bluuebunny/crossref_metadata_2025 huggingface dataset:
1192. Validation of an Electronic Dashboard in Identifying Excess Duration of Antibiotics for Pneumonia
Authors: Ferranti Mary , Degnan Kathleen , Do David , Hamilton Keith W , Dutcher Lauren
Published: November 2023

Background

Many inpatients receive inappropriately prolonged courses of antibiotics for community acquired pneumonia (CAP) and hospital acquired pneumonia (HAP). Identifying these patients is important for use in interventions to reduce unnecessary antibiotic exposure. In this study, we evaluate how well an electronic dashboard identifies inpatients receiving excess treatment for pneumonia and characterize reasons for excess antibiotic duration.

Methods

Within an academic health system, a dashboard was created to generate an alert when inpatients received antibiotics longer than 120 hours (5 days) or azithromycin longer than 72 hours (3 days) for CAP and 168 hours for HAP (7 days). We reviewed a random sample of encounters with an alert between November 2018 and January 2023. Through chart review, we collected medical history, provider documentation of antibiotic indication, duration of treatment, and reasons for excess duration. Descriptive statistics were used to report 1) the proportion of patients with true positive alerts (alerts generated for patients who truly received an excess duration of antibiotics for pneumonia) and false positive alerts (alerts generated but the patients had not received an excess duration of antibiotics for pneumonia) and 2) reasons for true positive and false positive alerts.

Results

Out of 200 patients, 156 (78.0%) were found to have a true positive alert, while 44 (22.0%) had a false positive alert. Of the patients who received a longer duration than needed for pneumonia (i.e. true positives), 24.5% had no documented reason for prolonged duration and 21.5% had documented inadequate clinical improvement as defined in Table 2. Excess days of azithromycin for CAP was also a common reason for true excess duration (13.5%). Incorrect antibiotic indication selection was the most common reason for a false positive alert (31.8%).

Conclusion

The electronic dashboard is a useful tool that can correctly identify inpatients receiving excess duration of treatment for pneumonia in a majority of cases. Future stewardship endeavors should focus on interventions to reduce such excess duration especially for the most common reasons found.

Disclosures

Kathleen Degnan, MD, Gilead: Grant/Research Support
1194. Implementation of Methicillin-Resistant Staphylococcus Aureus Nasal Swabs as an Antimicrobial Stewardship Tool in a Community Hospital
Authors: Gibson Heather D , Arnoczy Gretchen S , Lee Jayne , Cid Allison
Published: November 2023

Background

Methicillin-resistant Staphylococcus Aureus (MRSA) nasal PCRs are an effective stewardship tool in patients diagnosed with pneumonia and implementation has been shown to reduce use of anti-MRSA antibiotics.

Methods

A pre-post interventional study was conducted at FirstHealth Moore Regional Hospital from January 1st to March 31st, 2022 (pre-intervention, PRE) and January 1st to March 31st, 2023 (post-intervention, PO). Intervention was education by an antimicrobial stewardship (AMS) pharmacist to providers on the use of MRSA nasal PCRs. Primary outcomes were percent change in patients who had PCR ordered PRE and PO and percent patients who had anti-MRSA therapy (vancomycin, VANC) discontinued based on a negative result. Secondary outcomes include time from negative PCR to VANC discontinuation, length of VANC therapy, and number of VANC levels. Inclusion criteria were patients aged > 18 years old hospitalized for community-acquired pneumonia admitted to a medical floor receiving VANC. Exclusion criteria were patients < 18 years of age, pregnant patients, patients admitted to the ICU, or recent history of MRSA.

Results

For primary outcomes, 125 patients were in the PRE group. 42 were on VANC for > 24 hours and 8 had a MRSA nasal swab (6.4%). Of the 8 swabs, 1 patient (12.5%) had VANC discontinued based on a negative PCR. 2 patients were not started on VANC in response to the negative PCR (25%). 112 patients were in the PO group. 32 were on VANC for > 24 hours and 27 had a MRSA nasal swab performed (24.1%). Of the 27 swabs, 14 (51.9%) had VANC discontinued based on a negative PCR. 6 patients were not started on VANC in response to the negative PCR (22.2%). For secondary outcomes in the PRE group, time from negative PCR to discontinuation of VANC was 9 hours 54 minutes (1 patient), average VANC therapy was 4.8 days, and an average of 1.7 VANC levels were drawn. In the PO group, average time from negative PCR to discontinuation of VANC was 18 hours 18 minutes (14 patients), average VANC therapy was 3.4 days, and an average of 1.1 VANC levels were drawn.

Conclusion

Educating providers on the benefits of MRSA nasal PCRs led to a significant increase in number of PCRs orders and an increase in VANC discontinued with negative results. Secondary outcomes show continued room for improvement and potential for cost avoidance.

Disclosures

Jayne Lee, BSN, MPH, CIC, FAPIC, Medline: Advisor/Consultant
1196. Determining Risk Criteria for Direct Oral Penicillin Challenge in Hospitalized Adults with a History of Penicillin Allergy
Authors: Hamid Lina , Bell Christian
Published: November 2023

Background

Beta (β)-lactam antibiotics such as penicillin (PCN) and its derivatives are safe and effective for many bacterial infections. PCN allergies are self-reported in approximately 10% of Americans. Concerns for allergy cross-reactivity often causes the use of broad-spectrum antibiotics and second-line agents. This may increase the cost of care, lengthen therapy, increase side effects, contribute to the development of resistance, and worsen patient outcomes. Recent studies have shown direct oral penicillin challenge (DOC) may be safe and effective in patients with low to moderate risk for reaction.

Methods

This single-site retrospective analysis reviewed hospitalized adult patients with penicillin allergy assessment (PAST) completed by an antimicrobial stewardship team (AST) between May 1, 2017 and September 30, 2022 at a large academic medical center. Our primary aim is to determine risk stratification criteria for a DOC using primary literature and internal data. Secondary aims include cost avoidance analysis, updating PAST guidance, and creating an order set for the administration and monitoring of DOC.

Results

A total of 256 patients were screened and 200 were included. Most common reasons for exclusion were non-PCN allergies, PAST completed at a different hospital, and PAST not completed before discharge. There were 60 patients (30%) deemed to be high-risk for allergic reaction of which 58 (96.7%) received non-PCN alternative and 2 (3.3%) received no antibiotics. AST recommended oral or IV challenge for 107 patients (53.5%) of which 34 (31.8%) received a challenge, 68 (63.6%) received non-penicillin alternative antibiotics, 3 (2.8%) were directly de-labeled, and 2 (1.9%) received no antibiotics. No anaphylactic reactions occurred in patients that received a challenge. De-labeling based on history was recommended in 33 patients (16.5%) of which 12 (36.4%) were directly de-labeled, 2 (6.1%) received a challenge, and 19 (56.1%) received non-penicillin alternative antibiotics.

Conclusion

Our study confirms risk stratification for DOC is feasible and safe. Standardization of PCN allergy de-labeling with clinician and patient education may improve patient outcomes.

Disclosures

All Authors: No reported disclosures
1199. Effectiveness of Non-carbapenem vs Carbapenems Empiric Therapy for Extended-Spectrum β-Lactamase (ESBL)-producing Enterobacterales (PE) Infections in Non-ICU patients: A Real-world Investigation in a Hospital with High-prevalence of ESBL-PE
Authors: Kang Amy Y , Elkomos Mary W , Pham Danny , Guerrero Michelle , Miller Loren G
Published: November 2023

Background

Surviving Sepsis guidelines recommend empiric broad-spectrum therapy that covers likely pathogens. However, among hospitalized, non-ICU patients with less severe clinical presentations, it is unclear whether effective empiric antibiotics lead to improved outcomes.

Methods

We reviewed records of adult non-ICU patients admitted to a large urban medical center with confirmed ESBL-PE infection between Jan 2019 and Aug 2020. We excluded patients from our analysis if: antibiotics were started >48 h from the first positive culture; culture was polymicrobial; hospital length of stay was < 24 h; or positive cultures likely represented colonization. We grouped patients into receipt of empiric carbapenems or not. Our primary outcome was time until clinical stability from the first dose of the empiric antibiotic (in hours). Secondary outcomes included early clinical response and 30-day all-cause hospital readmission.

Results

Among 448 patients with ESBL-PE isolates during our study period, 143 met study criteria. Of these 143, 60 (42%) received empiric carbapenem therapy. Median age was 59 y, and 67% were Hispanic. The most common source was urinary (71%). Carbapenem receipt was associated with previous antibiotics within 6 months of admission (55% vs 28%, p< 0.01) and history of ESBL (57% vs 17%, p< 0.01). Most common empiric therapy in the non-carbapenem group was ceftriaxone (59%). We found no difference in hours until clinical stability from the first dose of the empiric antibiotic between carbapenem and non-carbapenem groups (24 (IQR 8-40) vs 25 (6-75), p=0.77). We also found no difference in early clinical response between groups (88% vs 90%, p=0.78). We found a non-significant trend towards higher 30-day all-cause hospital readmission in the carbapenem group (17% vs 8%, p=0.13).

Conclusion

Among hospitalized non-ICU patients with ESBL-PE infection, we found no difference in time to clinical stability after the first dose of the empiric antibiotic between those receiving carbapenems and those who did not. Our data suggest that empiric carbapenem use may not be an important driver of clinical response in patients with less severe ESBL-PE infection. Our findings may have important antibiotic stewardship implications.

Disclosures

Amy Y. Kang, Pharm.D., BCIDP, Paratek: Grant/Research Support Loren G. Miller, MD MPH, ContraFect: Grant/Research Support|GSK: Grant/Research Support|Medline: Grant/Research Support|Merck: Grant/Research Support|Paratek: Grant/Research Support
1202. Impact of CTX-M Rapid Diagnostic Testing via Biofire® FilmArray® Blood Culture Identification 2 Panel on Early Optimization of Antibiotic Treatment for Enterobacterales Bacteremia
Authors: Kim Brian , Kurator Kevin , Huizar Oscar E Gallardo , Arab Niki , Jeng Arthur
Published: November 2023

Background

Biofire® FilmArray® Blood Culture Identification 2 Panel (BCID2), compared to the original version, expands microbial targets and tests for seven additional resistance genes, including detection of CTX-M Extended-Spectrum Beta-Lactamase (ESBL). At Olive View-UCLA Medical Center (Sylmar, CA), BCID2 supplanted the original version for antimicrobial stewardship rapid diagnostic testing (RDT) of blood cultures (Bcx). We reviewed the impact of BCID2 CTX-M RDT on early optimization of antibiotic (abx) treatment (tx) for Enterobacterales bacteremia.

Methods

Retrospective chart review of adults (≥ 18 years) admitted with BCID2 detection of Enterobacterales from April 1, 2022 to March 31, 2023. Exclusion criteria included detection of carbapenemase, concomitant infection warranting continuation of empiric abx despite BCID2 result, suspected contamination of Bcx, and BCID2 detection of Serratia, Enterobacter, or Enterobacterales without identification of species. ESBL-active abx (EAA) was defined as either amikacin or a carbapenem; non-EAA was any abx except amikacin or a carbapenem. Days of therapy (DOT) saved was calculated by the difference in days between abx change and Bcx finalization (CF).

Results

120 BCID2 results met study inclusion. CTX-M was detected (CTX-Mpos) in 44 (37%) and was not detected (CTX-Mneg) in 76 (63%). In CTX-Mpos, 29 (66%) were started on an empiric non-EAA, of which 28 (97%) resulted in a change to an EAA < 24 hours (H) of BCID2 result; all 29 had a change to an EAA prior to CF. An average of 3 DOT [IQR 2-5] was saved. Five had a history (hx) of ESBL from any source. In CTX-Mneg, 13 (17%) were started on an empiric EAA, of which 8 (62%) had a change to a non-EAA < 24 H of BCID2 result. One had a change to a non-EAA ≥ 24 H of BCID2 result but prior to CF. Four had a change to a non-EAA after CF. An average of 3 DOT [IQR 2-3] was saved. Seven had a hx of ESBL from any source. BCID2 CTX-M results were 100% congruent with the presence or absence of ESBL on Bcx, respectively.

Conclusion

BCID2 CTX-M RDT resulted in early optimization of abx tx in the majority of cases, leading to early escalation of non-EAA empiric tx against ESBL-pathogens and early de-escalation of EAA against non-ESBL pathogens. Rapid diagnostic testing for CTX-M is a valuable tool for antimicrobial stewardship.

Disclosures

All Authors: No reported disclosures
1210. Prospective review of provider discontinuation of inappropriate intravenous (IV) vancomycin at a community teaching hospital in Chicago
Authors: Oderinde Jennifer , Chiang Anthony , Juska Alicia , ADEYEMI O L U W A D A M I L O L A A
Published: November 2023

Background

Vancomycin is often started empirically for its reliability with gram-positive pathogens, particularly Methicillin Resistant Staph aureus (MRSA). Consequently, it is often over-prescribed. Antimicrobial stewardship programs (ASP) have used time-outs to ensure therapies are tailored to the patient with proper indication and coverage.

Methods

Between November 2022 and February 2023 provider discontinuation of IV vancomycin was prospectively reviewed when it was no longer needed at a 298 licensed bed community teaching hospital in Chicago. Results of culture sensitivities including MRSA nares screen, blood, and wound cultures were used to analyze appropriateness. Appropriateness was defined as having a positive MRSA culture, positive MRSA nares for treatment of PNA only, gram positive infections with a true and severe beta-lactam allergy, gram positive infections with beta-lactam resistant pathogens (i.e. ampicillin resistant Enterococcus), purulent cellulitis without culture data, and pending or negative cultures for deep-seated infections (i.e. CNS, Cardiovascular, BJI) with ID consult.

Results

153 patients met criteria for discontinuation of IV vancomycin and 107 of those were able to be discontinued. Inappropriate regimens were continued in 46 patients for various indications including pneumonia, skin and soft tissue infections, intra-abdominal infections, urinary tract infections, and endocarditis without infectious disease (ID) consult.

Of the 107 patient encounters, pharmacists intervened and discontinued 62 (57.9%), ID discontinued 16 (14.9%) and the primary medical team discontinued 29 (27.1%).

Conclusion

30% (46/153) of patients studied continued an inappropriate vancomycin regimen. There is room for improvement in regards to proper education surrounding antimicrobial stewardship. An antimicrobial time-out can help further decrease inappropriate vancomycin use.

Disclosures

All Authors: No reported disclosures
1216. ASP Initiated Blood Culture Service Is Highly Accepted, Reduced Antibiotic Durations Associated with Good Safety Outcomes
Authors: Foo Geraldine Tingting , Chen Hui Hiong , Wu Jia En , Chew Ka Lip , Santoso Erna G , Somani Jyoti
Published: November 2023

Background

NUH is a 1200 bed academic medical center with quaternary medical services ; the ASP program was initiated in 2014. A 2020 review found 18.5% of bacteremic patients were on inappropriate antibiotics (ABX) or wrong duration, and the overall majority of bacteremias were gram-negative (E .coli and Klebsiella). Since out ASP program has been promoting shorter durations in general, we hypothesized that a blood culture service where recommendations for de-escalation and appropriate duration were given early would help shorten ABX durations in patients with uncomplicated bacteremias. On March 15, 2021, we initiated an ASP led blood culture (BC) service (SVC) which reviewed case notes of patients Monday to Friday as soon as blood culture (BC) susceptibilities were available. We report on the types of interventions (INV), acceptance rate, and the impact and outcomes of our BC SVX between patients in whom the INV was accepted versus rejected.

Methods

Prospective data on BC SVC interventions, acceptance rate, and patient status at five days were collected. Antibiotic duration (IV and oral), Length of Stay (LOS) and 30-day mortality as well as Charlson Comorbidity Index (CCI) were determined from electronic medical records for all ASP BCSVX interventions between March 15, 2021- December 31, 2022. Statistical analysis was performed in excel and STATA.

Results

790 INVs were made on 625 patients and 693 courses of ABX with an 83.9 % overall acceptance rate. De-escalate ABX and treatment duration were the most common INVs (Table 1). 92.5% of patients had improved or no change in Day 5 status when ASP INV was accepted compared to 84.3% when rejected (p=0.003). Mean days of ABX per course was 5.9 versus 7.3 (p= 0.008) in the accepted versus rejected groups. CCI and LOS were similar, while 30-day mortality almost reached significance in the accepted INV group (Table 2).

Conclusion

ASP led BC SVC was well accepted, saved 2.14 days of ABX per intervention, and was very safe.

Disclosures

All Authors: No reported disclosures
1222. Impact of Microbiology Reporting Changes in Treatment of AmpC Bloodstream Infections
Authors: Wesolowski Alec , Miller Jessica , Argotsinger Jill , Gavaghan Victoria , Dela-Pena Jennifer
Published: November 2023

Background

Recent literature suggests that AmpC production may be overcalled in Enterobacterales, leading to unnecessary broad-spectrum antimicrobial utilization. The Infectious Diseases Society of America (IDSA) has since reassessed classification of high and low risk organisms with inducible AmpC expression. With this updated guidance, our health system approved changes to our microbiology reporting of AmpC producers in an effort to guide prescribing of appropriate antibiotics. The primary objective of this project was to compare antibiotic prescribing patterns for high and low risk AmpC producers in patients with bloodstream infections (BSI) based on the addition of appended comments to antimicrobial susceptibility results.

Methods

This multicenter, retrospective, cohort study included patients with BSI from October 2022 to March 2023who received at least 48 hours of antimicrobial therapy for the following high and low risk AmpC producers: Citrobacter spp., Enterobacter spp., Klebsiella aerogenes, Serratia spp., Morganella spp., Providencia spp. The primary endpoint was the number of patients placed on optimal therapy based on adherence to the appended microbiology comment and IDSA guidance. Secondary endpoints included time to effective treatment, time to optimal treatment, duration of therapy, 30 day mortality, microbiological failure, microbiological relapse, 30 day readmission, length of stay, and hospital acquired Clostridioides difficile infection.

Results

A total of 191 positive blood cultures were identified with 93 patients (pre-appended comment = 57; post-appended comment = 36) meeting inclusion criteria. Patients were more likely to receive optimal therapy post-appended comment based on IDSA guidance for BSI (38.6% vs 72.2%, OR 4.14; 1.68-10.21). When stratified by high risk and low risk organism, the number of patients on optimal therapy increased in the post-appended comment group but was not statistically significant (high risk: 70.3% vs 88%, OR 3.08; 0.72-13.32; low risk: 10% vs 36.3%, 5.14; 0.92-28.50). No difference in secondary outcomes were detected.

Conclusion

Implementation of an appended microbiology note has the potential to have a positive impact on antimicrobial prescribing patterns in treatment of AmpC bloodstream infections.

Disclosures

All Authors: No reported disclosures
1224. Outcomes of Empirical Vancomycin De-escalation Based on Methicillin-Resistant Staphylococcus aureus Nares
Authors: Xu Jiachen , Chan Arthur , Wattengel Bethany A , Mergenhagen Kari A
Published: November 2023

Background

Vancomycin is a first-line therapy for methicillin-resistant Staphylococcus aureus (MRSA) infections. Studies found that vancomycin is associated with a higher incidence of nephrotoxicity, even within therapeutic range. MRSA nares screening allows for rapid identification of MRSA carriers. It has been proposed that MRSA nares screening may improve patient care by avoiding vancomycin. Clinical data showing the impact of de-escalation based on MRSA nares is sparse. The objective of this study is to examine the incidence of nephrotoxicity, length of stay and clinical outcomes in those who were empirically deescalated vs. those who were not.

Methods

This was a retrospective cohort study conducted across Veterans Affairs (VA) medical centers nationwide from 1 January 2018 to 1 August 2022. In addition to baseline patient characteristics, MRSA nares results on admission and vancomycin usage were obtained. Patients were stratified based on the timing of vancomycin de-escalation. Primary outcome was development of acute kidney injury, defined as a 50% increase in serum creatinine or increases in SCr by 0.3 mg/dL. Secondary outcomes included hospital length of stay and clinical course of empirical de-escalation. Odds ratios were generated from a multivariate logistic regression of significant factors.

Results

This cohort yielded 49,340 cases across the nation. Vancomycin was de-escalated after 1 dose in 7196 cases (14.58%) after MRSA nares results being documented in the electronic health record. AKI rates were lower with the early de-escalation (377/7196[5.24%] vs 3185/42144 [7.56%], P< 0.0001). In multivariate analysis, incidence of nephrotoxicity was reduced by 30% (OR = 0.686; CI 0.612-0.767). Additionally, the mean hospital length of stay was reduced (8.5 vs 12 days).

Conclusion

De-escalation of vancomycin based on MRSA nares screening result can reduce the risk of nephrotoxicity and decrease hospital length of stay.

Disclosures

All Authors: No reported disclosures
1231. Development of state public health goals for antimicrobial stewardship using local data
Authors: Biehle Lauren , Schaefer Rachel , Czaja Christopher A
Published: November 2023

Background

Antimicrobial stewardship (AS) is critical to effectively treat infections and combat antibiotic resistance. Our Healthcare-Associated Infections/Antimicrobial Resistance (HAI/AR) program used state-level data to set public health priorities for AS across diverse acute care (ACH) and critical access (CAH) hospital settings.

Infographic describing antimicrobial stewardship goals and priority actions for Colorado hospitals

Methods

Hospitals reported antibiotic use (AU) data and implementation of priority core elements of AS to the National Healthcare Safety Network (NHSN). The Colorado Department of Public Health and Environment (CDPHE) accessed the data according to a data use agreement with NHSN. We used these data and antibiotic resistance surveillance data to inform state public health goals for AS.

Results

AU data were available for 47/53 ACH (88%) and 18/31 (58%) CAH. Three antibiotics (ABS) of highest use were ceftriaxone (18% of all ABS reported), vancomycin (14%), and piperacillin-tazobactam (10%). Data from the NHSN Patient Safety Survey indicated prospective audit and feedback (PAF) occurred in 79% of ACH and 47% of CAH. Monitoring discharge duration of therapy was reported in 27% of ACH and 37% of CAH. We developed three goals: Goal One is to decrease broad-spectrum ABS used for community-acquired infections (BSCA) by 5% in five years by encouraging hospitals to achieve 75% adherence to facility-specific treatment guidelines by 2025. Goal Two is to reduce the use of ABS active against methicillin-resistant Staphylococcus aureus (MRSA) by 5% in five years by encouraging facilities to evaluate their empiric anti-MRSA ABS and provide PAF. Goal Three is to increase NHSN AU/AR reporting to 100%/75% of ACH and 75%/50% of CAH with support through virtual AU/AR office hours and financial grants. Finally, we identified an increase in carbapenemases as an urgent threat and will encourage facilities to review use of broad-spectrum ABS and provide PAF, while monitoring rates of carbapenemases. These initiatives will be promoted through AS collaborations and feedback reports, with progress monitored through the AU Targeted Assessment for Stewardship reports.

Conclusion

These novel state-wide AS initiatives are tailored by local data and best practices to support a common vision for action for hospital AS providers.

Disclosures

All Authors: No reported disclosures
1233. Leveraging Informatics to Evaluate and Sustain Improvements in Peri-Operative Antimicrobial Prophylaxis Achieved Under the Surgical Care Improvement Project (SCIP)
Authors: Branch-Elliman Westyn , Golenbock Samuel , Hederstedt Kierstin , Pendergast Jacquelyn , Shin Marlena , Engle Ryann , Elwy A Rani , Colborn Katie , Hawn Mary , Mull Hillary J
Published: November 2023

Background

The Surgical Care Improvement Project (SCIP) was a national quality improvement program designed to improve peri-operative outcomes. The SCIP Program included several guideline-based antimicrobial stewardship measures, including discontinuation of antibiotics within 48 hours of skin closure for cardiac surgeries (INF-3). INF-3 was retired at the end of 2015; since this time, no systematic tools have been developed to support ongoing quality assessments.

Methods

We developed a retrospective, national cohort of cardiac surgeries in the national VA healthcare system during the period from 2010-2015 and merged these data with data from the VA External Peer Review Program, which included manually-assessed SCIP metrics, including INF-3. We electronically re-created the SCIP program by mapping exclusion criteria and developing code to assess the duration of post-operative antimicrobial use (Table 1). Among the manually-adjudicated cohort, we then iteratively refined the electronic tool until pre-specified criterion validity were achieved. After development, INF-3 compliance as assessed manually and by the objective informatics tool were compared.

Results

During the study period, 11,361 cardiac surgeries representing 26 VA facilities met inclusion criteria. The overall estimated compliance rate was 97.7% in the EPRP-reviewed cases (N=11,361) and 95.9% as-assessed by the informatics tool (N=9,561 cases); facility quality rankings using both methods were similar but not exactly the same (Figure 1). Facility-level compliance trends were similar using both measurement methodologies and the correlation between the two measures was high (r=0.69); however, the informatics tool consistently estimated compliance to be approximately 1.9% lower than manually reviewed cases (Figure 2). As estimated by the manual review program, 16 facilities (61.5%) achieved >97% compliance rates versus 9 facilities (34.6%) as estimated by the informatics tool.

Figure 2. Facility-Level Compliance with INF-3 as Measured by Manual Review versus via Objective Electronic Tool

Conclusion

We developed a comprehensive, objective informatics tool for assessing ongoing compliance with SCIP INF-3. The tool can be applied in future investigations to assess the sustainability of practice changes achieved under the SCIP program and to identify areas for future improvement.

Disclosures

Westyn Branch-Elliman, MD, MMsc, DLA Piper, LLC/Medtronic: Advisor/Consultant|DLA Piper, LLC/Medtronic: Expert Testimony|Gilead Sciences: Grant/Research Support
1240. Perceptions of Antimicrobial Stewardship and Antibiotic Use by Healthcare Workers in Latin America
Authors: Fabre Valeria , Cosgrove Sara E , Lessa Fernanda C , Patel Twisha S , Patel Payal K , Quirós Rodolfo E
Published: November 2023

Background

The burden of antimicrobial resistance (AMR) in Latin America is high. Little is known about healthcare workers’ (HCWs) perceptions of antimicrobial stewardship (AS) and antibiotic use (AU) in the region.

Methods

HCWs from 42 hospitals in Panama, Guatemala, Colombia, Ecuador, and Argentina were invited to participate in an electronic, voluntary, anonymous survey regarding perceptions of AS and AU from March-April 2023. All participants were asked 21 questions; prescribers were asked additional questions about antibiotic prescribing. Answers with 5-point Likert scale were categorized into two groups, strongly agree/agree and neutral/disagree/strongly disagree.

Results

Of 475 HCWs that completed the survey, 52% were physicians (29% in training), 28% nurses, 13% pharmacists, 3% microbiologists, and 3% “other.” Median years of experience was 12 (interquartile range 6, 20). Although 93% indicated optimizing AU was a priority at their healthcare facility (HCF), only 69% said the importance of AS was communicated at their HCF. Nurses and those in “other” roles were more likely to report lack of familiarity with the term AS than physicians (32% and 27% respectively vs. 21%, P< 0.01).

Most (99%) respondents acknowledged that appropriate AU can reduce AMR and that inappropriate AU could harm patients. However, fewer thought antibiotics were overused (30%) or AMR was a problem (52%) in their HCF. Thirty-eight percent of HCWs did not have access to guidelines and 24% did not value recommendations by the AS team (Figure 1). Of prescribers, 99% reported to modify antibiotics based on culture results, 55% do not consult non-physician staff (e.g., pharmacists, nurses) to make antibiotic decisions, 20% do not use local guidelines or do not receive training on how to interpret culture results to make antibiotic decisions (Figure 2). Prescribers felt pressure from colleagues (38%) and patients or their families (63%) to make antibiotic decisions.

Conclusion

Although most HCWs perceived improving AU as a priority, they did not perceive AU or AMR to be a problem in their HCF. Opportunities to optimize AU include improved access and adherence to guidelines, access to AMR data, teamwork, and education on AS for HCW.

Disclosures

Sara E. Cosgrove, MD, MS, Debiopharm: Advisor/Consultant|Duke Clinical Research Institute: Advisor/Consultant Payal K. Patel, MD MPH, qiagen: Honoraria
1246. Impact of Leveraging Clinical Decision Support Tools to Implement a Tiered Antimicrobial Stewardship Workflow at a Rural Academic Medical Center
Authors: Howard Catessa A , Freeman Lauren , Mehta Meera , Grimm Derek , Guilfoose John A
Published: November 2023

Background

The Infectious Diseases Society of America and The Joint Commission recommend Antimicrobial Stewardship Programs (ASPs) incorporate preauthorization and/or prospective audit and feedback (PAF) as mechanisms for stewardship interventions. However, each institution must customize their ASP workflow. The ASP at West Virginia University Hospitals (WVUH), a rural, comprehensive academic medical center, was recently revamped by leveraging clinical decision support (CDS) tools via a tiered workflow in efforts to prioritize stewardship interventions for preauthorization and PAF.

Methods

In March 2021 ASP pharmacists created a tiered workflow incorporating CDS tools from Theradoc® and Epic®. Review of patients identified on CDS alerts (Table 1), preauthorization, and PAF were conducted Monday through Friday 8:00 am to 5:00 pm by ASP pharmacist(s). Tiered workflow effectiveness was measured by internal and external benchmarking: antimicrobial days of therapy (DOT)/1000 days present, antimicrobial spend, and Standardized Antimicrobial Administration Ratio (SAAR). Interventions were documented within the electronic medical record and tracked via a Quality Assurance and Performance Improvement (QAPI) format. Post implementation data from March 2021 to March 2023 was analyzed and compared to baseline 2019 data.

CRE: Carbapenem-resistant Enterobacterales; ESBL: Extended Spectrum Beta-Lactamase; HIV: Human Immunodeficiency Virus

Results

The following outcomes were observed within the post implementation timeframe. Monthly average DOT/1000 days present decreased ≥ 20% for the following antimicrobials: vancomycin (27%), ceftaroline (53%), cefepime (20%), ertapenem (59%), aztreonam (68%), tigecycline (23%), fosfomycin (80%), micafungin (27%), ceftazidime-avibactam (40%). Monthly average total antimicrobial SAAR decreased by 11% from 1.216 to 1.074. Additionally, monthly average antimicrobial spend/patient day decreased by 36% from $26.47 to $16.95. QAPI data demonstrated a 74% intervention acceptance rate including correction of 344 drug-bug matches.

Conclusion

Implementation of a tiered ASP workflow effectively identified patients for interventions, decreased antimicrobial utilization, and demonstrated antimicrobial cost containment. Acceptance of stewardship interventions was favorable. This tiered approach may serve as a model for other ASPs.

Disclosures

All Authors: No reported disclosures
1271. Antimicrobial Appropriateness after Ambulatory Antimicrobial Stewardship Program for Uncomplicated Cystitis
Authors: Thongwitokomarn Harit , Yasri Saowaluck , Chaiwarith Romanee
Published: November 2023

Background

Urinary tract infection (UTI) is a common bacterial infection found in outpatient departments. Previous studies showed the rising trend of fluoroquinolone use for urinary tract infections treatment coinciding with the increase of fluoroquinolone-resistance uropathogens. The major cause of this problem is inappropriate antimicrobial use. Therefore, we implemented antimicrobial stewardship programs to improve antimicrobial appropriateness and treatment outcome in ambulatory uncomplicated cystitis patients at Maharaj Nakorn Chiang Mai Hospital.

Methods

We conducted a retrospective pre-post intervention study design among ambulatory uncomplicated cystitis patients aged ≥ 18 years in Maharaj Nakorn Chiang Mai Hospital compared the pre-intervention group (1 March 2021 – 31 August 2021) and post-intervention group (1 October 2021 – 31 March 2022).

Results

There were 49 patients included in the study; 29 were in the pre-intervention group and 20 were in the post-intervention group. Antimicrobial appropriateness increased significantly (0% vs 55%, P< 0.001) after antimicrobial stewardship programs’ implementation attributed to significant improvement in appropriate antimicrobial choice (6.9% vs 95%, P< 0.001), dose (0% vs 89.5%, P= 0.029) and duration (6.9% vs 95%, P< 0.001). The antimicrobials were indicated in post-intervention group more than pre-intervention group but did not reach statistically significance (44.8% vs 65%, P=0.164). There was a significant improvement in concordant antimicrobial therapy after the antimicrobial stewardship programs’ implementation (25% vs 92.3%, P= 0.001), although there was no difference in treatment failure between groups (12.5% vs 7.1%, P= 1.000).

Conclusion

Antimicrobial appropriateness and concordant antimicrobial therapy increased significantly after antimicrobialstewardship programs’ implementation. However, there was no difference in treatment failure between groups.

Disclosures

All Authors: No reported disclosures
1272. Teaching the ABCs of ASB in a 60-minute educational intervention. A quality improvement project.
Authors: Enriquez Paulina Vega , Bouls Ruayda , Alvarado Ed W , Maldonado Jose Campo
Published: November 2023

Background

Asymptomatic bacteriuria (ASB) refers to the presence of bacteria in the urine of individuals that do not present with symptoms of urinary tract infection (UTI). Treatment for ASB is not recommended in most cases. [1] Previous studies have shown that provider education on proper antibiotic use has been effective in mitigating the ongoing wave of antimicrobial-resistant organisms across hospitals in the United States.[2] We aimed to decrease the proportion of cases classified as having asymptomatic bacteria by 20% in four months after the intervention using a small group discussion and a presentation.

Methods

We evaluated the rates of inappropriate antimicrobial prescribing for asymptomatic bacteriuria (ASB) for 4 months before educational intervention and 4 months after. Data was extracted from the electronic medical record (Cerner®), imported into REDCap®, and with standardized manual chart review. Data analysis was completed using STATA® 17 & 18.

Results

The mean duration of antibiotic therapy was 7.9 days in the pre-intervention group and 6.1 days in the post-intervention group. See Table 1 for more details on demographics. Following the intervention, the rate of inappropriate use of antimicrobial therapy in ASB was reduced by 29.8% (p-value 0.035). The mean duration of antibiotic therapy decreased by almost 2 days in the post-intervention group.

Conclusion

This quality improvement project suggests that focused interventions of short interactive educational sessions in small groups may reduce the inappropriate use of antibiotics in ASB by almost 30%. The mean duration in days of antibiotic treatment decreased from 7.9 days to 6.1 days in the pre and post-intervention groups (p-value 0.060). Of note the total number of cases with providers selecting UTI as an indication was also lower in the post-intervention group and although we can’t determine causality, it provided evidence of a lower number of cases, providers initially classified as UTI between the pre and post-intervention period from 33 to 19. Further research may include incorporating small groups and interprofessional educational interventions to help implement good antimicrobial stewardship in inpatient care facilities. [4,5,6]

Disclosures

All Authors: No reported disclosures
1283. Native Wrist Septic Arthritis: a 10-year Single Center Experience
Authors: Damronglerd Pansachee , Khodadadi Ryan B , Zein Said El , McHugh Jack W , Suh Gina A , Tande Aaron J , Yuan Brandon J , Abu Saleh Omar M
Published: November 2023

Background

Native joint septic arthritis (NJSA) of the wrist is a rare condition, with published literature suggesting an incidence of approximately 1.5% among patients presenting with acute painful and swollen wrist. The aim of this study was to investigate the characteristics, management, and outcomes of wrist NJSA at our institution.

Methods

We conducted a retrospective study of all adults diagnosed with wrist NJSA who underwent surgical intervention at Mayo Clinic facilities from January 2012 to December 2021. The diagnosis was confirmed based on clinical presentation, synovial fluid white blood cell count, and aspiration or operative cultures.

Results

A total of 557 patients developed NJSA during the study period, of whom 55 (9.9%) were diagnosed with wrist NJSA, median age was 63, with the associated demographics (Table 1). 12 (21.8%) had a history of antecedent trauma or procedure, 11 (20%) had synchronous joint infections, and 22 (40%) had positive blood cultures. The median synovial white blood cell count was 94,050/mm3 (IQR 51,920 – 139,941 /mm3). Crystals were detected in 5 patients (8.8%). Additional diagnostic data are available in Table 2. Open debridement was performed in 35 (61.4%) patients, and the rest underwent arthroscopy. Positive Gram stain results were detected in the preoperative synovial fluid of 12 (21.8%) cases. The most common pathogen isolated was Staphylococcus aureus in 13 (24%) of cases. The median duration of antimicrobial therapy was 31 days (IQR 26 – 45 days). There was no statistically significant difference in the incidence of complications between patients who underwent open debridement and those who underwent arthroscopy (Table 3). The most common complication of both groups was compromised range of motion of the wrist joint.

Conclusion

Native wrist septic arthritis comprised 9.9 % of all NJSA during the study period. Concomitant bacteremia and synchronous joint infections were common, highlighting the importance of obtaining blood cultures and comprehensive joint exam in this setting. Crystals and Gram stains were detected in 10 % and 22% of cases, respectively. These findings should not rule out NJSA. Decreased range of motion was common complication, affecting 21% of all cases.

Disclosures

Gina A. Suh, M.D., Adaptive Phage Therapeutics: Grant/Research Support|Adaptive Phage Therapeutics: IP royalties|Phagelux: Grant/Research Support Aaron J. Tande, M.D., Musculoskeletal Infection Society: Board Member|Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support Brandon J. Yuan, M.D., American Association of Orthopaedic Surgeons: Board Member|DePuy, A Johnson & Johnson Company: Advisor/Consultant|Mid America Orthopaedic Association: Board Member|Stryker: Advisor/Consultant
1285. Risk Factors for Infection Following Revision Hip and Knee Arthroplasty
Authors: DeBiase Joseph , Carroll Ryan , Colburn Nora , Day Shandra R
Published: November 2023

Background

Patients undergoing revision total hip (THA) and knee (TKA) arthroplasties are at increased risk for surgical site infections (SSI) with prior infection representing a common indication for revision. Our aim was to evaluate patient characteristics and risk factors in patients with THA and TKA infection following revision arthroplasty.

Methods

A single center retrospective review of patients with THA or TKA SSIs from 01/01/2017 to 11/01/2022 was performed utilizing National Healthcare Safety Network (NHSN) definitions and surgical revision codes. Index surgery was defined as the THA or TKA to which the SSI was attributed per NHSN guidelines. Patients meeting NHSN PATOS (present at time of surgery) definition were excluded. Pertinent demographics data, surgical histories and microbiology were collected and the determination of new vs. persistent infection was made based on microbiologic data.

Results

Forty-seven cases were included with median age of 62, 45% male and 51% current/former smokers. BMI was ≥35 in 36% of patients, with 33% having diabetes mellitus and 13% were immunocompromised. Twenty-seven (57%) patients had a prior infection at the involved joint with 18/27 (67%) occurring within 1 year of the index surgery. Table 1 includes index surgery details and infection data. Median time to infection was 25 days. Leading pathogens were S. aureus 16 (34%), Enterococcus species 11 (23%), enterobacterales 10 (21%), and polymicrobial infections 10 (21%).

Conclusion

Over half of patients that developed revision THA/TKA SSI had a prior infection but less than 15% had a persistent infection. Most patients had multiple prior surgeries which may contribute to longer operative times and delayed wound healing. S. aureus was the most common pathogen identified but many cases involved less typical SSI pathogens. These results highlight the importance of focusing on patient specific risk factors, surgical infection prevention strategies and wound care, rather than additional pathogen specific antibiotics. While more study is needed to delineate SSI risk factors following revision arthroplasty, our study highlights the multitude of potential factors involved in these highly morbid infections.

Disclosures

All Authors: No reported disclosures
1290. Impact of Implementing an IV to PO Antibiotic Treatment Protocol for Orthopedic Infections
Authors: Gray Julie , Benefield Russell J , Cummins Heather , Certain Laura
Published: November 2023

Background

Oral (PO) regimens have been utilized more frequently for orthopedic infections in place of intravenous (IV) regimens at our center following publication of the OVIVA trial. Given limited published experience of this approach at US medical centers, we reviewed safety and effectiveness outcomes at ours.

Methods

This was a retrospective, propensity-score matched, cohort study of adult patients hospitalized for orthopedic infections from 9/30/2020 to 4/30/2022. Patients discharged on PO antibiotics were matched to patients discharged on IV antibiotics, using a 1:1 nearest neighbor approach without replacement. Variables expected to be associated with treatment selection and/or outcome were included in the propensity score (Table 1). Primary outcomes were early (60-day) and late (1-year) treatment failure following discharge. Secondary outcomes were incidence of adverse drug events (ADE), readmissions, and ED encounters within 60 days of discharge. Outcomes were assessed through chart review.Table 1:Baseline Characteristics

Results

Six hundred sixty-four patients were screened and 401 met criteria for inclusion. Of these, 123 PO-treated patients were matched to 123 IV-treated patients. Baseline characteristics were similar in the two groups after matching, although there were differences in microbiological indication, and patients discharged on PO regimens were treated for shorter durations and were more likely to be discharged home (Table 1). There was no significant difference in the proportions of patients on PO vs IV antibiotics experiencing treatment failure at 60 days (14% vs 9%, P = 0.23), treatment failure at 1 year (21% vs 20%, P = 0.75), ADE within 60 days (6% vs 11%, P = 0.16), 60-day readmission (26% vs 33%, P = 0.26), or 60-day ED encounter (11% vs 10%, P = 0.83). Survival analyses identified no significant differences in time-to-event between PO and IV treatment for any of the outcomes assessed (Figure 1).Figure 1:Kaplan-Meier Survival Plots

Conclusion

There was no appreciable difference in outcomes between patients discharged on PO compared to IV regimens. Quality-improvement interventions to increase prescribing of PO antibiotics for the treatment of orthopedic infections should be encouraged.

Disclosures

Russell J. Benefield, PharmD, BCPS-AQ ID, Paratek Pharmaceuticals: Grant/Research Support
1300. Comparison of the Clinical Characteristics and Outcomes of Anaerobic Prosthetic Joint Infections (PJI) and Aerobic PJIs : A Retrospective Review
Authors: Non Lemuel R , Sekar Poorani
Published: November 2023

Background

PJI is an uncommon but serious complication of joint arthroplasties that can result in significant morbidity and cost. There is a paucity of studies in the literature on PJIs caused by anaerobic organisms either as the sole pathogen or part of a polymicrobial infection. The purpose of this study was to compare the clinical presentation and outcomes of PJI caused by anaerobes as opposed to aerobes.

Methods

This was a retrospective review of 306 patients who met Musculoskeletal Infection Society (MSIS) criteria for PJI from 2014 to 2020 at the University of Iowa Hospitals and Clinics (UIHC). 38 patients with anaerobic PJI were compared to 268 patients with aerobic PJI. Statistical analyses were performed using Pearson’s Chi square, Fisher exact test, t-test, and binary logistic regression.

Results

PJI with anaerobes represented 12.4% of all PJI cases in our institution, which is higher than the 3-6% reported in literature. Patients with anaerobic PJI had longer duration of symptoms (19.4 weeks vs 10.9 weeks, p = 0.012), were more likely to have a sinus tract on exam (23.7% vs 5.9%, p < 0.001), less fever on presentation ( 13.2% vs 30.2%, p = 0.029), more radiographic abnormalities (50.0% vs 31.1%, p< 0.001), lower erythrocyte sedimentation rate (49.0mm/hr vs 67.7 mm/hr, p = 0.003), lower C-reactive protein (6.6 mg/dL vs 12.1mg/dL, p = 0.004), and more likely to be polymicrobial (42.1%vs 8.0%, p < 0.001) compared to aerobic PJI. There was a higher proportion of anaerobes in shoulder PJIs compared to other joints (39.5% vs 5.5%, p< 0.001). Two-stage exchange was the most common surgical treatment in patients with anaerobic PJI (39.4%) whereas debridement and implant retention was the most common (44.5%) surgical treatment done in patients with aerobic PJI. No significant differences were seen between the two groups in terms of recurrences. Independent factors associated with anaerobic infection were shoulder prosthetic joint (AOR 10.5, CI 3.4 - 32.8) and presence of sinus tract (AOR 10.1, CI 3.1 - 32.6).

Conclusion

Anaerobic cultures should be performed in patients with PJI, and they should especially be considered on the differential in patients with shoulder PJI, longstanding symptoms, sinus tract on examination and abnormalities noted on radiographs.

Disclosures

All Authors: No reported disclosures