bluuebunny/crossref_metadata_2025 huggingface dataset:
2209. Reducing Inappropriate Antibiotic Prescribing for the Treatment of Urinary Tract Infections (UTI) in Urgent Care Clinics
Authors: Vu Christine A , Salazar Veronica , Patel Fenil , Abbo Lilian M , Rosa Rossana
Published: November 2023

Background

In 2020, The Joint Commission released new standards to promote expansion of antimicrobial stewardship into the ambulatory care setting. Urinary tract infections (UTIs) are one of the most common bacterial infections encountered in the outpatient setting and therefore an opportunistic area for intervention. The aim of our study was to evaluate current outpatient prescribing patterns for the treatment of UTIs and develop a methodology to improve antibiotic prescribing.

Methods

A single-center, retrospective study was conducted across 5 Jackson Health-University of Miami Urgent Care Clinics (UCC) in Miami, Florida. We utilized ICD-10 diagnosis codes to identify adults diagnosed with UTIs between January 1, 2021 and October 31, 2022. We identified the top five prescribers and audited 10% of their prescriptions. The data was analyzed and as our intervention, we shared results with UCC leadership and disseminated provider-specific report cards to highlight inappropriate prescribing practices. After this, we allowed 3 months for change to occur and set a goal of reducing the percentage of inappropriate UTI durations by 50%.

Results

For baseline data, 123 charts were reviewed. We identified 95 patients with cystitis (77.3%), 26 pyelonephritis (21.1%), and 2 asymptomatic bacteriuria (1.6%). Inappropriate prescribing ranged from 17.6% to 80.6% between the UCC prescribers (Figure 1). Various types of prescribing opportunities were identified, with the most common being prolonged length of therapy (Figure 2).

For post-intervention, 114 charts were reviewed. We identified 90 patients with cystitis (78.9%), 22 pyelonephritis (19.3%), and 2 asymptomatic bacteriuria (1.8%). Inappropriate durations of UTI treatment were reduced by 25% (Figure 3), with the greatest improvement seen in nitrofurantoin prescribing (Figure 4).

Figure 1

Figure 2

Figure 3

Conclusion

Retrospective audit and feedback using provider-specific report cards was an effective antimicrobial stewardship strategy for the ambulatory care setting. Our intervention led to reduced durations of UTI treatment for nitrofurantoin but not necessarily with fluoroquinolones, trimethoprim/sulfamethoxazole, or beta-lactams. Next steps will include providing more education to further promote appropriate use of all classes of antibiotics.

Figure 4

Disclosures

Lilian M. Abbo, MD, MBA, Ferring: Advisor/Consultant|Pfizer: Advisor/Consultant|Regeneron: Grant/Research Support|Shionogi: Advisor/Consultant
2210. Reducing Inappropriate Antibiotic Prescribing for Acute Uncomplicated Bronchitis
Authors: Williams Sabrina , Olivero Rosemary M , Engels Julie , Ogrin Sara
Published: November 2023

Background

Antimicrobial stewardship (AS) programs aim to slow the growing threat of antimicrobial resistance. The majority of antibiotic prescribing occurs in outpatient settings. This study examines the effect of an AS intervention bundle on the proportion of inappropriate antibiotic prescriptions given to adult patients with bronchitis in outpatient settings of a large healthcare system.

Methods

The Institutional Review Board approved this retrospective study of antibiotic prescription rates for adults (≥18 years old) diagnosed with bronchitis (identified using ICD-10 codes J20.9 or J20.8) during 2020 and 2021 in outpatient settings. An AS intervention bundle involving training and auditing of physicians’ antibiotic prescribing habits was enacted in January of 2021. A total of 8,176 encounters were reviewed for appropriateness of antibiotic prescriptions. Instances where no antibiotics were prescribed or antibiotics were prescribed for a comorbid condition were considered appropriate. Percentages of inappropriate antibiotic prescribing pre- and post-intervention were then compared via Chi-square analysis using SAS Enterprise Guide version 7.15 software.

Results

The proportion of inappropriate antibiotic prescribing for bronchitis decreased significantly from 44.9% pre-intervention to 32.5% post-intervention (p< 0.0001). Comparison of inappropriate prescribing rates by month showed significant decreases between the pre- and post-intervention periods in March (48.1% to 31.8%, p=0.0002), October (44.4% to 30.3%, p< 0.0001), and November (42.2% to 27.0%, p< 0.0001).

Conclusion

AS activities can decrease inappropriate antibiotic prescribing for bronchitis in outpatient settings. Further analyses on site-specific, seasonal and demographic differences on the effect of our AS intervention bundle may further enlighten on how programs can decrease unnecessary antibiotic use for respiratory tract infections.

Disclosures

All Authors: No reported disclosures
2214. Retrospective Analysis of the Implementation of a Novel Discharge Reconciliation service in OPAT by Pharmacists (RAINDROP)
Authors: Caverzagie Brady , Ross Jennifer
Published: November 2023

Background

Outpatient parenteral antimicrobial therapy (OPAT) has become a standard mechanism for delivery of antimicrobial regimens over a prolonged period in a non-acute care setting. Adverse drug reactions, vascular access device complications, and unscheduled healthcare use have been attributable to OPAT. Existing literature suggests OPAT errors at the time of hospital discharge are high, around 30-40%. The purpose of this study is to evaluate the impact of a novel OPAT reconciliation service on pharmacist interventions on OPAT discharge plans.

Methods

Adult OPAT patients who discharged from an academic medical center between 6/2020 and 6/2023 on parenteral antimicrobial(s) with placement of a pharmacist OPAT note were included in this retrospective pre/post implementation cohort study. Patients with cystic fibrosis were excluded. Data on patient characteristics, antibiotic regimen, labs, and any changes to the discharge OPAT plan were collected from the electronic health record. Categorical values and outcomes were reported as counts and rates.

Results

The implementation of a new OPAT plan reconciliation process for infectious diseases pharmacists was implemented on January 18th, 2023, and is outlined in Figure 1. Target enrollment will be approximately 640 patients split evenly between two cohorts. An interim analysis was performed on 553 patients, 320 patients in the pre-implementation cohort and 233 in the post implementation cohort. There was a total of 53 pharmacist interventions observed during the pre-implementation period and 61 interventions in the post-implementation period, yielding an intervention rate of 0.17 (6.04 patients/intervention) and 0.26 (3.82 patients/intervention), respectively. Common interventions included changes to lab and therapeutic drug monitoring, dose, agent chosen with culture follow-up, and changes to the infusion method (continuous vs. intermittent infusion). A breakdown of the interventions observed in the two cohorts is shown in Table 1.Figure 1:Pre and Post Implementation OPAT Plan Reconciliation Process for Infectious Disease PharmacistsTable 1:Pre and Post Implementation Infectious Disease Pharmacist Intervention Type Breakdown

Conclusion

During our interim analysis, we observed an increased rate of pharmacist interventions after the start of a new reconciliation service for OPAT discharges.

Disclosures

All Authors: No reported disclosures
2218. Evaluation of Bacteremia in Febrile Neutropenia and Implications on Antimicrobial Stewardship
Authors: Kalava Sowmya , Arab Niki , Gonzalez Rolando Zamora , Kim Brian , Jeng Arthur
Published: November 2023

Background

Febrile neutropenia (FN) is a common complication in cancer patients. IDSA guidelines for FN in cancer patients recommend the initiation of an empiric antibiotic (abx) against Pseudomonas aeruginosa (PsA). At Olive View-UCLA Medical Center (Sylmar, CA), we reviewed FN cases to determine the prevalence of PsA bacteremia and assess the necessity of anti-PsA abx.

Methods

Retrospective chart review on all adult (≥ 18 years) positive blood cultures (Bcx) from January 1, 2017 to December 30, 2022. Positive Bcx were matched with ICD-10 code for neutropenia on inpatient encounter. Exclusion criteria consisted of absolute neutrophil count ≥ 500, FN not related to malignancy, and untreated suspected contamination. Charts were reviewed for Bcx results, source of bacteremia, antibiotic prescribing, and 30-day all-cause mortality.

Results

Of 1,303 neutropenia encounters and 3,755 positive Bcx, 92 were matched, and 48 met inclusion criteria. Enterobacterales was found in 28 (58.3%), whereas PsA was found in 5 (10.4%) [Figure 1]. Gram negative bacteremia was more common than gram positive [Figure 2]. The most common source of bacteremia was intra-abdominal (n=17, 35.4%), followed by line-associated infection (n=9, 18.8%) [Figure 3]. All 48 cases were started on empiric anti-PsA abx; 31 (72.1%) were continued on anti-PsA abx for an average of 11 days [IQR 5-14] despite no PsA in Bcx. 30-day all-cause mortality was not significantly different between those who continued on anti-PsA abx versus those in whom anti-PsA abx was stopped when PsA was not isolated [5/31 versus 3/13, p=0.5]. All cases of PsA bacteremia had at least one risk factor for nosocomial acquisition, e.g. hospitalization and/or abx exposure ≤ 90 days.Figure 1:Frequency of Isolated OrganismsFigure 2:Breakdown of Organism ClassificationsFigure 3:Sources of Bacteremia

Conclusion

The most common organism causing bacteremia in FN was Enterobacterales. The prevalence of PsA bacteremia was low, yet most were continued on anti-PsA abx despite Bcx showing a different organism. Continuation of anti-PsA abx did not make a difference in all-cause 30-day mortality when PsA was not isolated. Even when neutropenic, the risk factors for PsA bacteremia was the same as that for other patients; thus, as an abx de-escalation strategy, patients can be risk stratified. Further stewardship efforts can be focused on de-escalating anti-PsA abx in FN when PsA is not isolated.

Disclosures

All Authors: No reported disclosures
2219. Guiding stewardship interventions through tracking of bone cultures in diabetic lower extremity infections
Authors: Ketema Pawlose , Adenew Ayne , McKnight Angela Y , Thompson Janette , Liappis Angelike P
Published: November 2023

Background

Lower extremity infections (LEIs) of diabetic patients poses a challenge to addressing over-utilization of broad spectrum antibiotics (BSA). To guide the development of educational and behavioral initiatives, we employed ASP quality improvement surveillance practices to explore podiatric-surgery collected bone cultures (BC), pre-procedural tissue cultures (PTC) and results of resection margin pathology.

Methods

Washington DC VAMC is an urban medical center with 220 acute and LTC beds with acute and outpatient surgical Podiatry Service and supported by an active ASP (PharmD/MD/NP). Between 2020-2022 positive BCs collected in podiatric LEI procedures for presumed osteomyelitis were reviewed by ASP with CDSS (TheraDoc, Inc) and EMR (VISTA_CPRS). A positive post-resection margin (Margin+), empiric antibiotic selection and microbiology including regimen altering organisms such as MRSA and P. aeruginosa (PSAR) were collected.

Results

Diabetic individuals had 94 positive BCs in 296 procedures among nearly 2,000 total cultures. Subjects were predominately male (97%), mean age 68 ± 8.7 (45-93y); and nearly a third had > 1 BC. Intraoperative BCs made up 79% of episodes and half were Margin+. Subjects had high rates of PVD (45%), insulin-dependence (49%) and HbA1c > 10 mg/dL (21%). Empiric BSA selection consisted mainly of MRSA and PSAR coverage with no deaths < 30d from BC. Among BC with PTC, 61% had partial or complete correlation in microbiology; MRSA and PSAR incidence were the same if PTC:BC findings were concordant or not. PTC:BC microbiologic non-concordance vs concordance for Margin+ was not significantly different between the groups (45.8% vs 59.4%, P=NS) and among PTC:BC concordant samples, PSAR rates trended higher (12.9% vs 4.8%, P=NS) with no difference in MRSA incidence.

Conclusion

Providers have limited information in predicting LEI results in advance of path and micro. Empiric BSAs remains a challenge for ASPs. Less than half of patients had a BC finding that would have been predicted by the PTC and for those with a concordant prior to procedure sample, the finding of organisms that directed the empiric selection were not reflective of final cultures. There are opportunities for ASP interventions that address empiric selection in diabetic LEIs.

Disclosures

All Authors: No reported disclosures
2223. Evaluation of the Microbiology and Clinical Outcomes of Spontaneous Bacterial Peritonitis (SBP) within a US Academic Health System
Authors: Chris Parish P , Taylor Alex D , Stone Tyler J , Luther Vera , Ohl Christopher , Beardsley James R
Published: November 2023

Background

2021 SBP treatment guidelines recommend empiric therapy with spectra broader than 3rd generation cephalosporins (TGC) in patients (pts) at risk for multidrug-resistant organisms (MDOs), including those admitted to ICUs, with nosocomial infections, or with recent hospitalization. This study aimed to characterize the microbiology and clinical outcomes of SBP in our health system to determine the applicability of these guidelines.

Methods

Setting: 5-hospital academic health system with > 1500 beds. Design: retrospective, observational study. Adult pts from 2010-2022 with ICD 9/10 codes for SBP & liver dysfunction were screened. Pts with concomitant secondary peritonitis were excluded. Study included all pts with culture-positive (CX-pos) SBP and randomly screened pts with culture-negative (CX-neg) SBP to provide a total sample of 80 pts. Primary outcome was % of peritoneal fluid CX with organisms non-susceptible to ceftriaxone (CRO) in CX-pos pts. Secondary outcomes included mortality & effect of MDO risk factors (hospitalization in prior 90 days, ICU admission, or nosocomial infection) on microbiological & clinical outcomes.

Results

49 pts with CX-pos and 31 pts with CX-neg SBP were included. Median age was 59; median MELD score was 25; 26 (33%) were admitted to the ICU. 67 of 80 (84%) total pts had ≥ 1 MDO risk factor; 40 of 49 (82%) in the CX-pos cohort. 8 (16%) isolates were CRO-non-susceptible, 7 in the 40 CX-pos pts with MDO risk factors (17.5%) vs. 1 in the 9 CX-pos pts without risk factors (11%) (p=NS). 49 (61%) pts received initial TGC therapy. Mortality at 30 days & 90 days was 29 (43%) & 40 (60%) and 3 (23%) & 6 (46%) for pts with and without MDO risk factors, respectively. Outcomes based on empiric therapy are summarized in Table 1.

Conclusion

In our facilities, 16% of isolates in CX-pos SBP pts were not susceptible to CRO. There was no significant difference in the number of non-susceptible isolates in pts with and without MDO risk factors. Treatment with broader therapy was not associated with improved outcomes. Within our health system, giving all SBP pts with MDO risk factors broad empiric therapy may not be necessary. Evaluating local microbiologic data may help health systems assess the local applicability of national treatment guidelines.

Disclosures

Tyler J. Stone, PharmD, ViiV Healthcare: Employee
2238. Effect of Cefazolin Breakpoint Update in Susceptibility Reports on Antimicrobial Use
Authors: Buckley Valerie , Scott Ferren R , Zaidan Noor , Britt Rachel S , Reynoso David
Published: November 2023

Background

The Clinical Laboratory Standards Institute updated the breakpoints for cefazolin in the treatment of E. coli, Klebsiella, and Proteus (EKP) infections in 2011 to reflect doses used in clinical practice and achievable therapeutic concentrations in different body sites (urine vs. non-urine). The UTMB clinical microbiology laboratory adopted this update in January 2022 with the introduction of MicroScan™ technology. Our objective was to evaluate the effect of the cefazolin breakpoint update on antimicrobial use in EKP bloodstream infections.

Methods

This was a retrospective, multicenter, pre-post, study conducted at four UTMB hospitals. Pre-intervention data was collected from January 2021 to December 2021 and post-intervention data was collected from February 2022 to March 2023. Patients ≥ 18 years old were included if they were admitted to a UTMB hospital and received antibiotics for EKP bacteremia. Texas Department of Criminal Justice patients, those with beta-lactam anaphylaxis, polymicrobial bacteremia, immunocompromised patients, and Klebsiella aerogenes isolates were excluded. The primary outcome was cefazolin days of therapy (DOTs) for EKP bacteremia. Extended-spectrum beta-lactamase (ESBL)-producing isolates and Clostridioides difficile (C. difficile) infection six months after the index admission, and in-hospital and 28-day mortality were also assessed.

Results

There were 50 and 48 patients included in the pre- and post-intervention periods, respectively. Most patients were female (59%) with a mean age of 67.8 years (standard deviation [SD] 14.9). The most isolated gram-negative pathogen was Klebsiella pneumonia (81%) followed by Proteus mirabilis (13%) from urinary sources of infection (59%). There was no significant difference in median cefazolin DOTs before (0 days; interquartile range [IQR] 0,0) and after (0 days; IQR 0,0) the breakpoint update (p=0.35). There was no difference in ESBL-producing pathogens (2 vs. 3, p=0.67), C. difficile infection (1 vs. 2, p=0.61), in-hospital (3 vs. 7, p=0.20), or 28-day mortality (0 vs. 0, p=1) between the pre- and post-breakpoint update groups.

Conclusion

Updating the breakpoint to a lower value for EKP isolates in the blood did not have an effect on cefazolin use.

Disclosures

All Authors: No reported disclosures
2239. Antibiotic Sensitivity Spectrum Of Acute Bacterial Cholangitis: Trends From A Tertiary Referral Center In Pakistan
Authors: Butt Muhammad Abdurrahman , Khan Maahin Manzoor , Omar Myyra , Rafique Mehwish , Badshah Maaz , Salih Mohammad , Atiq Muslim
Published: November 2023

Background

Acute bacterial cholangitis can result in significant morbidity. Aggressive antibiotic therapy and prompt endoscopic or percutaneous biliary decompression are key to improving outcomes. However, evolving antimicrobial resistance patterns pose a significant challenge to treating these infections especially when deciding about empiric therapy.

Methods

The study was conducted at Shifa International Hospital in Islamabad. All the patients with the diagnosis of Acute bacterial cholangitis between July 2016 and June 2022 were included. The study was approved by institutional IRB. Data was analyzed using the Pearson Chi-Squared test.

Results

In this study, a total of 144 consecutive patients were included, out of which 51 (35.4%) had a growth on blood cultures. The most commonly identified organism was E. Coli found in 30 (58.8%) followed by Pseudomonas in 7 (4.9%), Klebsiella pneumonia in 6 (11.8%), Proteus in 3 (5.9%), and Enterococcus in 1 (2.0%) patients. Other organisms were found in 15 (29.4%) patients. Polymicrobial infection was found in 12 (23.5%) patients. Out of the blood cultures with growth, 10 (19.607%) were identified as multi-drug resistant (MDR) species, while 19 (37.25%) were identified as extended-spectrum beta-lactamase (ESBL) species. Patients who have undergone prior biliary intervention (ERCP, PTBD or both) were more likely to be infected with E.Coli (MDR)(P=0.026), Proteus(P=0.033), or polymicrobial strains (P=0.040). Antibiotic sensitivity was 10.9% for Ceftazidime, 29.5% for Piperacillin/Tazobactam, 31.3% for Ertapenem, 59.4% for Colistin, 71.7% for Meropenem and 72.9% for Imipenem.

Organisms Identified on Culture. (Table 1)

Organisms Identified on Culture. (Table 1)

Antibiotic Sensitivity Spectrum. (Graph 1)

Antibiotic Sensitivity Spectrum. (Graph 1)

Conclusion

Antibiotic resistance poses a major challenge in treating Acute Bacterial Cholangitis. The most effective antibiotics found for treating this condition in our population were Meropenem, Colistin, and Imipenem, while high resistance patterns were observed for Ertapenem, Ceftazidime, and Piperacillin/Tazobactam. A balance in prescribing broad-spectrum antibiotics and avoiding their use without definitive evidence of infection is crucial in mitigating the growing threat of antimicrobial resistance in cholangitis.

Disclosures

All Authors: No reported disclosures
2252. Characteristics and Management of non-ICU Patients with Community-Acquired Pneumonia (CAP)
Authors: Goetz Matthew B , Vaughn Valerie , Graber Christopher J , Kelly Allison , Jones Makoto M
Published: November 2023

Background

Pneumonia is the most common reason for hospitalization and is often associated with excessively broad empiric therapy & long antibiotic duration. To evaluate overuse, we assessed the indications & frequency of MDRO therapy, risk factors & post-admission culture positivity for MDRO, time to stability and duration of therapy in hospitalized persons with CAP not receiving intensive care.

Methods

We identified patients in the VA Corporate Warehouse with discharge ICD-10 codes consistent with pneumonia from 1/2022 to 3/2023. Exclusion criteria included < 2 days of antibiotic therapy, ICU admission, concurrent infections, > 14 days of antibiotic therapy & severe immunocompromise. Per ATS/IDSA guidelines, we allowed anti-MRSA therapy for patients with a prior positive MRSA culture, anti-pseudomonal (PSA) therapy for patients a prior positive PSA culture, and both anti-MRSA & anti-PSA therapy in patients with severe pneumonia (defined by > 1 ATS/IDSA minor criteria [mental status & x-ray data were not evaluable]) and intravenous antibiotics in the prior 3 months. Similarly, we assessed antibiotic duration and considered > 6 days inappropriate if patients were clinically stable (no more than one sign of instability) or discharged by day 5.

Results

The median age of the 19223 patients was 75 (IQR 68,81); 4.6% were women. 42%, 35% & 22% of patients had CURB-65 scores of 0-1, 2 & 3-4. While 32% (6185/19223) of patients received empiric MDRO therapy, per ATS/IDSA guidelines, only 12% (2330 patients) warranted MDRO therapy (593 had severe disease with prior IV antibiotics, 1737 had prior positive MRSA [1381] and/or PSA [457] cultures). Overall, 90% (5600/6185) of patients who received MDRO therapy were potentially overtreated while 6.5% (1213/19233) were potentially undertreated (Figure 1). MDRO were recovered in 6.3% of cases (Table 1). Across all patients, 98% (18870) were stable by day 5, 42% (7997) of whom received >6 days of therapy (Figure 2).

Figure 1

Table 1

Figure 2

Conclusion

We found substantial opportunities to reduce overuse of MDRO antibiotics and the duration of therapy in persons with CAP. Strengths of this analysis include the breadth and depth of the VA EHR. Limitations include the inability to assess selected measures of disease severity and stability (mental status changes and radiographic abnormalities).

Disclosures

All Authors: No reported disclosures
2256. Racial and Socioeconomic Disparities Evident in Inappropriate Antibiotic Prescribing in the Emergency Department
Authors: Klein Eili , Saheed Mustapha O , Irvin Nathan A , Balhara Kamna S , Badaki-Makun Oluwakemi , Poleon Suprena E Z , Kelen Gabor , Cosgrove Sara E , Hinson Jeremiah S
Published: November 2023

Background

Inappropriate antibiotic prescribing for acute respiratory infections is a common source of low-value care in the emergency department. Racial disparities have been noted in episodes of low-value care, particularly in children, but the intersection between race and socioeconomics in inappropriate prescribing has received less attention. Decisions to prescribe antibiotics outside of guideline recommendations may result from underlying bias. We evaluated inappropriate prescribing by race and socioeconomic status in five emergency departments of a large hospital system.

Methods

We conducted an observational analysis of antibiotic prescribing in adult and pediatric EDs at five hospitals between October 2015 and March 2023. We calculated the rate of inappropriate prescribing for ED encounters that had an ICD-10 for an acute respiratory tract infection (ARTI) that did not require antibiotics and that had no secondary ICD-10 code on the record for which antibiotics may be indicated. Multivariable regression analysis controlling for comorbidities and patient-level factors was used to estimate the odds ratio of prescribing.

Results

A total of 147,402 ED encounters were included, of which ∼50% identified as Black, 23% as White, and 15% as Hispanic. Inappropriate prescribing rates were 8.5% overall, 13.6% for White patients, 7% for Black patients and 6% for Hispanic patients. After adjusting for patient-level factors, including socioeconomic status,White patients had 1.39 (95% CI, 1.32-1.47) higher odds of receiving an inappropriate prescription compared to Black patients. Patients residing in areas of greater socioeconomic deprivation, regardless of race, had 0.70 (95% CI, 0.66-0.75) lower odds of receiving a prescription.

Inappropriate Prescribing Rate by Year and Race

The overall rate of inappropriate prescribing did fall over the years, both overall (black line) and by race, but differences in prescribing by race persisted.

Odds ratios of a patient being prescribed an inappropriate antibiotic

Conclusion

Our results suggest that after controlling for patient-level factors, White patients and patients from wealthier areas are more likely to receive inappropriate antibiotic treatment. While likely multifactorial in origin, it is possible that these disparities are driven by clinicians’ implicit biases that lead to overtreatment of White and wealthier patients. Further qualitative and quantitive approaches are needed to elucidate mechanisms and solutions to these disparities in care.

Disclosures

Oluwakemi Badaki-Makun, MD, PhD, Beckman Coulter: Grant/Research Support Sara E. Cosgrove, MD, MS, Debiopharm: Advisor/Consultant|Duke Clinical Research Institute: Advisor/Consultant Jeremiah S. Hinson, MD, PhD, Beckman Coulter: Advisor/Consultant|Beckman Coulter: Grant/Research Support|Beckman Coulter: TriageGO
2260. Differences in the Prevalence of Inappropriate Antibiotic Prescribing by Payer Type
Authors: Ladines-Lim Joseph B , Chua Kao-Ping , Fischer Michael , Linder Jeffrey A
Published: November 2023

Background

Understanding the relationship between inappropriate prescribing and patient insurance type could inform the targeting of antibiotic stewardship initiatives. However, few national data on this topic exist.

Methods

We analyzed the National Ambulatory Medical Care Survey, a nationally representative survey of office-based physician visits. We included all years from 2016 to 2019 except 2017, a year during which the survey was not fielded. We identified visits resulting in an oral antibiotic prescription among children and non-elderly adults who were privately insured, publicly insured, or uninsured. The exposure was safety-net status (publicly insured/uninsured versus privately insured). The outcome was inappropriate antibiotic prescribing, defined as an antibiotic prescription in a visit for which none of the diagnosis codes justified antibiotic use (following the approach of Chua et al, BMJ 2019). We assessed the association between safety-net status and inappropriate antibiotic prescribing using linear regression, controlling for patient characteristics, calendar quarter, and specialty. Models accounted for the complex design of the survey and employed designed-based variance estimators.

Results

Of 413,830,032 weighted visits for children, 16.9% resulted in an antibiotic prescription. Among these visits, the unadjusted prevalence of inappropriate antibiotic prescriptions was 29.1% overall, 23.4% for safety-net patients, and 32.4% for privately insured patients (adjusted difference, safety-net minus private: -11.9%, 95% CI: -20.6%, -3.2%). Of 1,240,610,825 weighted visits for non-elderly adults, 11.0% resulted in an antibiotic prescription. Among these visits, the unadjusted prevalence of inappropriate antibiotic prescriptions was 50.1% overall, 60.7% for safety-net patients, and 47.9% for privately insured patients (adjusted difference, safety-net minus private: 11.3%, 95% CI: 2.4%, 20.3%).

Conclusion

Safety-net status was associated with a lower rate of inappropriate antibiotic prescribing among children but a higher rate among non-elderly adults. Antibiotic stewardship initiatives targeting clinicians who care for privately insured children and adults with safety-net insurance may be warranted.

Disclosures

Jeffrey A. Linder, MD, MPH, FACP, Amgen, Biogen, Eli Lily: Stocks/Bonds
2950. Guideline discordant antibiotic treatment in the Emergency Department is associated with increased adverse events and length of stay
Authors: Breeden Maddy , Chanderraj Rishi , Petty Lindsay A
Published: November 2023

Background

Skin and soft tissue infections (SSTI) are the 3rd most common infectious disease treated in the Emergency Department (ED). Observational studies have shown poor adherence to IDSA guidelines in the ED. While there are numerous descriptive studies of guideline-discordant antibiotic treatment for SSTI in the ED, less is known about the impact of discordance on outcomes.

Figure 1

Inappropriate antibiotic treatment is associated with an increased hospital stay in patients admitted with a skin and soft tissue infection (Mean length of stay 4.62 days among appropriately treated patients and 10.63 days in inappropriately treated patients).

Methods

In this retrospective cohort study, 214 consecutive SSTI admissions treated with IV antibiotics at the Ann Arbor Veterans Affairs Hospital from 2020-2022 were reviewed by 2 Infectious Diseases physicians. Guideline concordance was adjudicated based on IDSA guidelines. Outcomes were hospital length of stay (LOS) and incidence of hospital-associated adverse events as defined by the Center for Medicare Services. The primary exposure was the concordance of antibiotic treatment with IDSA guidelines. Covariates included demographics, the burden of medical comorbidities by the Charlson index, and the severity of illness measured by the Severe Organ Failure Score (SOFA). We modeled the risk of hospital-associated adverse events with a multivariable logistic regression model and hospital LOS with a multivariable Poisson model.

Results

Of 214 patients with SSTI treated with IV antibiotics, only 15.7% (N=19) received guideline-concordant therapy, and only 32% (N=69) had indications for IV treatment. 27 patients (12.6%) had a hospital-associated adverse event. Vancomycin was the most common inappropriate antibiotic (n=76, 35%), and kidney injury was the most common adverse event (n=12, 9.8%). Guideline-discordant antibiotic treatment was associated with an increased length of stay after adjusting for covariates (0.83 more hospital days in guideline discordant, 95% CI 0.73-0.93 hospital days, p=0.027, Figure 1), and increased odds of hospital-associated adverse events (OR 1.03, 95% CI 1.002-1.08, p=0.04).

Conclusion

Guideline-discordant therapy for SSTI in the ED was associated with unnecessary IV treatment, longer hospitalization, and increased hospital-associated adverse outcomes. Stewardship interventions should target treatment of SSTI in the ED to improve patient outcomes.

Disclosures

All Authors: No reported disclosures
2278. The Safety of Aztreonam vs. Ceftazidime in Patients with Penicillin Allergy: A Matched Cohort Study
Authors: Tan Jun Jie , Zhou Peijun Yvonne , Chua Nathalie Grace Sy , Hung Kai Chee , Lee Winnie , Lee Lai Wei , Le Lim Jia , Lim Yun Chun Shena , Liew Yixin , Loo Li Wen , Koomanan Narendran S/O , Tang Sarah , Teoh Boon San , Yii Daphne , Thien Siew Yee , Cherng Pei Zhi Benjamin , Chlebicki Maciej Piotr , Kwa Andrea , Chung Shimin Jasmine
Published: November 2023

Background

Penicillin allergy (PA) is the most common drug allergy and is reported in up to 15% of hospitalized patients. Traditionally, aztreonam (AZT), a monobactam with low cross-reactivity to penicillin (PCN), has been recommended as an alternative antibiotic for patients with PA in our institutional empiric antibiotic guidelines. However, due to global AZT shortage in 2022, ceftazidime (CTZ), a cephalosporin with similar R1-side chain to AZT and low cross-reactivity to PCN, was used as a substitute for AZT. Fortuitously, this was cheaper - AZT (SGD $44.03 per 1g vial) vs CTZ (SGD $2.86 per 1g vial). There is a paucity of real-world data on the safety of CTZ in patients with PA. We proceeded to evaluate our experience with using CTZ as an alternative to AZT.

Methods

This is a 1:1 matched, retrospective cohort study comparing patients with PA who received AZT from October 2022 to December 2022, with those who received CTZ from December 2022 to February 2023. They were matched based on severity of allergic reaction (AR) to PCN, age and gender. The risk of AR was stratified as low, medium or high based on the classification provided by the American Academy of Allergy, Asthma and Immunology. The severity of AR was based on the Delphi study grading system. The primary outcome was development of AR after initiation of AZT or CTZ. The secondary safety outcomes include hepatotoxicity and neurotoxicity.

Results

There were 132 patients: 52 patients (39.4%) were males, with a median age of 70 (IQR, 61 – 76) years, and majority were Chinese (n = 84 (63.6%)). The number of patients with low, medium and high risk of AR to PCN were 60 (45.4%), 54 (40.9%), and 18 (13.6%) respectively. The incidence of AR was similar in both groups: 1 patient (1.52%) in AZT arm vs 2 patients (3.03%) in CTZ arm (p = 1.0). The patient in the AZT arm had generalized urticaria (Grade 2). Both patients in the CTZ arm developed localized skin reaction (Grade 1). All 3 patients were deemed high risk of developing AR to PCN. Another patient in the AZT arm developed hepatotoxicity (raised alanine phosphatase and alanine transaminase), with a Naranjo score of 3 (possible adverse drug reaction).

Conclusion

CTZ is a safe alternative to AZT for patients labelled with PA, and may be a more cost-effective alternative in our setting.

Disclosures

All Authors: No reported disclosures
2280. Surveillance of Life-Long Antibiotics (SOLLA) 2: Patients on Life-Long Antibiotics in an Australian Healthcare Network
Authors: van Leerdam Taylah , Lau Jillian , Woolley Ian , Browne Mitchell , O’Bryan Jessica
Published: November 2023

Background

There is a range of conditions for which long-term antibiotics are prescribed, most of which lack high quality evidence. Apart from promoting antimicrobial resistance, long-term antibiotics also impact the individual patient, disrupting the normal microbiome, and increasing the risk of infection with multi-resistant organisms (MROs). Previous work conducted at Monash Health, in Victoria, Australia, in 2014 noted great heterogeneity in both indications for prolonged antibiotic courses and the antimicrobial agents used.

Methods

The current study aimed to reassess prescribing trends within the same health network, across two time periods in 2019 and 2021. Outpatient prescriptions were extracted from the Monash Health pharmaceutical database at two time points, from 1st January 2019 – 30th June 2019, and 1st January 2021 – 30th June 2021.

Results

From 4,704 outpatient prescriptions, 929 patients were identified as being on either one or more antibiotics for an intended duration of ≥ 12 months. There were a total 536 (57.7%) males and 393 females (42.3%), with a mean age of 58.20 years. Sixty-eight patients died between the two follow-up periods. Data was separated into 3 groups: primary prophylaxis in the setting of immunosuppression (n = 687), secondary prophylaxis for infections deemed incurable (n = 78), and “Other” (n = 164). Six hundred and four patients (88%) on primary prophylaxis were for Pneumocystis jirovecii pneumonia, and 83 (12%) post splenectomy. Trimethoprim/sulfamethoxazole was predominantly prescribed for PJP prophylaxis (n = 583), followed by dapsone (n = 21). Prosthetic joint infections made up 57 (73%) of those on suppressive antibiotics for infections deemed incurable. An array of antibiotics was utilised to treat them, as seen in Figure 1. The “Other” category included those on antibiotics for difficult to treat infections, such as mycobacterial infections (n = 43), chronic airways disease (n = 38), spontaneous bacterial peritonitis (n = 23) and recurrent urinary tract infections (n = 12). Data on comorbidities, hospitalisations and MROs between groups can be viewed in Table 1.

Conclusion

Further research is needed. Prospective data examining long-term patient outcomes, and patterns of prescribing across different health networks would be of benefit.

Disclosures

Jillian Lau, MBBS, FRACP, Gilead: Advisor/Consultant|Gilead: Grant/Research Support|MSD: Grant/Research Support|Viiv Healthcare: Advisor/Consultant Ian Woolley, MBBS, FRACP, DTM&H, MD, Gilead: Educational support, investigator for Gilead supported trial|MSD: educational support, participation in a clinical trial|Pfizer: Educational support|ViiV: Educational Programs, Advisory Board member, ViiV sponsored trials
2290. Neurological Symptoms of Long - COVID in Mexican Ambulatory Adults with Mild COVID-19
Authors: Díaz-Ramírez Jorge-Baruch , Marquez Jorge Bryan Ortega , González-Valadez Yazmín , Cortazar-Maldonado Luis-Alberto , Morales-Fernández José-Antonio , Pérez-Sastré Miguel A , Rojas Roberto Martínez , Trujillo García Leopoldo D , García Martha Fragoso , Salinas Diana Mondragón , Hernández Lissete Navarrete , Acosta Diana Pérez , García-León Miguel Leonardo , Bautista-Carbajal Patricia , Ángel-Ambrocio Antonio H , Camacho-Morales Jorge , Villa Antonio R , Wong-Chew Rosa-María
Published: November 2023

Background

The COVID-19 pandemic represents one of the greatest public health crises in this century . Since the beginning of the pandemic there were reports of persistence of symptoms after an average recovery period of 2-5 weeks. Long-COVID syndrome was defined as a continuation or onset of symptoms within 3 months of the initial infection, lasting for at least 2 months with no explanation. There are few studies focused on neurological symptoms of long COVID in ambulatory patients who suffered a mild disease.

Methods

We conducted a prospective cohort study with a univariate and Kaplan-Meier survival analysis with data obtained between January 2020 to November 2022 from ambulatory adults with mild to moderate COVID-19 diagnosed at our UNAM Faculty of Medicine COVID-19 Diagnostic Center in Mexico City. Patients were systematically called every 15 days during 6 months to evaluate self-perceived neurological symptoms after being diagnosed.

Results

We assessed 169 COVID 19 patients, the mean age was 39 (SD 15) years, 42% were men, 97% were Mexican, 90% developed a new neurologic symptom after the COVID-19 acute period. The most common symptoms reported during the follow up were in the first 21 days: fatigue (84%), headache (70%), sleep disorders (69%), sadness (61%), concentration difficulties (60%), emotional liability (57%), anger (56%) and irritability (55%) among others. The highest cumulative incidence (per 1,000 persons) was for headache (187), fatigue (168), sleep disorders (108), concentration difficulties (88), anger (81), dizziness (79), paresthesia (73), speaking and thinking difficulties (67) among others.

The survival analysis showed an increased cumulative probability to develop neurological symptoms during the 6 months follow-up, with the highest risk for headache (50%) and fatigue (40%).

Conclusion

The probability of presenting neurologic symptoms after suffering a mild COVID 19 disease increased during the 6 months follow up. Additionally, most symptoms were of new onset after the initial recovery from an acute mild COVID-19 episode or persisted from the initial illness and fluctuated over the follow-up, except for seizures that were present as an isolated symptom during acute phase and absent during the follow-up.

Disclosures

All Authors: No reported disclosures
2294. Severity and characteristics of patients hospitalized during Delta and Omicron-predominant COVID-19 time periods in Los Angeles County
Authors: Greene Carmon , Sato Heidi D , OYong Kelsey , Traub Elizabeth , Rubin Zachary
Published: November 2023

Background

We examined risk factors and disease severity in patients hospitalized during Delta and Omicron SARS COV-2-predominant periods in a diverse metro area.

Methods

A retrospective cohort study was conducted using data reported to Los Angeles County Department of Public Health on adults aged 18 years and older with a laboratory-confirmed COVID (PCR/NAAT) test collected on or within 14 days of hospital admission between 6/19/2021 - 1/3/2023. Case data were matched with: 1) California Immunization Registry data to determine vaccination status and 2) whole genome sequencing results when available.

Infection with an inferred variant was defined as having a laboratory collection date during the time period when the variant exceeded 50% of sequenced specimens (Delta-predominant period: 6/19/2021-12/11/2021; Omicron-predominant period: 12/18/2021-1/3/2023). Confirmed infection was defined as having a sequenced specimen with either Delta or Omicron variant. Demographic and clinical metrics were examined (Tables 1-4). Patients with Delta and Omicron were compared using Chi-square tests. P-values < 0.05 were considered statistically significant.

Results

During the study period, 13,790 inferred Delta and 38,264 inferred Omicron hospitalized cases were reported. 2,660 cases (of 61,983 sequenced specimens) had confirmed Delta and 1,983 (of 61,534 sequenced specimens) had confirmed Omicron infections. Cases hospitalized with both inferred and confirmed Delta were more likely to have a COVID-related hospitalization, admitted to ICU and longer length of stay (Tables 3, 4). Cases hospitalized with both inferred and confirmed Omicron were significantly older and more likely to have a comorbidity (Tables 3, 4).

Conclusion

Based on the longer length of stay and higher ICU admission, COVID patients hospitalized during the Delta-predominant time period have a more severe outcome and are more likely to have COVID-related diagnoses than COVID patients hospitalized during the Omicron-predominant time period.

This study was limited by an unadjusted analysis, which did not control for potential confounders during the different time periods, such as vaccination coverage, prior infections, hospital capacity, and percent of sequenced specimens.

Disclosures

All Authors: No reported disclosures
2953. PK/PD Comparison of a New Dosing Scheme for Meropenem Adapted to Outpatient Parenteral Antimicrobial Therapy (OPAT) in Non-Critically-Ill Patients
Authors: Briquet Caroline , Pharmacist Hospital , Ngougni Pokem Perrin , Wijnant Gert-Jan , Cornu Olivier , Yildiz Halil , Van Bambeke Françoise , Cyr Yombi Jean
Published: November 2023

Background

A pilot OPAT project has been started in Belgium for the continuation at home of the treatment (initiated in hospital) of patients infected by multi-resistant Gram-negative bacteria when no oral options are available. In Belgium, meropenem is the only available carbapenem, but its limited stability at room temperature does not allow a sustained administration over 12 or 24 h via IV pumps. As the replacement of the perfusion is not feasible after working hours for home care nurses, the aim of this prospective study was to compare the pharmacokinetic profile and time above MIC for 2g meropenem administered TID (20 minutes infusion) over 12h (typically at 8h,14h, 20h) in comparison with the traditional 24h regimen (typically at 8h,16h, 24h).

Methods

Patients received first meropenem 2g q8h. At steady state ( > 3 doses), 4 blood samples were collected over 8h. The penultimate day of the treatment, patients were switched to the OPAT-compatible dosage regimen (2g q6h over 12h) and, at steady state, a total of 8 blood samples were collected during the first and third dosing intervals. Unbound meropenem concentrations were determined in ultrafiltrated plasma by a validated LC-MS/MS procedure. Time above MICs ≤ 8 mg/L (EUCAST susceptibility breakpoint) were estimated for both schemes based on PK profiles.

Results

Twenty-two patients were included. The mean pharmacokinetic profile for each scheme is shown in the Figure 1. The Table 1 shows that plasma concentrations remained > 4 mg/L during 100% time with the conventional scheme and > 2 mg/L with the OPAT-compatible scheme but still at least ∼80% time > 8 mg/L with both therapeutic schemes. Periods of inadequate coverage are spread at the end of each dose with the conventional dosing regimen but essentially concentrated overnight with the new scheme.

Conclusion

PK/PD models recommend for meropenem therapeutic schemes with plasma concentrations > MIC during 30-40% of the time in non-critically ill patients. This target is easily achieved with the proposed OPAT-compatible dosing regimen, including during night, and could therefore be safely used in a context of limited nurse resources.

Disclosures

All Authors: No reported disclosures
2304. Surveillance strategies for the detection of new SARS-CoV-2 variants across epidemiological contexts
Authors: Roster Kirstin Oliveira , Kissler Stephen M , Omoregie Enoma , Wang Jade , Amin Helly , Di Lonardo Steve , Hughes Scott , Grad Yonatan H
Published: November 2023

Background

Rapid identification of new SARS-CoV-2 variants is a critical component of the public health response to the COVID-19 pandemic. However, we lack a quantitative framework to assess the expected performance of sampling strategies in varying epidemic contexts.

Methods

To address this gap, we used a multi-patch stochastic model of SARS-CoV-2 spread in New York City to evaluate the impact of the volume of testing and sequencing, geographic representativeness of sampling, location and timing of variant emergence, and relative variant transmissibility on the time to first detection of a new variant.

Results

The strategy of targeted sampling of likely emergence locations offered the most improvement in detection speed. Increasing sequencing capacity reduced detection time more than increasing testing volumes. The relative transmissibility of the new variant and the epidemic context of variant emergence also influenced detection times, showing that individual surveillance strategies can result in a wide range of detection outcomes, depending on the underlying dynamics of the circulating variants.

Detection time by test volume and fixed sequencing capacity.

Lines depict the mean duration between variant introduction and detection in days as a function of daily testing volume, colored by the maximum sequencing volume (A), and as a function of daily maximum sequencing volume, colored by the test volume (B) (at variant introduction 50 days after the prior variant and baseline sampling strategy).

Detection time by proportion of tests allocated in a single location.

Lines depict the average detection time for scenarios where between 20% and 100% of tests are sampled from a single location, and the remaining tests are evenly distributed across the remaining locations by population size. The lines distinguish between scenarios where the variant emerged in the primary allocation location, i.e., test over-sampling and emergence occurred in the same location (blue), and scenarios where the variant emerged in one of the other locations, i.e., test over-sampling and emergence occurred in different locations (red). Ribbons depict the 95% confidence interval for the detection time.

Conclusion

These findings help contextualize the design, interpretation, and trade-offs of genomic surveillance strategies.

Disclosures

Stephen M. Kissler, PhD, ModernaTx: Advisor/Consultant Yonatan H. Grad, MD, PhD, Day Zero Diagnostics: Board Member|GSK: Advisor/Consultant