bluuebunny/crossref_metadata_2025 huggingface dataset:
169. Development of a Real Time Electronic Algorithm to Identify Hospitalized Patients with Community-Acquired Pneumonia
Authors: Fabre Valeria , Fabre Valeria , Jones George , Amoah Joe , Klein Eili , Leeman Hannah , Milstone Aaron , Milstone Aaron , Smith Aria , Levin Scott , Cosgrove Sara E
Published: January 2021

Background

Syndrome-based antibiotic stewardship can be limited by difficulty in finding cases for evaluation. We developed an electronic extraction algorithm to prospectively identify CAP patients.

Methods

We included non-oncology patients ≥18 years old admitted to The Johns Hopkins Hospital from 12/2018 to 3/2019 who 1) received common CAP antibiotics for ≥48 hours after admission and 2) had a bacterial urinary antigen and chest imaging ordered within 48 hours of admission that was not for assessment of endotracheal tube or central line placement. Charts of patients meeting these criteria were reviewed by 2 authors to identify true cases of CAP based on IDSA guidelines. Cases identified in 12/2018 (n=111) were used to explore potential indicators of CAP, and cases identified 1–3/2019 (n=173) were used to evaluate combinations of indicators that could identify patients treated for CAP who did have CAP (true CAP) and did not have CAP (false CAP). This cohort was divided into a training and a validation set (2/3 and 1/3, respectively). Potential indicators included vitals signs, laboratory data and free text extracted via natural language processing (NLP). Predictive performance of composite indicators for true CAP were assessed using receiver-operating characteristics (ROC) curves. The Hosmer-Lemeshow goodness fit test was used to test model fit and the Akaike Information Criteria was used to determine model selection.

Results

True CAP was observed in 41% (71/173) of cases and 14 potential individual indicators were identified (Table). These were combined to make 45 potential composite indicators. ROC curves for selected composite indicators are shown in the Figure. Models without use of NLP-derived variables had poor discriminative ability. The best model included fever, hypoxemia, leukocytosis, and “consolidation” on imaging with a sensitivity and positive predictive value 78.7% and specificity and negative predictive value of 85.7%.

Table. Indicators evaluated to identify patients with CAP

Figure. ROC curves for composite indicators

Conclusion

Patients with CAP can be identified using electronic data but use of NLP-derived radiographic criteria is required. These data can be linked with data on antibiotic use and duration to develop reports for clinicians regarding appropriate CAP diagnosis and treatment.

Disclosures

All Authors: No reported disclosures
170. Development of Key Indicators for Appropriate Antibiotic Use in Republic of Korea: a Systematic Review followed by Delphi Procedure
Authors: Kim Bongyoung , Lee Myung Jin , Park Se Yoon , Moon Song Mi , Song Kyung Ho , Kim Tae Hyong , Kim Eu Suk , Kim Hong Bim
Published: January 2021

Background

The aim of this study was to develop a set of key quality indicators (QIs) for application to nationwide point surveillance of appropriateness of antibiotic usage in Republic of Korea.

Methods

A systematic literature review was performed in order to retrieve a list of potential key QIs. These candidates were evaluated by multidisciplinary expert panel using a RAND-modified Delphi procedure, using two online questionnaires and a face-to-face meeting between them. Twenty-five expert panels with diverse backgrounds (infectious diseases specialist, urologist, laboratory medicine doctors, pediatric infectious disease specialists, otorhinolaryngology doctors, gastrointestinal doctors, pulmonologist, general surgeon, and researcher in National Evidence-Based Healthcare Collaborating Agency) participated in the consensus procedure. A Likert scale (ranging 1–7) was used for the evaluation of appropriateness of the potential key QIs and items with median score 6 or 7 were accepted if there was no disagreement. In addition, we grade each QI into admission, outward, or surgical prophylaxis using the Likert scale. If the score was 6 or 7, we considered it as appropriate application.

Results

The systematic literature review identified 23 potential QIs, from 21 studies. Ultimately, 17 key indicators were retained, with a high level of agreement (13 QIs for admitted patients, 7 for outward patients and 3 for surgical prophylaxis) (Figue 1). After sum of importance score and applicability, 6 key QIs [6 QIs (1–6) for admitted patients and 3 (1, 2 and 5) for outward patients] were finally selected: (1) prescribe empirical antibiotic therapy according to guideline, (2) change empirical to pathogen-directed therapy, (3) take cultures from suspected sites of infection, (4) take 2 blood cultures, (5) adapt antibiotic dosage to renal function, and (6) document antibiotic plan (Table 1). In surgical prophylaxis, prescribe according to guideline and initiate antibiotics one hour before incision was finally selected (Table 2).

Figure 1. Flowchart of the study

Table 1. Ranking in key indicators for admitted and out patients and applicability in point surveillance study.

Table 2. Ranking in key indicators for surgical prophylaxis and applicability in point surveillance study.

Conclusion

We identified key QIs to measure the appropriateness of antibiotics. These QIs can be used to identify targets for improvement and to evaluate the effects of antibiotic stewardship intervention.

Disclosures

All Authors: No reported disclosures
173. Identification of Inappropriate Antibiotic Orders During a Pharmacy-Supported Antimicrobial Stewardship Program in the Primary Care Setting: A Retrospective Analysis
Authors: Eckardt Paula , Mohammed Sheerida Hosein , Singh-Franco Devada , Wolowich William R
Published: January 2021

Background

In Florida, the number of antibiotic prescriptions has increased from 710–779 prescription/1000 population in 2012 to 748–839 prescription/1000 population in 2017. Antimicrobial stewardship in the outpatient setting is a suggested solution to combat antibiotics misuse in ambulatory practices.

Methods

This was a retrospective review of oral antimicrobial orders generated by primary care providers. The research protocol received approval from Memorial Healthcare System’s Institutional Review Board prior to any research related analysis being conducted. Orders from January 1-December 31, 2018 were reviewed for appropriateness by pharmacy based on IDSA guidelines. Appropriateness was assessed based on the need to prescribe the antibiotic for indication, selection, dose and duration of therapy. Descriptive statistics were used to analyze data.

Results

Of 2995 orders, 50.2% were inappropriate. The most common infections associated with inappropriate antibiotic use were upper/lower respiratory tract infections (URTIs (65%) and LRTIs (61%)), oral cavity infections (61%), and skin/soft tissue infections (SSTI (54%)). Inappropriately-prescribed antibiotics were penicillin (62%), cephalosporins (56%), quinolones (50%), macrolides (49%), and sulfamethoxazole/trimethoprim (46%). Penicillin use for URTIs were inappropriate (406 orders) for the following reasons: duration of therapy only 116/137 (85%); dose and duration 36/58 (62%), drug and dose 12/58 (21%) and all three (drug, dose, duration 85/93 (91%)).

Conclusion

Implementation of a pharmacist-driven antibiotic stewardship program in the primary care setting identified a significant proportion of orders that were inappropriate for type of antibiotic, dose, and duration of therapy in the management of patients with URTIs. These results serve as an avenue to implement the audit feedback process to promote appropriate use of antibiotics. A process improvement plan will include sharing of the findings, educating primary care physicians per IDSA guidelines and continuous review of prescribing trends. A programmatic evaluation will continue on an on-going basis to decrease the number of inappropriately prescribed antibiotics.

Disclosures

All Authors: No reported disclosures
174. Impact of Cascade Reporting of Antimicrobial Susceptibility on Antimicrobial Consumption at a Veterans Affairs Medical Center
Authors: Vissichelli Nicole C , Orndahl Christine M , Cecil Jane A , Hill Emily , Sabo Roy T , Stevens Michael , Tassone Daniel , Vaughan Leroy , Markley John D , Hitchcock Matthew M
Published: January 2021

Background

Cascade reporting (CR) is a strategy of reporting antimicrobial susceptibility test results in which secondary agents are only reported if an organism is resistant to primary, narrow spectrum agents within a drug class. A multidisciplinary team developed CR algorithms for Gram-negative bacteria based on the local antibiogram and infectious diseases practice guidelines.

Methods

CR was implemented at a 399-bed tertiary care VAMC in March 2018. In a quasi-experimental study, antimicrobial use data across 8 inpatient units were extracted from the CDC’s NHSN AU module from April 2017 – March 2019 (12 months pre- and post-implementation of CR), reported as antimicrobial days of therapy (DOT) per 1000 days present (DP). T-tests and linear mixed models accounting for seasonal and random unit effects were used to compare antimicrobial use pre- and post-CR implementation.

Figure 1A. Cascade reporting algorithm for antimicrobial susceptibility reporting for Enterobacteriaceae

Figure 1B. Cascade reporting algorithm for antimicrobial susceptibility reporting for Pseudomonas aeruginosa

Results

Following CR implementation, mean monthly meropenem (p=0.005) and piperacillin/tazobactam (p=0.002) use decreased, while cefepime use increased (p< 0.001). The slope of ciprofloxacin use decreased by 2.16 DOTs/1,000 DP per month (SE=0.25, p< 0.001). The slope of cefpodoxime and moxifloxacin use decreased by 18% (p< 0.001), and 7% (p< 0.001), respectively. The slope of cephalexin use decreased by 0.55 DOTs/1,000 DP (SE=0.26, p< 0.001). The slope of ceftriaxone and cefepime use increased by 1.51 (SE=0.59, p=0.011) and 1.06 (SE=.32, p=0.002) DOTs/1000 DP per month, respectively. There were no significant changes in the slope of amoxicillin/clavulanate, levofloxacin, or meropenem consumption. Rates of Clostridioides difficile infection did not significantly change.

Figure 2A. Average monthly use of oral antibiotics across all units in average days of therapy (DOTs) per 1000 days present. CR = Cascade reporting. *For Cefpodoxime and moxifloxacin medians were reported as data was not normally distributed.

Figure 2B. Average monthly use of intravenous antibiotics across all units in average days of therapy (DOTs) per 1000 days present. CR = Cascade reporting.

Table 1. Slope of Antimicrobial Utilization Pre and Post-Cascade Reporting Implementation.

Conclusion

After implementation of CR, the slope of ciprofloxacin use decreased and mean monthly meropenem use decreased. CR is a valuable tool that can be employed by ASPs to encourage optimal use of antibiotics.

Disclosures

All Authors: No reported disclosures
176. Impact of pharmacist electronic communication on the appropriateness of antimicrobial therapy at renewal time
Authors: Taqi Ahmad , Elarabi Salwa , Fleisher Jorge
Published: January 2021

Background

Inappropriate antibiotic use increases the risk of antimicrobial resistance and adverse events. Our institution adopts all elements recommended by the CDC to improve antimicrobial stewardship (AMS). Compliance with such elements requires education, coaching and decision support tools. The objective of the study intervention is to engage prescribers to critically evaluate and improve antibiotic utilization through renewal communication in the electronic medical record (EMR).

Methods

This is a single center study with a retrospective phase and prospective phase. During the intervention period from October 1st, 2019 to January 1st, 2020 the pharmacist monitored targeted antibiotics and initiated an AMS EMR note. Prescribers were then requested to evaluate the appropriateness of therapy utilizing pre-defined criteria developed in agreement with the infectious disease (ID) service at 48 hours, in-line with the EMR time-out alert. Adults receiving vancomycin (VAN), piperacillin/tazobactam (TAZ), cefepime (CEF) or meropenem (MPN) for at least 48 hours were included. The historical group included patients on the targeted antibiotics between July 1st, 2019 and September 30th, 2019. The primary outcome was median days of therapy (DOT). Secondary outcomes were median DOT per antibiotic, percentage of ID consults and percentage of antibiotic optimization. Statistical analyses were conducted using T-test and chi-square test for continuous and categorical variables respectively.

Results

A total of 81 and 72 patients were included in the intervention and historical groups respectively. No statistical difference in the primary outcome of median DOT was observed (4.5 vs 4, p=0.5). However, Non-significant numerical reductions in DOT were observed for VAN (3 vs 3.5, p=0.5), CEF (3 vs 4, p=0.6) and TAZ (3 vs 4, p=0.3), but not for MPN (6 vs 5, p=0.6). The intervention resulted in more ID consults when prescribing targeted antibiotics (59.3% vs 41.6%, p=0.03). In the intervention group, antibiotic treatment was optimized in 87.7% of patient, in which 39.6% were treatment de-escalation and discontinuation.

Conclusion

Pharmacist clinical guidance through the electronic medical record can provide a powerful educational tool to promote adherence to antimicrobials best practice

Disclosures

All Authors: No reported disclosures
177. Implementation of Pharmacist-Driven Penicillin Allergy Evaluation and Testing with a Focus on Bypassing Penicillin Skin Testing at an Academic Medical Center
Authors: Ham YoungYoon , Joshi Shyam , Sukerman Ellie , Tucker Kendall J , Yu Diana , Lewis James
Published: January 2021

Background

Penicillin allergies are reported by approximately 10% of the US population; however, studies reveal that >90% of those patients can tolerate penicillins. Penicillin allergies are associated with negative health outcomes, both clinical and financial, due to reduced efficacy and increased adverse effects of alternative antibiotics. Patient interview, penicillin skin testing (PST) and/or an oral graded challenge can be used to evaluate penicillin allergies. Different facilities use various algorithms for testing. The objective of this project was to determine whether a pharmacist-driven penicillin allergy evaluation and testing protocol which largely bypasses PST could safely de-label patients.

Methods

Adult patients (≥18 years) admitted with a penicillin allergy were evaluated for eligibility between September 2019 and June 2020. Pregnant patients, critically-ill patients, and patients receiving test-invalidating medication were excluded. Patients were evaluated and tested using institutional protocols, which allowed for the majority of patients to be challenged without PST. Allergies were removed with standardized documentation, and patients were given a pamphlet and counseled to discourage relabeling. Data collected included but were not limited to, the number of patients challenged and de-labeled, number of patients who were relabeled, and number of patients whose change in allergy status resulted in change of therapy.

Results

Forty-eight patients were interviewed and evaluated. One patient was evaluated by PST and oral graded challenge while 27 patients underwent an oral graded challenge only. Twenty patients were de-labeled as a result of patient interview. One patient failed oral challenge with minor itching that did not require any treatment, while 27 patients passed. Forty-seven allergies were removed or modified. Two patients who were de-labeled were relabeled with no record of a new reaction. Of de-labeled patients, 50% received a penicillin following removal of the allergy.

Conclusion

Penicillin allergies can be evaluated and removed using a pharmacy-driven algorithm that prioritizes direct challenges when appropriate. Risks of a reaction are low, and removal leads to change in treatment in a significant portion of patients.

Disclosures

All Authors: No reported disclosures
180. Leveraging the Electronic Medical Record as a Method of Antibiotic Stewardship
Authors: Kaul Christina M , Molina Eric , Armellino Donna , Schilling Mary Ellen , Jarrett Mark
Published: January 2021

Background

Overutilization of antibiotics remains an issue in the inpatient setting. What is more, many protocols geared toward curbing improper antibiotic use rely heavily on resource- and personnel-intensive interventions. Thus, the potential for using the EMR to facilitate antibiotic stewardship remains largely unexplored.

Methods

We implemented a novel change for ordering certain antibiotics in our EMR: ceftriaxone, daptomycin, ertapenem, imipenem, meropenem, and piperacillin-tazobactam. When ordering one of these antibiotics, providers had to note a usage indication, which assigned a usage duration as per our Antibiotic Stewardship Committee guidelines. Pre-intervention, manual discontinuation was required if a provider did not enter a duration. The intervention was enacted August 2019 in 13 hospitals. Data was collected from January 2018 to February 2020. Antibiotic usage was reported monthly as rate per 1000-patient days. Monthly pre- and post-intervention rates were averaged, respectively. Paired samples t-tests were used to compare pre- and post-intervention rates per unit type per hospital. A p-value of less than 0.05 was considered significant. Units with minimal usage, as defined by a pre- or post-intervention mean of 0, were excluded from analysis.

Example of Ordering an Antibiotic Prior to Intervention

Example of Ordering an Antibiotic After Intervention

Results

Ertapenem was noted to have a statistically significant decrease in utilization in seven units at three hospitals. Piperacillin-tazobactam was found to have a decrease in utilization in 19 units at eight hospitals. Daptomycin was found to have a decrease in utilization in one unit. Significant decreases in the utilization of ceftriaxone, imipenem, and meropenem were not noted.

Example of Statistically Significant Decreased Utilization in Piperacillin-Tazobactam on a Medical-Surglcal Unit

Conclusion

Our study showed a statistically significant decrease in use of ertapenem, piperacillin-tazobactam and daptomycin using a simple built-in EMR prompt that curtails provider error. This should allow for an increased ease of integration, as the protocol does not require a host of resources for maintenance. Of note is decreased utilization of piperacillin-tazobactam and ertapenem across multiple hospitals, most notably on the medical and surgical wards. Thus, usage of the EMR without personnel-intensive protocols is a viable method for augmenting antibiotic stewardship in health systems.

Disclosures

All Authors: No reported disclosures
181. Limited Effectiveness of an EMR Alert-Based Antibiotic Timeout Procedure in Solid Tumor Cancer Patients
Authors: Hyak Jonathan M , Mohajer Mayar Al , Musher Benjamin
Published: January 2021

Background

Computer-based antibiotic time-outs, in which providers receive automated electronic medical record (EMR) alerts regarding continuation of inpatient antibiotics (Anb), are common stewardship initiatives. We assessed the efficacy of such an intervention in oncology patients (pts), who frequently receive Anb when hospitalized.

Methods

An EMR alert triggered 48 hours after starting vancomycin (vanc), cefepime (cef), piperacillin-tazobactam (pip-tazo), meropenem (mero), and fluoroquinolones (flq) was initiated in a tertiary care hospital in November 2018. To assess the efficacy of the intervention in adults with solid tumor malignancies, demographic, vital sign, laboratory, and treatment data were extracted retrospectively from the EMR. Pts with neutropenic fever, organ transplant, trauma, and cardiopulmonary arrest were excluded. We compared length of therapy [LOT; days of therapy per 1000 patient-days (DOT/1000 pd)] via t-test and incidence rate ratio (IRR) for 3- and 12-month periods preceding and following the intervention. November 2018 was excluded as a washout period.

Results

The groups did not differ by age, sex, length of stay, or rate of bacteremia (Table 1). Comparing the 3 months before and after the intervention, neither mean LOT (2.9 ± 0.20 vs 2.6 ± 0.14 DOT/1000 pd, p=0.31) nor rate of Anb use changed (IRR 0.97, p=0.32). However, when considering only the Anb targeted by the intervention, cef usage was 1.4 times higher post- intervention (p=0.002), while use of other Anb was similar (Table 2). Comparing 12 months before to 12 months after the intervention, mean LOT was longer after (0.74 ± 0.018) than before (0.68 ± 0.020 DOT/1000 pd; p=0.03), and Anb use increased (IRR 1.3, p< 0.0001). Specifically, mero (IRR 1.8, p< 0.0001) and cef (1.6, p< 0.0001) were used more frequently after the intervention while none were used less (table 2).

Table 1: Study Group Characteristics

Table 2: Antibiotic Use Three Months Before and After, and Twelve Months Before and After, the Intervention

Conclusion

Despite wide adoption and efficacy in other populations, an EMR-based Anb time-out did not mitigate the continuation of Anb among inpatients with solid tumors. The intervention may require additional measures, such as an active role for pharmacy, to be effective. However, qualitative studies may also be required to understand why providers are hesitant to limit Anb use in this population.

Disclosures

All Authors: No reported disclosures
183. Optimization of an Outpatient Antimicrobial Stewardship Process for Patients Discharged from the Emergency Department at an Academic Medical Center
Authors: Kafisheh Hannah , Hinton Matthew , Binkley Amanda , Cimino Christo , Edwards Christopher
Published: January 2021

Background

Suboptimal antimicrobial therapy has resulted in the emergence of multi-drug resistant organisms. The objective of this study was to optimize the time to antimicrobial therapy modification for patients discharged from the emergency department (ED) of an academic medical center through implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative (ASI).

Methods

This was a pre-post, quasi-experimental study that evaluated the impact of a pharmacist-driven outpatient antimicrobial stewardship initiative at a single academic medical center. The pre-cohort was evaluated through manual electronic medical record (EMR) review, while the post-cohort involved a real-time notification alert system through an electronic clinical surveillance application. The difference in time from positive culture result to antimicrobial therapy optimization before and after implementation of the pharmacist-driven ASI was collected and analyzed.

Results

A total of 166 cultures were included in the analysis. Of these, 12/72 (16%) in the pre-cohort and 11/94 (12%) in the post-cohort required antimicrobial therapy modification, with a 21.9-hour reduction in median time from positive culture result to antimicrobial optimization in the post-cohort (43 h vs. 21.1 h; p < 0.01). Similarly, the median time from positive culture result to review was reduced by 20 hours with pharmacist-driven intervention (21.1 h vs. 1.4 h; p < 0.01).

Conclusion

The implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative resulted in a significant reduction in time to positive culture review and therapy optimization for patients discharged from the ED of an academic medical center set in Philadelphia, PA.

Disclosures

All Authors: No reported disclosures
189. Validating a Hospitalist-Specific Antibiotic Prescribing Metric across Four Acute Care Hospitals
Authors: Howard-Anderson Jessica , Nys Cara , Kubes Julianne N , Dube William C , Albrecht Benjamin , Jones K Ashley , Shabbir Hasan , Jacob Jesse T , Zanthia Wiley , Fridkin Scott
Published: January 2021

Background

Peer comparison reduces unnecessary outpatient antibiotic prescribing, but no prescribing metric has been validated for inpatient comparison. We aimed to evaluate if an electronically derived antibiotic prescribing metric correlated with indicated antibiotic days in hospitalized patients.

Methods

We previously created a hospitalist-specific adjusted antibiotic use metric (observed:expected [O:E]) for National Healthcare Safety Network-defined broad-spectrum antibiotics. From May-Oct 2019 at four Emory Healthcare hospitals, we identified outlier hospitalists prescribing in the top (high O:E) and bottom (low O:E) 15th percentile. We randomly selected 10 days of antibiotic administration from each outlier and reviewed days with > 2 days of consecutive days of antibiotics. For pneumonia, chronic obstructive pulmonary disease (COPD), or urinary tract infection (UTI) we determined if each day of antibiotics was indicated, assuming the diagnosis was accurate. We compared high vs. low O:E providers and used regression modeling to determine if the metric predicted indicated days of antibiotics.

Results

Among 997 days, 510 (51%) were from high and 487 (49%) from low O:E providers. High O:E providers had a greater proportion of days with > 2 prior days of antibiotics (60%) compared to low O:E providers (54%, p = 0.03). In the subset of days with > 2 prior days of antibiotics (n = 569), high O:E providers had more patient-days with longer hospital stays, diabetes and Charlson comorbidity index (CCI) >3, and fewer days supervising (resident/advanced practice provider, Table 1). The primary diagnosis was pneumonia, COPD exacerbation or UTI in 260 (25%) days; 91% were indicated based on duration with no difference between high and low O:E providers (88% vs. 94%, p = 0.1). After controlling for days of hospitalization, CCI, immunocompromised status, and supervisory role, a high O:E was not associated with indicated antibiotic use (OR 0.5, 95% CI 0.2 – 1.3).

Description of days with a patient on greater than two days of antibiotics, comparing high- versus low-metric providers

Conclusion

A high hospitalist antibiotic prescribing metric correlated with patients receiving > 2 consecutive days of antibiotics on any given day but did not predict unindicated antibiotic use for a subset of diagnoses. Evaluating indicated use by validating diagnoses may improve metric performance.

Disclosures

Jessica Howard-Anderson, MD, Antibacterial Resistance Leadership Group (ARLG) (Other Financial or Material Support, The ARLG fellowship provides salary support for ID fellowship and mentored research training)
190. Which antibiotic are you? Evaluation of a global antibiotic awareness personality quiz
Authors: Langford Bradley J , Laguio-Vila Maryrose R
Published: January 2021

Background

Improving understanding of the impact of antibiotic overuse is a key component of the global action plan to address antibiotic resistance. Play is an underutilized opportunity to engage adults in learning about antibiotic resistance and the importance of appropriate antibiotic use in mitigating this public health threat. Our objective was to evaluate the reach of a web-based antibiotic awareness personality quiz.

Figure 1. Antibiotic Personality Quiz Participants

Methods

A personality quiz (http://www.tiny.cc/antibioticquiz) was developed using an online platform (Tryinteract.com). The quiz included a series of short personality-based questions. Once complete, based on the responses provided, the respondent was automatically assigned an antibiotic that best matched their personality. This result was accompanied by key teaching points about the assigned antibiotic, a statement about the importance of appropriate antibiotic use and links to find more information. The quiz was launched in November 2017 to coincide with World Antibiotic Awareness Week and disseminated via social media. It was updated iteratively each year. We evaluated usage statistics from November 7 2017 to June 7 2020.

Results

During the 31-month evaluation period, there were 287,868 views of the quiz, and it was completed 207,148 times. The quiz was shared extensively on social media (Facebook 1667 shares, Twitter 1390 clicks). From a subset of 37,825 recent participants who were asked about their profession, most identified as non-infectious diseases healthcare professionals (n= 18,235, 48.2%), followed by infectious disease healthcare professionals (n=8,119, 21.8%), and healthcare students (n=6,986, 18.5%) (Figure 1). Respondents were well-represented globally, including US, Canada, Spain, France, India, United Kingdom, and Indonesia.

Conclusion

This exploratory analysis suggests incorporation of play into social media campaigns may augment the size of the receiving audience. An antibiotic awareness personality quiz engaged a high volume and broad range of non-infectious disease experts in learning more about antibiotic resistance. Antimicrobial stewards and public health campaign leaders should incorporate play into awareness opportunities and evaluate their impact.

Disclosures

All Authors: No reported disclosures
194. Antibiotic-resistant bloodstream infections in pediatric oncology patients on levofloxacin prophylaxis
Authors: Sridhar Sunita , Agrawal Anurag K , Ferrerosa Lauren , Lee Brian , Singh Prachi
Published: January 2021

Background

Levofloxacin prophylaxis in pediatric oncology patients with chemotherapy-induced severe prolonged neutropenia has been shown to reduce risk for febrile neutropenia and systemic infections. With increased use of prophylaxis there is concern for development of antibiotic-resistant infections. We analyzed bloodstream infections (BSI) in pediatric oncology patients exposed to levofloxacin prophylaxis during prolonged severe neutropenic episodes to determine the rate of antibiotic resistance

Methods

We performed a retrospective chart review of pediatric oncology patients who received levofloxacin prophylaxis between January 2015 – December 2019. Patients were placed on levofloxacin prophylaxis based on institutional guidelines for patients at risk for severe prolonged neutropenia (i.e., absolute neutrophil count [ANC] < 500 cells/µL for >7 days). Demographic information, start and end dates for levofloxacin prophylaxis, and all BSI episodes within 2 months after exposure to the fluoroquinolone were collected

Results

Thirty-five patients were identified who received levofloxacin prophylaxis. There were 32 BSI in 12 patients. Twenty-five BSI involved gram-positive organisms (GP), including nine (36%) due to coagulase negative Staphylococcus and seven (28%) due to viridans Streptococcus. Seven BSI episodes involved gram-negative (GN) organisms with 4 (57%) from E.coli. Resistance to fluroquinolones was noted in 42% and 48% of BSI from GN and GP organisms respectively. The vast majority (85%) of viridans Streptococcus isolates were resistant to levofloxacin. In contrast, 8% of viridans Streptococcus isolates were resistant to fluoroquinolones from the same time frame per our hospital antibiogram.

Conclusion

In this recent cohort of pediatric oncology patients with BSI after exposure to levofloxacin prophylaxis, there was a high percentage infected with fluoroquinolone-resistant organisms.This contrasts with some of the earlier published data from adults which reported low rate of fluoroquinolone resistance. This case series highlights the need for close monitoring for development of antibiotic resistance as utilization of prophylactic levofloxacin increases in pediatric oncology patients.

Disclosures

All Authors: No reported disclosures
195. Antimicrobial Stewardship Incorporating New Antimicrobials for Use against Multi-Drug Resistant Pseudomonas aeruginosa in Cystic Fibrosis
Authors: Jo Jinhee , Gonzales-Luna Anne J , Garey Kevin W
Published: January 2021

Background

Cystic fibrosis (CF) is a life-limiting genetic disease affecting approximately 80,000 people worldwide, including 30,000 in the United States. Chronic Pseudomonas aeruginosa (PA) infections in CF often develop to be multidrug-resistant (MDR) and are associated with worse clinical outcomes. Ceftolozane/Tazobactam (C/T) has shown benefits over other standards of therapy in selected populations with MDR-PA infections, but studies are lacking in the CF population. The objective of this study was to evaluate the current use and antimicrobial stewardship of C/T in CF patients with MDR-PA.

Methods

This is a retrospective study of hospitalized CF patients with infections due to positive cultures for MDR-PA from 2016–2019 at Baylor St. Luke’s Medical Center in Houston, Texas. Electronic medical records were reviewed for patient demographics, presence of infectious diseases (ID) consult, antibiotics use, and clinical outcomes. A descriptive analysis was performed to compare the patient demographics and clinical outcomes between patients receiving C/T-based and non-C/T therapies.

Results

A total of 56 CF patients with positive MDR-PA cultures were identified (18 receiving C/T and 38 receiving non-C/T antibiotics). Most MDR-PA was cultured from the lungs (94.6%, 54/56). Patient age, weight, and body mass index were similar between those receiving C/T and non-C/T therapies as was the overall duration of antibiotic therapy 16.3 (± 8.7) vs. 13.9 (± 3.5) days in C/T and non-C/T groups, respectively. More patients in the C/T group had severe forced expiratory volume in 1 s (FEV1) [£40%] at baseline (66.7% vs. 21.1%) and higher ICU admission rates (44.4% vs 2.6%). All C/T patients had an ID consult placed (3 ± 3.1 days after admission) but none in the non-C/T group. The 30-day recurrent pulmonary exacerbation rate was comparable between C/T and non-C/T groups (22.2% vs. 15.8%).

Conclusion

C/T was reserved for the sickest group of CF patients with severe FEV1. Given the devastating disease progression with MDR organisms in CF, new antibiotics with better clinical outcomes against chronic MDR-PA should be considered earlier in therapy for this population. Larger studies are warranted to analyze cost-effectiveness and clinical outcomes.

Disclosures

Kevin W. Garey, PharMD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator)
196. Assessing the Clinical Impact of Intravenous Acyclovir Dosing in Obese Patients: Should We Be Using Ideal, Adjusted, or Total Body Weight?
Authors: Mulvey Nicole , Jain Sumeet , Falsetta Keith , Doan Thien-Ly
Published: January 2021

Background

Obesity impacts the pharmacokinetics and pharmacodynamics of medications. Pharmacokinetic studies of intravenous (IV) acyclovir have demonstrated that dosing obese patients according to their ideal body weight (IBW) may provide a sub-therapeutic dose, while dosing based on total body weight (TBW) may increase adverse effects. This has led to the use of adjusted body weight (AdjBW) for dosing in this population; however, this has not been evaluated clinically. The purpose of this study is to assess the impact of different dosing strategies of IV acyclovir in obese patients.

Methods

This retrospective observational chart review evaluated adult patients admitted to Long Island Jewish Medical Center with a body mass index greater than or equal to 30 kg/m2 who received at least 48 hours of high-dose IV acyclovir therapy during the study period of January 2014 to August 2019. Patients were stratified to IBW, AdjBW, and TBW for analysis. The primary statistical tests utilized include descriptive statistics and logistic regression. The primary endpoint was the outcome of infection. The secondary endpoints included duration of therapy, length of stay, and adverse effects.

Results

51 patients were included in the efficacy analysis and 84 patients were included in the safety analysis. Treatment failure occurred in 3 out of 51 patients (1 patient in IBW group, 2 patients in AdjBW group, p=0.445). There was no significant difference in median length of stay (p=0.977) or median duration of IV therapy (p=0.78). Nephrotoxicity occurred in 22.2%, 19.2%, and 22.7% of patients in the IBW, AdjBW, and TBW groups respectively (p=1).

Conclusion

When comparing different dosing modalities, there was no significant difference in the outcome of infection, duration of therapy, or length of stay. The results of this study were limited by small sample size. However, dosing patients according to AdjBW led to smaller doses of acyclovir, and therefore less drug exposure.

Disclosures

All Authors: No reported disclosures
198. Clinical Prediction of Bacteremia and the Need for Early Antibiotic Therapy in Solid Tumor Cancer Patients
Authors: Hyak Jonathan M , Mohajer Mayar Al , Musher Daniel , Musher Benjamin
Published: January 2021

Background

Cancer patients (pts) frequently receive empiric antibiotics without clear indication. This retrospective study investigated the relationship between the systemic inflammatory response syndrome (SIRS), early antibiotic (Anb) use, and bacteremia in solid tumor pts presenting to the emergency department (ED).

Methods

We extracted data from the electronic medical records of adults with solid tumors admitted to a tertiary care hospital through the ED for any reason over a 2 year period. Pts with neutropenic fever, organ transplant, trauma, or cardiopulmonary arrest were excluded. Rates of SIRS and bacteremia among pts receiving early Anb (eAnb, within 8 hours of admission) were compared to all others using χ 2. Binomial regression and receiver operator curves assessed predictors of bacteremia.

Results

Of 3580 eligible pts, 1344 pts were SIRS positive (≥ 2 criteria) and 2236 were SIRS negative; 501 (37%) and 493 (22%), respectively, received eAnb (p< 0.001). eAnb use increased with additional SIRS criteria (Fig 1). Of SIRS positive pts, 860 (64%) had BCs drawn within 48 hrs of presentation, of which 19% were positive. Of SIRS negative pts, 826 (37%) had cultures drawn within 48 hrs of presentation, of which 14% were positive (19% vs 14%, p=0.004). Of pts who had BCs drawn, the proportion of positive BCs among those who received eAnb and those who did not was identical (16% in each group; p=1). Of 276 pts ultimately proven to have bacteremia within 48 hrs, only 59% were SIRS positive, and only 49% received eAnb in the ED. By regression, only two SIRS components predicted bacteremia, fever (OR 1.8 ± 0.39, p=0.01) and tachycardia (1.4 ± 0.22, p=0.03), and SIRS criteria as a whole were poorly predictive of bacteremia (AUC 0.57, Table 1). A more robust model, which included additional labs and vital signs, was only marginally better (AUC 0.61, Table 2).

Figure 1: Proportion of patients receiving early antibiotics by SIRS score

Table 1: SIRS as a predictor of bacteremia

Table 2: Best predictive model of bacteremia

Conclusion

Clinicians still use SIRS criteria to determine the need for eAnb. However, SIRS criteria are poor predictors of bacteremia in solid tumor pts, who frequently manifest them due to complications of cancer or cancer-directed therapy rather than infection. Furthermore, patients who are SIRS negative may be bacteremic. More reliable models are needed to guide judicious use of Anb in the solid tumor population.

Disclosures

All Authors: No reported disclosures
199. Evaluating long-term care pharmacy dispense data to monitor antibiotic use in U.S. nursing homes
Authors: Gouin Katryna A , Creasy Stephen M , Kulkarni Manjiri , Wdowicki Martha , Stone Nimalie D , Hicks Lauri , Kabbani Sarah
Published: January 2021

Background

Automated reporting of antibiotic use (AU) in nursing homes (NHs) may help to identify opportunities to improve antibiotic prescribing practices and inform implementation of stewardship activities. The majority of U.S. NHs contract with long-term care (LTC) pharmacies to dispense prescriptions and provide medication monitoring and reviews. We investigated the feasibility of leveraging LTC pharmacy electronic dispensing data to describe AU in NHs.

Methods

We analyzed all NH antibiotic dispenses and monthly resident-days in 2017 reported by a large LTC pharmacy. The dispense-level data included facility and resident identifiers, antibiotic class and agent, dispense date and days of therapy (DOT) dispensed. We identified NH antibiotic courses, inclusive of both antibiotic starts and continuations from hospital-initiated courses, by collapsing dispenses of the same drug to the same resident if the subsequent dispense was within three days of the preceding end date. The course duration was the sum of DOT for all dispenses in the course. The AU rate was reported as DOT and courses per 1,000 resident-days.

Results

AU was described in 326,713 residents admitted to 1,348 NHs (9% of U.S. NHs), covering 38.1 million resident-days. There were 576,228 dispenses for a total of 3.3 million antibiotic DOT at a rate of 86 DOT/1,000 resident-days. After collapsing dispenses, 324,306 antibiotic courses were defined at a rate of 9 courses/1,000 resident-days. During the year, 45% of residents received an antibiotic. The most frequently prescribed classes by DOT and courses were cephalosporins, penicillins, urinary anti-infectives and quinolones (Fig. 1). The top agents by DOT were levofloxacin (12%), sulfamethoxazole/trimethoprim (12%) and cephalexin (11%). Most course durations were 1–7 days (54%) or 8–14 days (35%) (Fig. 2). Long-term antibiotic courses (> 30 days) contributed to 5% of courses and 30% of overall DOT. The mean duration per course was 7.5 days when courses > 30 days were excluded.

Figure 1. Distribution of antibiotic courses and days of therapy by antibiotic class for 324,306 antibiotic courses and 3.3 million days of antibiotic therapy dispensed to 1,348 nursing homes from a long-term care pharmacy in 2017

Figure 2. Distribution of antibiotic course duration and cumulative percent of total antibiotic days of therapy for 324,306 antibiotic courses dispensed to 1,348 nursing homes from a long-term care pharmacy in 2017

Conclusion

LTC pharmacy dispenses may be an accessible data source to report NH AU rates and prescribing patterns by antibiotic class and agent. Further evaluation of data sources for facility- and national-level AU reporting in NHs is needed to support stewardship implementation.

Disclosures

All Authors: No reported disclosures
200. Frequency and Characteristics of Patients Switched from Intravenous to Oral Antibiotic Therapy on Discharge to Nursing Homes
Authors: Colangeli Hailey N , Noble Brie N , Crnich Christopher J , McGregor Jessina C , Bearden David T , Chan Dominic , Furuno Jon P , Furuno Jon P
Published: January 2021

Background

Determining eligibility for intravenous (IV) to oral (PO) antibiotic conversion is challenging in patients transitioning to nursing homes (NHs) due to atypical infection presentation, increased diagnostic uncertainty, and multimorbidity. Understanding current practice and patient characteristics influencing prescriber behavior is necessary to provide effective antibiotic stewardship in this vulnerable population. We compared the frequency and characteristics of patients discharged with IV antibiotics to those switched from IV to PO therapy.

Methods

This was a retrospective cohort study of Oregon Health & Science University Hospital patients treated with IV antibiotics and discharged to a NH from 1/1/2016-12/31/2018. We focused on IV to PO antibiotic switch within 48 hours of discharge. Using a repository of electronic health record data, we collected patient demographic, diagnosis, length of stay, and treatment duration data.

Results

Among 2,410 patients discharged to a NH on antibiotics, 1,483 (61.5%) received an IV antibiotic within 48 hours of discharge. IV to PO switch occurred in 46.7% of patients prior to discharge, and these patients had fewer baseline comorbidities (Table 1). Of those continuing IV antibiotics, 96.1% were prescribed a different PO medication at discharge indicating potential to take PO medications. Cephalosporins (45%) and penicillins (22%) were the most commonly prescribed IV antibiotics, with IV to PO conversion rates of 26% and 46%, respectively. The median (interquartile range) outpatient duration of therapy was 21 (12–33) days for IV antibiotics and 7 (4–10) days for PO antibiotics. Osteomyelitis diagnosis was more frequent among IV therapy patients; pneumonia and urinary tract infections were more frequent in IV to PO switch patients. IV to PO switch patients were less likely to experience a hospital stay > 7 days or receive an infectious disease consult (p < 0.001).

Table 1. Comparison of Patient and Treatment Characteristics among IV and Oral Antibiotic Prescriptions on Discharge

Conclusion

The proportion of patients discharged to a NH on IV antibiotics remains high, even among patients able to tolerate PO medication. Continuing IV therapy was associated with longer treatment durations, hospital stays, and broad spectrum regimens, while patients with IV to PO switch had a higher comorbidity burden at baseline.

Disclosures

All Authors: No reported disclosures
203. Opportunities for Antimicrobial Stewardship in Febrile Neutropenia
Authors: Shoff Christopher , Baskett Jordan , Messina Julia A , Baker Arthur W , Turner Nicholas A , Spivey Justin , Wrenn Rebekah , Moehring Rebekah W , Spires Steven S
Published: January 2021

Background

Emerging evidence suggests antibiotics may be safely discontinued before neutropenia resolves in patients without identifiable infection. We estimated the volume of encounters and antibiotic use for future stewardship interventions shortening FN treatment duration.

Methods

This retrospective cohort study used electronic health records from inpatient encounters on the hematologic malignancies ward at Duke University Hospital from 5/21/2018 to 12/31/2019 where patients received at least one antibiotic for an indication of “neutropenic fever.” The primary outcome was length of therapy (LOT) of broad Gram-negative (GN) agents, including cefepime, piperacillin-tazobactam, meropenem, or aztreonam. FN LOT was counted by calendar day, starting with the first day of administration of a broad GN agent and ending with antibiotic discontinuation or hospital discharge. Encounters with at least one positive blood culture (positive cohort) were compared to those with no positive blood cultures (negative cohort) to assess if culture positivity was associated with differences in FN LOT. We included the first FN LOT from each encounter in the negative cohort and the FN LOT associated with the first positive blood culture in the positive cohort. We used descriptive statistics and a Gaussian density function to calculate the percent of encounters exceeding FN LOT of 14 days and the percent of broad GN agent days.

Results

We evaluated 15,678 GN antibiotic administrations from 471 unique FN encounters. Blood culture results were available for 443 encounters— 122 (27.5%) in the positive cohort, and 321 (72.5%) encounters in the negative cohort. Thirty percent of encounters (36/122) in the positive cohort received more than one GN treatment course, compared to 10% (32/321) of those in the negative cohort. FN LOT was significantly longer in the positive cohort (median 10.5, IQR 13 days vs. 6, IQR 8 days, p < 0.001). Among encounters with negative cultures, 57 (17.8%) had a first FN LOT greater than 14 days, accounting for 44% of broad GN agent days within that population (Figure 1).

Gram-Negative Antibiotic Therapy in Blood Culture-Negative Febrile Neutropenia

Conclusion

Nearly 20% of blood culture-negative encounters received initial GN treatment courses exceeding 14 days, representing a sizeable target for antimicrobial stewardship interventions focused on FN treatment duration.

Disclosures

Rebekah W. Moehring, MD, MPH, Agency for Healthcare Quality and Research (Grant/Research Support)Centers for Disease Control and Prevention (Grant/Research Support)