Carbapenem-Resistant Enterobacterales Infection After Massive Blast Injury: Use of Cefiderocol Based Combination Therapy

ABSTRACT A military soldier sustained a blast injury in Afghanistan, resulting in amputations and hemipelvectomy. He developed New Delhi metallo-beta-lactamase-producing E. coli bacteremia, soft-tissue infection, and sacral osteomyelitis. These organisms are being increasingly discovered in different communities around the world. He was successfully treated with tigecycline and cefiderocol. Cefiderocol is a novel siderophore-based cephalosporine developed to treat serious infections, including those caused by carbapenem-resistant Enterobacterales.

334. Treatment Duration of Antibiotics for Sacral Osteomyelitis After Skin Flap Procedure

Background Patients with spinal cord injuries frequently develop sacral osteomyelitis. Optimal treatment often involves intravenous antibiotics and skin flap closure of the ulcer; however, best practices for the duration of antibiotic therapy pre- and post-procedure are unknown. Methods This was a retrospective, cohort study of spinal cord injury patients at the VA St. Louis undergoing a skin flap procedure from 1 October 2014 to 31 March 2019. Patients aged 18 to 89 years with a documented spinal cord injury and receiving treatment for sacral osteomyelitis with antibiotics and skin flap placement were considered for inclusion. The primary outcome was to determine if there was a difference in antibiotic treatment duration, both pre-procedure and post-procedure, between those that failed combination therapy and those patients for which the treatment was successful. Treatment failure was defined as documentation of no resolution of sacral osteomyelitis after treatment, re-initiation of antibiotics for sacral osteomyelitis of the same area, documented flap break-down, or an unplanned flap-related procedure within 1 year of completion of antibiotic therapy. Results Twelve patients were identified for inclusion. Baseline characteristics were similar between groups; 5/8 patients successfully treated received vancomycin, compared to 4/4 patients that failed therapy. Overall, 75% (8/12) had a successful treatment outcome at 12 months. In qualifying patients, average days of pre-procedure and post-procedure antibiotics were similar between patients who achieved success and those who failed (45.5 vs. 44.3 days pre-procedure, respectively (p >0.05) and 39 vs. 43 days post-procedure (p >0.05), respectively). When evaluated by weeks of therapy, no statistically significant differences were noted in treatment success rates between those treated for less than 6 weeks versus those treated for longer (66.6% [2/3] vs. 63.6% [6/9], p >0.05). Conclusion No difference in pre- or post-flap procedure antibiotic duration was observed in patients who failed therapy compared to those who were successfully treated. Disclosures All Authors: No reported disclosures

Large presacral abscess in a patient with Crohn’s disease

A presacral abscess with sacral osteomyelitis and gluteal abscesses is a very rare complication of Crohn’s disease and is often clinically unsuspected or overlooked. We report a case of a 58-year-old male who presented for right hip pain after a fall. An abdominal and pelvic CT scan showed an atypical presacral abscess with a fistulizing tract extending through the sciatic notch and lateral to the gluteus medius and minimus muscles forming an intramuscular abscess. The endoscopic transanal approach was used to drain the presacral abscess. This method of drainage was successful and the patient had a favorable prognosis.

1423. Antibiotic Utilization and Outcomes in Patients with Sacral Osteomyelitis and Decubitus Ulcers

Background Osteomyelitis is a common complication of advanced stage pressure ulcers and known to be associated with increased mortality, length of stay (LOS), and treatment costs. However, limited data and lack of guidelines regarding appropriate diagnosis and treatment result in variability in management. We sought to investigate whether microbiology data are associated with reduced antibiotic utilization in patients with osteomyelitis secondary to decubitus ulcers. Methods This retrospective cohort study included hospitalized patients from 2007 to 2015 with an advanced stage (IV or unstageable) sacral decubitus ulcer and clinical concern for osteomyelitis. The exposure group was those who underwent tissue culture (superficial swab, deep bedside or surgical tissue, or bone biopsy). The primary outcome was antibiotic days of therapy (DOT). Additional secondary outcomes including clinical characteristics at presentation, LOS, readmission rates, and antibiotic-related complications were evaluated using Fisher’s exact or Wilcoxon-Mann–Whitney test for continuous variables. Results A total of 220 cases of advanced-stage decubitus ulcer with clinical concern for osteomyelitis were identified. Data abstracted from 40 cases show that tissue cultures were obtained in 22 (55%). Bacterial growth was identified from 100% of samples sent for culture. Antibiotic use prior to admission was the most significant predictor of failure to obtain tissue cultures (P = 0.0002). MRI was performed in 15% of abstracted cases, with radiographic evidence of osteomyelitis noted in 100%. Bone biopsy was performed in 4 cases; bone pathology was not sent in any of these instances. Median antibiotic DOT was 84 days in both groups. Conclusion In cases of sacral osteomyelitis secondary to decubitus ulcers, antibiotic use prior to admission was inversely related to the likelihood of obtaining a tissue culture. When tissue cultures were obtained, they were uniformly positive; however, in our preliminary analysis of 40 cases, this did not appear to influence antibiotic utilization as determined by DOT. Bone biopsy was rarely performed, and when done, was not sent for pathology despite this being recognized as the gold standard in the diagnosis of osteomyelitis. Disclosures All authors: No reported disclosures.