28. The Paradox of an Integrated MAT OPAT Program

Abstract Background Patients with substance use disorders (SUD), specifically opioid use disorder (OUD) and injection drug use (IDU) utilize healthcare resources for prolonged inpatient treatment of serious infections stemming from their addictions. For a variety of reasons, physicians treating these patients refuse to send these patients home to receive outpatient parenteral antimicrobial therapy (OPAT), and instead keep the patient in the hospital for several weeks or longer to complete treatment for the injection-related infections. Patients who do not have history of IDU are sent home with a PICC line to receive OPAT once they are no longer acutely ill and therefore no longer meet criteria to remain inpatient, which is the established standard of care. Patients with OUD and IDU are not allowed the same standard of care, and furthermore do not receive adequate, if any, therapy for their primary problem and reason for their serious infection – the addiction. Flow chart of the MAT-OPAT process Methods Medication-assisted treatment (MAT) with buprenorphine-naloxone has been approved for treating adults with opioid use disorder as part of a comprehensive treatment program that also includes counseling and behavioral therapy. Until now in our healthcare system there has been no comprehensive and integrated program to safely discharge patients with OUD and IDU to receive OPAT via a PICC line, while simultaneously treating their addiction. We describe the implementation of a MAT-OPAT program. Please refer to the chart included. Results We present a successful case of a 36-year-old male with a history of endocarditis associated with IV drug use and the intervention of the Healthcare System to link the patient to appropriate Infectious disease, behavioral health and medication adherence treatment for opioid abuse. The patient completed the IV antibiotic therapy and remained enrolled in the behavioral health program with a successful outcome. Conclusion MAT-OPAT implementation in large healthcare system with continuous outpatient support that includes Infectious Disease services, behavioral health and drug abuse rehabilitation therapy can be a successful strategy to minimize readmisión, cost and complications in patients with history of IV drug use and infections that require prolonged intravenous antibiotic therapy. Disclosures All Authors: No reported disclosures

Background. Patients with substance use disorders (SUD), specifically opioid use disorder (OUD) and injection drug use (IDU) utilize healthcare resources for prolonged inpatient treatment of serious infections stemming from their addictions. For a variety of reasons, physicians treating these patients refuse to send these patients home to receive outpatient parenteral antimicrobial therapy (OPAT), and instead keep the patient in the hospital for several weeks or longer to complete treatment for the injection-related infections. Patients who do not have history of IDU are sent home with a PICC line to receive OPAT once they are no longer acutely ill and therefore no longer meet criteria to remain inpatient, which is the established standard of care. Patients with OUD and IDU are not allowed the same standard of care, and furthermore do not receive adequate, if any, therapy for their primary problem and reason for their serious infection -the addiction.

Flow chart of the MAT-OPAT process
Methods. Medication-assisted treatment (MAT) with buprenorphine-naloxone has been approved for treating adults with opioid use disorder as part of a comprehensive treatment program that also includes counseling and behavioral therapy. Until now in our healthcare system there has been no comprehensive and integrated program to safely discharge patients with OUD and IDU to receive OPAT via a PICC line, while simultaneously treating their addiction. We describe the implementation of a MAT-OPAT program. Please refer to the chart included.
Results. We present a successful case of a 36-year-old male with a history of endocarditis associated with IV drug use and the intervention of the Healthcare System to link the patient to appropriate Infectious disease, behavioral health and medication adherence treatment for opioid abuse. The patient completed the IV antibiotic therapy and remained enrolled in the behavioral health program with a successful outcome.

Conclusion.
MAT-OPAT implementation in large healthcare system with continuous outpatient support that includes Infectious Disease services, behavioral health and drug abuse rehabilitation therapy can be a successful strategy to minimize readmisión, cost and complications in patients with history of IV drug use and infections that require prolonged intravenous antibiotic therapy. Background. Broad-spectrum antimicrobials, like carbapenems, are often initiated empirically and can be continued for long periods of time, which may increase rates of multi-drug resistant organisms. Antimicrobial stewardship programs (ASP) have been shown to decrease the duration of antimicrobial therapy. Since July 2017 at UTMB Health, meropenem use has been restricted to infectious diseases and intensive care unit (ICU) providers. This study evaluated the impact of an electronic medical record (EMR)-based ASP intervention on meropenem days of therapy (DOT) in patients transitioning from the ICU to the general floors.

Impact of Antimicrobial Stewardship Intervention on Unrestricted Meropenem Use Upon Transitions of Care
Methods. Patients aged at least 18 years with an active medication order for meropenem upon transition from an ICU to a medical/surgical unit were included. Once transitioned, the active meropenem order appeared in the "review" column of the pharmacists' queue. Pharmacists contacted the primary team, requested infectious diseases or ASP approval to continue therapy, and documented communication in the chart. Data for the preand post-intervention groups was collected retrospectively for the months of November 2017 to April 2018 and March 2020 to August 2020. The primary outcome of the study was meropenem DOT after transition from the ICU to the medical/surgical unit. Secondary outcomes of the study included meropenem total DOT, total number of meropenem doses after transfer to the medical unit, 30-day all-cause mortality, and 30-day readmission.
Results. A total of 163 patients were evaluated in both the pre-intervention (n = 87) and post-intervention groups (n = 76). Median meropenem DOT after transition of care (3 days vs. 2 days, P = 0.0004) and number of meropenem doses after transition (6 doses vs. 4 doses, P = 0.014) were significantly lower after TOC intervention implementation. However, total meropenem DOTs were not different at 5 days in both groups. Recommendations for de-escalation or discontinuation were accepted 60% of the time among providers.
Conclusion. An EMR-based ASP intervention did decrease meropenem DOT after patients were transitioned from the ICU to the medical/surgical floors. Results of the meropenem EMR-based ASP intervention may be used to expand to other broad-spectrum antimicrobials/antifungals in patients transitioning levels of care. Background. The purpose of this study is to implement the PEN-FAST Penicillin Allergy Screening Tool in the emergency department to identify low risk patients with inappropriate penicillin-related allergies to transition them to a beta-lactam. Newly published, validated, penicillin allergy clinician decision tool (PEN-FAST) allows healthcare providers to identify low risk penicillin allergies with a negative predictive value of 96%. This quick, five question clinical decision tool allows healthcare providers and antimicrobial stewardship programs to identify patients who would also test negative if a formal penicillin allergy test was performed, making the process to confidently identify inappropriately labeled penicillin-related allergies more efficient.

Implementation of the PEN-FAST Penicillin Allergy Screening Tool in the Emergency Department During Medication Reconciliation
Methods. During routine medication reconciliations, pharmacists will identify patients who have a documented penicillin-related allergy in the EMR and use the PEN-FAST screening tool. Patients meeting inclusion criteria will have their penicillin-related allergy updated in the EMR based upon their assessed risk of very low, low, moderate, or high. The primary outcomes for this study are the percentage of patients screened that were classified as "very low and low risk" and percentage penicillin-related allergies updated. The secondary outcomes are the percentage of patients that required antibiotic therapy (post-allergy update) that were transitioned to a beta-lactam, inpatient broad-spectrum antibiotic usage before and after allergy update, and time spent interviewing each patient.
Results. A total of 59 patients were interviewed using the PEN-FAST Tool. The results for the primary outcomes indicate 92% (n=54) of patient allergies updated in the EMR, 24% (n=13) of patients classified as "very low risk" and 34% (n=18) of patients classified as "low risk". Results for the secondary outcome showed out of the 36 patients that were on non-beta lactams during allergy update, 72% (n=26) of those patients were transitioned to a beta-lactam. The average time to complete the PEN-FAST Tool was 4.2 minutes.
Conclusion. The results of this study support the use of the PEN-FAST Tool in efficiently updating patient's allergies in the EMR and identifying low risk patients who may be eligible for beta-lactam therapy.
Disclosures. All Authors: No reported disclosures