, and B) In-hospital death alone.
Models included time (in quarters), an indicator of the post-SEP-1 implementation period (starting Q12016, to allow for evaluation of an immediate policy effect), and a two-way interaction term to assess whether SEP-1 implementation resulted in a change in trend. Analyses were adjusted for patient severity of illness and baseline characteristics including age, sex, race, initial vital signs (systolic blood pressure, temperature, respiratory rate, heart rate), and initial laboratory results (creatinine, platelet count, bilirubin, white blood cell count) if done within 24 hours.
Conclusion. SEP-1 implementation was associated with an immediate increase in lactate testing rates, no significant change in already-rising rates of broad-spectrum antibiotic use, and no change in short-term mortality rates for patients with suspected sepsis in a large cohort of hospitals. Other approaches to decrease sepsis mortality may be warranted.

Impact of an OPAT Pharmacist on Guideline Adherence and Clinical Outcomes
Alice Lin, PharmD 1 ; Trisha S. Nakasone, PharmD, BCPS AQ-ID 1 ; Nancy N. Nguyen, PharmD, BCPS, AAHIVP, FCSHP 2 ; Catherine Yang, PharmD 1 ; Background. Outpatient parenteral antibiotic therapy (OPAT) provides select patients a cost-effective alternative to completing intravenous (IV) antibiotic therapy outside the hospital. The Infectious Diseases Society of America (IDSA) OPAT practice guidelines and handbook recommend weekly laboratory monitoring and timely follow-up for OPAT patients. An analysis at VA Palo Alto Healthcare System (VAPAHCS) conducted prior to pharmacist involvement demonstrated that IDSA recommendations were not routinely followed, leading to a clinical cure rate of 62.7%. This led to the implementation of an OPAT pharmacist in 2019. This analysis aims to determine the impact of a pharmacist-managed OPAT program at VAPAHCS.
Methods. This comparative, retrospective analysis included patients who received OPAT at VAPAHCS between October 1, 2019 and September 30, 2020 and those who received OPAT in a prior analysis. Primary outcomes included rates of adherence to IDSA recommendations on follow-up visits and weekly lab monitoring during OPAT. Secondary outcomes included rates of clinical cure, 90-day readmission, and adverse events or complications. Data was analyzed using Fisher's exact test and independent t-test.
Results. This analysis included 74 patients and 76 total OPAT episodes. Bacteremia was the most common diagnosis (n=35, 38.0%), and the most common organism was methicillin-susceptible Staphylococcus aureus (MSSA) (n=23, 29.9%). With respect to guideline adherence pre-and post-pharmacist-managed OPAT, 31.3% versus 93.4% of patients had follow-up within 7 to 14 days of discharge (p< 0.001). Rates of weekly lab monitoring of CBC, BMP, and LFTs pre-pharmacist were 63.2%, 63.3%, and 49.5%, respectively, compared to post-pharmacist rates of 93.0%, 92.1%, and 83.6%, respectively. Clinical cure rates were 62.7% pre-pharmacist and 89.6% post-pharmacist (p< 0.001). More adverse drug reactions were identified in the post-pharmacist period, of which 30% required pharmacist intervention.  Conclusion. Pharmacist involvement in OPAT significantly increased IDSA guideline adherence to lab monitoring and follow-up visits, and clinical cure rates. Identification of adverse drug reactions prompting pharmacist intervention further highlights the importance of follow-up in OPAT patients. Background. Cytopenias are rare complications of prolonged beta-lactam use; however, incidence and associated risk factors are not well described.

Risk Factors of B-lactams Associated Cytopenias during Outpatient Parenteral Antimicrobial Therapy: Results from a Large National Sample
Methods. Patients aged 18-64 years in the 2010-2016 IBM MarketScan Commercial Database discharged from the hospital on cephalosporin, penicillin, or carbapenem outpatient Parenteral Antimicrobial Therapy (OPAT) were included. The primary endpoint was hospital admission coded for neutropenia, leukopenia, or thrombocytopenia within the first 6 weeks post index discharge and within 7 days of beta-lactam discontinuation. Patients with history of malignancy and those who are on chemotherapy were excluded. Significant factors in univariate analysis were incorporated into a multivariable logistic regression model with sequential exclusion of variables with p > 0. Conclusion. Readmissions with cytopenias during beta-lactam OPAT were rare and carbapenem use was associated with lower risk compared to other classes of beta-lactams. Combination of beta-lactam with vancomycin was associated with an increased risk of cytopenias, and those patients might benefit from closer monitoring.