812. The Impact of Post-Operative Cephalexin on Surgical Site (SSI) Infections During a Cefazolin Shortage

Abstract Background Drug shortages directly impact patient care. Rates of drug shortages have declined except for antimicrobials, where shortage rates remain similar each year.1 In November 2018, a national cefazolin shortage occurred driving health systems to implement a therapeutic interchange of cefazolin for cephalexin for post-operative antimicrobial prophylaxis. The objective of this study is to determine whether SSI-rates change when post-operative cephalexin is used in placed of cefazolin. Methods This was a retrospective, observational cohort study of patients receiving post-operative antimicrobial prophylaxis at a community-based health system in Oregon and Washington between May 2018 – August 2019. Participants were divided into 3 periods for SSI-rate trend analysis: pre-shortage (May 2018 – October 2018), shortage (November 2018 – February 2019), and post-shortage (March 2019 – August 2019). The primary outcome was SSI-rates between groups. Results There were 6,378 patients in total (5,840 cefazolin vs. 538 cephalexin). There were no significant differences in baseline characteristics of age, sex, body mass index (BMI), or hospital location. The rate of SSI between pre-shortage and post-shortage cefazolin groups was not statistically different (14 [0.5%] vs. 23 [0.8%]; p=0.16). The primary outcome of SSI in the shortage group who received cephalexin was not statistically different (37 [0.6%] vs. 0 [0%]; p=0.07). Conclusion National drug shortages significantly impact patient care, often leading to seeking evidence-poor alternative medications. These results suggest cephalexin may be an acceptable post-operative prophylaxis antimicrobial if cefazolin is unavailable. Disclosures All Authors: No reported disclosures


Impact of the COVID-19 Pandemic on Surgical Volume and Surgical Site Infections (SSI) in a Large Network of Community Hospitals
Erin Gettler, MD 1 ; Jessica Seidelman, MD, MPH 2 ; Becky A. Smith, MD 2 ; Deverick J. Anderson, MD, MPH 3 ; 1 Duke University School of Medicine, Durham, NC; 2 Duke University, Durham, NC; 3 Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC Session: P-44. HAI: Surgical Site Infections Background. The COVID-19 pandemic significantly impacted hospitalizations and healthcare utilization. Diversion of infection prevention resources toward COVID-19 mitigation limited routine infection prevention activities such as rounding, observations, and education in all areas, including the peri-operative space. There were also changes in surgical care delivery. The impact of the COVID-19 pandemic on SSI rates has not been well described, especially in community hospitals.
Methods. We performed a retrospective cohort study analyzing prospectively collected data on SSIs from 45 community hospitals in the southeastern United States from 1/2018 to 12/2020. We included the 14 most commonly performed operative procedure categories, as defined by the National Healthcare Safety Network. Coronary bypass grafting was included a priori due to its clinical significance. Only facilities enrolled in the network for the full three-year period were included. We defined the pre-pandemic time period from 1/1/18 to 2/29/20 and the pandemic period from 3/1/20 to 12/31/20. We compared monthly and quarterly median procedure totals and SSI prevalence rates (PR) between the pre-pandemic and pandemic periods using Poisson regression.
Results. Pre-pandemic median monthly procedure volume was 384  and the pre-pandemic SSI PR per 100 cases was 0.98 (IQR 0.90-1.04). There was a transient decline in surgical cases beginning in March 2020, reaching a nadir of 185 cases in April, followed by a return to pre-pandemic volume by June (figure 1). Overall and procedure-specific SSI PRs were not significantly different in the COVID-19 period relative to the pre-pandemic period (total PR per 100 cases 0.96 and 0.97, respectively, figure 2). However, when stratified by quarter and year, there was a trend toward increased SSI PR in the second quarter of 2020 with a PRR of 1.15 (95% CI 0.96-1.39, table 1).

Conclusion.
The decline in surgical procedures early in the pandemic was shortlived in our community hospital network. Although there was no overall change in the SSI PR during the study period, there was a trend toward increased SSIs in the early phase of the pandemic (figure 3). This trend could be related to deferred elective cases or to a shift in infection prevention efforts to outbreak management. Background. Drug shortages directly impact patient care. Rates of drug shortages have declined except for antimicrobials, where shortage rates remain similar each year. 1 In November 2018, a national cefazolin shortage occurred driving health systems to implement a therapeutic interchange of cefazolin for cephalexin for post-operative antimicrobial prophylaxis. The objective of this study is to determine whether SSI-rates change when post-operative cephalexin is used in placed of cefazolin.

The Impact of Post-Operative Cephalexin on Surgical Site (SSI) Infections During a Cefazolin Shortage
Methods. This was a retrospective, observational cohort study of patients receiving post-operative antimicrobial prophylaxis at a community-based health system in Oregon and Washington between May 2018 -August 2019. Participants were divided into 3 periods for SSI-rate trend analysis: pre-shortage (May 2018 -October 2018), shortage (November 2018 -February 2019), and post-shortage (March 2019 -August 2019). The primary outcome was SSI-rates between groups.
Results. There were 6,378 patients in total (5,840 cefazolin vs. 538 cephalexin). There were no significant differences in baseline characteristics of age, sex, body mass index (BMI), or hospital location. The rate of SSI between pre-shortage and post-shortage cefazolin groups was not statistically different (14 [0.5%] vs. 23 [0.8%]; p=0.16). The primary outcome of SSI in the shortage group who received cephalexin was not statistically different (37 [0.6%] vs. 0 [0%]; p=0.07).
Conclusion. National drug shortages significantly impact patient care, often leading to seeking evidence-poor alternative medications. These results suggest cephalexin may be an acceptable post-operative prophylaxis antimicrobial if cefazolin is unavailable.
Disclosures. Background. Staphylococcus aureus surgical site infection (SSI) is common and devastating clinically. Pre-operative decolonization is associated with reduced incidence, but has been variably adopted due to barriers implementing high-efficacy prevention bundles, including unintentional non-compliance applying intra-nasal mupirocin by patients at home. Three Veterans Affairs (VA) facilities attempted to implement an alternate evidence-based SSI prevention program that included intranasal povidone-iodine used in the pre-operative setting to reduce challenging patient-burden steps and to overcome other mupirocin barriers. Our objective was to identify strategies used for successful implementation of intranasal povidone-iodine.
Methods. We conducted pre-and post-implementation semi-structured interviews and site visits at three VA hospitals. Participants included surgery and clinic staff (e.g., nurses, physicians, care managers), infection control staff, and administrative leadership. Interviews were audio recorded and transcribed. Our interdisciplinary team performed a deductive and inductive consensus-based analysis.
Results. Implementation of this SSI prevention process was successful when nurse champions drove the implementation. Qualitative interviews indicate that nurses used a variety of strategies and messages variant on their audience. Nurse-driven facilitators included: key leadership buy-in and strategic decisions about timing and setting of implementation (i.e., start implementation in units with likely early adopters then when project is working well circle back to the early detractors). The primary implementation barrier identified was lack of a champion. One site stated that in the absence of a champion, a mandate or top-down approach may be needed for implementation at their facility.
Conclusion. Nurse champions facilitated successful SSI prevention process implementation. Nurses used strategies and approaches dependent on their knowledge and understanding of the stakeholders and setting to obtain buy-in. Background. CA PDI is increasingly recognized. CA is felt to create a slime layer that makes infection more likely and treatment more difficult in this setting. Traditional management has included prosthetic device explantation (PDE), prolonged antibiotic treatment, and delayed reimplantation. Recent interest in the use of oral treatment regimens and single stage procedures with long duration antibiotic therapy led us to treat a series of patients with oral treatment and retained prosthesis after debridement. We report those results.
Methods. Sequential patients with CA PDI treated with oral therapy were identified. All patients underwent debridement of the tissue, exchange of components and/or reimplantation of the prosthetic device. Only patients with exchanges were included. PDE was excluded. MIC testing for CA isolates was obtained when possible. Initial treatment was recorded at time of surgery. LR was the treatment of choice unless toxicity developed. A minimum of a 3-month follow-up post treatment was required to be included. 6 and 12 month follow up were obtained for all patients but 1 at this time.
Results. 10 patients were treated (Table 1). Shoulder joint infections were most common. All patients were treated with LR. All completed a minimum of 42 days of treatment ( Table 2). The medication was well tolerated. The most common adverse events were nausea. 9/10 patients with 12 month follow up had no evidence of relapse. 1/10 had no relapse at 3 months. Typical for CA infection laboratory markers for infection were not markedly elevated. Notably thrombocytopenia did not occur (Table 3).

Conclusion.
We demonstrated the ability to successfully treat 10/10 patients with CA PDI without explantation using prolonged oral treatment with LR after debridement. This combination should be considered a treatment option and explored further as a low cost, well tolerated, high value treatment approach to this difficult infection.