bluuebunny/crossref_metadata_2025 huggingface dataset:
11. Missed Vaccine Opportunities During the COVID-19 Pandemic
Authors: Shallal Anita , Vahia Amit T , Kenney Rachel , Weinmann Allison J
Published: January 2021

Background

The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults over the age of 65 to reduce S. pneumoniae pneumonia. Our institution follows a standing order for nurses to vaccinate adults who meet the Advisory Committee on Immunization Practices (ACIP) criteria. During the COVID-19 pandemic surge, the pneumococcal vaccine and influenza vaccine nurse-driven protocol was determined to be non-essential on 3/23, and 4/2 respectively. Our study aims to characterize missed vaccine opportunities among patients hospitalized with COVID-19 during this surge.

Methods

A retrospective cross-sectional study of PCR-positive COVID-19 patients admitted to an inner-city hospital and discharged alive between the dates of 3/23 and 4/21/2020. Patients under the age of 65 were excluded. Data collected included patient age, gender, race, length of stay, co-morbidities that would indicate a vaccine opportunity, prior vaccinations, and whether there was a vaccine opportunity for PPSV23 and influenza defined by ACIP indications. Vaccine history was evaluated using the electronic medical record (EMR) and Michigan Care Improvement Registry. If there was a vaccine opportunity, we documented whether a vaccine was given before hospital discharge. Total numbers of vaccines given for time periods in 2019 and 2020 were collected from EMR for comparison.

Results

100 patients over the age of 65 were included. The average age was 72.8 years, and most patients (66%) were of African American race. The mean length of stay was five days. 52 patients were identified as having an opportunity to receive PPSV23, and 0 patients received the vaccine. 67.3% had more than one indication for PPSV23. 37 patients were eligible to receive influenza vaccine, and 0 received the vaccine. Results are summarized in table 1. Figures 1 and 2 display the number of pneumococcal and influenza vaccines given per EMR, respectively.

Figure 1

Figure 2

Table 1

Conclusion

Due to prioritization of potential staffing shortages and clustering nursing care, an opportunity to vaccinate patients with pneumococcal and influenza vaccines was missed. It is important for health care providers to be aware of this potential opportunity for vaccination of high-risk patients in order to promote primary prevention in future waves of pandemics.

Disclosures

All Authors: No reported disclosures
12. Randomized Studies of Two Clostridioides (Clostridium) difficile Vaccine Formulations
Authors: Lawrence Jody , Kitchin Nicholas , Anderson Annaliesa S , Pride Michael W , Jansen Kathrin U , Gruber William C , Peng Yahong , Yi Kevin , Knirsch Charles , Webber Chris
Published: January 2021

Background

Two formulations of investigational bivalent Clostridioides (Clostridium) difficile vaccine (QS-21 adjuvanted toxoid and toxoid-alone) were assessed for safety and immunogenicity in randomized studies in healthy adults 50–85 years of age.

Methods

The Phase 1 study of QS-21 adjuvanted toxoid vaccine randomized subjects 3:1 to 100 μg QS-21-containing C difficile vaccine or placebo; 3 doses were given according to 2 different schedules: a shortened month (Months 0, 1, 3) or day (Days 1, 8, 30) regimen. The Phase 2 toxoid-alone vaccine study randomized subjects 3:3:1 to receive 100 or 200 μg unadjuvanted C difficile vaccine formulation or placebo in Stages 1 and 2 (sentinel cohorts of different age groups), and 3:1 to receive the selected dose of unadjuvanted C difficile vaccine formulation or placebo in Stage 3. Three doses were given on a day (Days 1, 8, 30) regimen. Safety was the primary outcome for both studies. Immunogenicity was determined by measuring serum toxin A– and B–specific neutralizing antibodies.

Results

In the day regimen, 10 reports across both studies of grade 3 injection site redness postdose 2 triggered predefined stopping rules. Local reactions in both studies were more common among vaccine versus placebo recipients. Injection site pain predominated and was generally mild in severity. Systemic events were infrequent and generally mild-to-moderate in severity. Adverse events were reported by 50.0%–75.0% and 16.7%–50.0% of subjects in the QS-21 and toxoid-alone studies, respectively. Immune responses peaked around Day 37 (shortened-month regimen) or between Day 15 and Month 2 (day regimen), and remained above baseline throughout follow-up.

Conclusion

Both formulations demonstrated robust immunogenicity. However, both studies stopped early due to grade 3 injection site redness postdose 2 of the day (Days 1, 8, 30) regimen; neither formulation progressed to later stage development. Instead, an aluminum hydroxide-containing formulation of the vaccine candidate administered at 0, 1, and 6 months, which was safe and immunogenic in phase 1 and 2 studies, advanced to phase 3 studies.

Disclosures

Jody Lawrence, MD, Pfizer, Inc (Employee) Nicholas Kitchin, MD, Pfizer, Inc (Employee) Annaliesa S. Anderson, PhD, Pfizer (Employee, Shareholder) Michael W. Pride, PhD, Pfizer (Employee, Shareholder) Kathrin U. Jansen, PhD, Pfizer (Employee, Shareholder) William C. Gruber, MD, Pfizer (Employee, Shareholder) Yahong Peng, PhD, Pfizer (Employee, Shareholder) Charles Knirsch, MD, Pfizer (Employee) Chris Webber, MD, Pfizer Inc (Employee, Shareholder)
20. Cost-Effectiveness of Implementing 13-Valent Pneumococcal Conjugate Vaccine (Pcv13) for Adults Aged ≥19 Years with Underlying Conditions
Authors: Kobayashi Miwako , Stoecker Charles , Xing Wei , Cho Bo-Hyun , Pilishvili Tamara
Published: January 2021

Background

In June 2019, the U.S. Advisory Committee on Immunization Practices changed the recommendation for routine PCV13 use in immunocompetent adults aged ≥65, including those with certain chronic medical conditions (CMC); PCV13 is now recommended based on shared clinical decision-making. Adults with CMC continue to be at increased risk for pneumococcal disease. We assessed the cost-effectiveness of adding PCV13 to the recommended PPSV23 dose for adults aged ≥19 years with CMC.

Methods

We used a probabilistic model following a cohort of 19-year-old U.S. adults. We used Monte Carlo simulation to estimate the impact on program, medical, and non-medical costs (in 2017 U.S. dollars [$] using the societal perspective), and pneumococcal disease burden when administering PCV13 in series with PPSV23. Table 1 shows vaccine effectiveness (VE) assumptions for the base case. We performed one-way sensitivity analyses assuming higher PCV13 VE against serotype 3 disease.

Vaccine effectiveness assumptions by age group used for the base case

Results

In the base-case scenario, adding a dose of PCV13 upon CMC diagnosis cost $689,299 per QALY. Results of one-way sensitivity analyses are presented in Table 2.

Base case and one-way sensitivity analyses of adding PCV13 at diagnosis of CMC

Conclusion

Adding PCV13 in series with PPSV23 for adults 19 years or older with CMC was not cost-saving. Results were sensitive to assumptions on PCV13 VE against serotype 3 disease.

Disclosures

All Authors: No reported disclosures
21. Current and Nadir CD4+ Counts Are Associated with Heplisav-B Seroprotection Rates in People with HIV
Authors: Schnittman Samuel , Zepf Roland , Cocohoba Jennifer , Sears David
Published: January 2021

Background

A two-dose hepatitis B (HBV) vaccine with an immunostimulatory adjuvant (HBV-ISS, Heplisav-B), was FDA approved in 2017 for adults 18 years and older. In randomized controlled trials (RCTs), HBV-ISS demonstrated a seroprotection rate (SPR) of 90–95% versus 65–80% for Engerix-B (HBV-Eng). No RCTs, however, included people with HIV (PWH), and the SPR and its predictors in this population are unknown.

Methods

This retrospective cohort study enrolled PWH ages 18 years and older without current HBV seroprotection at an HIV clinic at a tertiary care center. HBV seroprotection was defined as an anti-HBV surface antibody level >= 10 mIU/mL. Patients without follow-up titers after immunization were excluded. The primary outcome was the SPR, the proportion of patients with HBV seroprotection at any point following the first HBV-ISS vaccination.

Results

Among the 51 PWH included, 50 received 2 doses of HBV-ISS (1 patient who received 1 dose developed seroprotection) (Table 1). Median time to antibody titer measurement was 11 weeks (IQR 7–19 weeks). Median age was 59 years, 90% were men, and 96% had VL < 200. There were no pregnant or breastfeeding patients. The SPR was 82% (42/51) in the cohort, and 86% (38/44) when patients with significant non-HIV immunosuppression (decompensated cirrhosis, solid organ transplantation, active chemotherapy) were excluded. There were no significant differences in SPR based on age, sex, BMI, diabetes mellitus, chronic kidney disease, history of remote anti-HBV surface or core antibody positivity, or prior HBV vaccination (Table 2). Lower current and nadir CD4+ counts were associated with progressively lower SPRs (P for trend < 0.0001 for both) (Figure 1).

Table 1. Baseline Demographics and Characteristics

Table 2. Seroprotection Rate (SPR) by Variables of Interest

Figure 1. Seroprotection Rate (SPR) by Current and Nadir CD4+ Count

Conclusion

The SPR from HBV-ISS in PWH appears comparable to the immunocompetent patients included in RCTs, especially when patients with significant non-HIV immunosuppression are excluded. The SPR demonstrated in this single-arm, retrospective study was higher than that of HBV-Eng in immunocompetent patients, and consideration should be given to establishing HBV-ISS as first-line HBV vaccination in PWH. Finally, SPR is significantly reduced in those with lower current and nadir CD4+ counts. Further research on the effectiveness of a repeat vaccination series or higher dosing in these subgroups is needed.

Disclosures

Jennifer Cocohoba, PharmD, AAHIVP, BCPS, Viiv (Grant/Research Support)
22. Description of Hospitalized Patients with Influenza Vaccine Failure
Authors: Kimball Joanna , Zhu Yuwei , Wyatt Dayna , Talbot Helen
Published: January 2021

Background

Despite influenza vaccination, some patients develop illness and require hospitalization. Many factors contribute to vaccine failure, including mismatch of the vaccine and circulating strains, waning immunity, timing of influenza season, age and patient comorbidities such as immune function. This study compared vaccinated, hospitalized patients with and without influenza.

Methods

This study used 2015–2019 Tennessee data from the US Hospitalized Adult Influenza Vaccine Effectiveness Network database. Enrolled patients were ≥ 18 years vaccinated for the current influenza season and admitted with an acute respiratory illness. Patient or surrogate interviews and medical chart abstractions were performed, and influenza vaccinations were confirmed by vaccine providers. Influenza PCR testing was performed in a research lab. Statistical analyses were performed with STATA and R using Pearson’s chi-squared, Kruskal-Wallis and Wilcoxon rank-sum tests and multivariate logistic regression.

Results

1236 patients met study criteria, and 235 (19%) tested positive for influenza. Demographics, vaccines and comorbidities were similar between the two groups (Table 1) except for morbid obesity, which was more common in influenza negative patients (13% vs 8%, p = 0.04), and immunosuppression, which was more common in the influenza positive (63% vs 54%, p = 0.01). Logistic regression analysis demonstrated older patients (OR 1.47, 95% CI 1.03–2.10) and immunosuppressed patients (OR 1.56, 1.15–2.12) were at increased risk for influenza (Table 2 and Figure 1). Immunosuppression also increased the risk for influenza A/H3N2 (OR 1.86, 95% CI 1.25–2.75). A sensitivity analysis was performed on patients who self-reported influenza vaccination for the current season without vaccine verification and demonstrated increased risk of influenza in older adults (OR 1.66, 95% CI 1.16–2.39).

Table 1: Demographics of influenza positive versus influenza negative patients in influenza vaccinated, hospitalized patients.

Table 2: Logistic regression analyses of vaccinated, hospitalized influenza positive patients; vaccinated, hospitalized patients with influenza A subtypes and self-reported vaccinated, hospitalized influenza positive patients.

Figure 1: Predicted Probability of Hospitalization with Influenza, Influenza A/H1N1 and Influenza A/H3N2 in Vaccinated Patients by Age.

Conclusion

Our study demonstrated an increased risk of influenza vaccine failure in older patients and immunosuppressed patients. These groups are also at increased risk for influenza complications. To improve protection of these patients against future influenza illnesses, more effective vaccines are needed, and more research on ring vaccination should be pursued.

Disclosures

All Authors: No reported disclosures
23. Did You Pneu?: Impact of an Adult Pneumococcal Immunization Campaign Across Independent Community Pharmacies
Authors: Faggioni Mara , Wong Rachel , Tilli Tiana
Published: January 2021

Background

Canada’s pneumococcal immunization goal for adults 65 years and older aims to achieve 80% coverage, yet uptake is only 58% in this population. Barriers include lack of awareness and lack of recommendations by healthcare providers. A pneumococcal immunization campaign was designed to address barriers and increase vaccine uptake from independent community pharmacies.

Methods

A “Did You Pneu?” pneumococcal immunization campaign was developed by a pharmacist at the head office of an independent community pharmacy banner. The campaign consisted of pharmacist educational materials, in-pharmacy marketing materials, and pharmacy operational supports (Figure 1). In November 2018, a month-long in-pharmacy campaign was carried out across the banner. Feedback collected from pharmacists via telephone interviews was used to inform updates to campaign materials for the November 2019 campaign. A convenience sample of ten independent community pharmacies located across Ontario was selected for a retrospective observational analysis of pneumococcal vaccine purchases from January 2017 to December 2019.

Figure 1. “Did You Pneu?” campaign toolkit showing pharmacist educational materials, in-pharmacy marketing materials, and pharmacy operational supports developed and distributed across a banner of independent community pharmacies as part of an adult pneumococcal immunization campaign.

Results

Analysis of ten independent community pharmacies revealed an increase in the total number of pneumococcal vaccines purchased in November in years a campaign took place compared to baseline. The total number of pneumococcal vaccines purchased in November increased 23% during the first campaign and another 213% during the second campaign (13 vs. 16 vs. 50 vaccines purchased in November 2017, 2018, and 2019, respectively).

Increased vaccine uptake was also observed in months subsequent to the in-pharmacy campaign. Analysis of ten independent community pharmacies revealed a 47% increase in the mean number of pneumococcal vaccines purchased per month by the banner (8.8 mean number of pneumococcal vaccines purchased per month twelve months pre-implementation vs. 12.9 twelve months post-implementation).

Conclusion

A comprehensive pneumococcal adult immunization campaign implemented across a banner of independent community pharmacies led to immediate and sustained increases in vaccine uptake. As pharmacists have a role in promoting adult pneumococcal immunizations, advocacy efforts should be undertaken to include pharmacists in publicly funded immunization programs.

Disclosures

Tiana Tilli, PharmD, RPh, ACPR, Pfizer Canada Inc. (Grant/Research Support, Speaker’s Bureau)
25. Effectiveness of High Dose Influenza Vaccine in HIV-positive Patients for the Winter 2017–2018 Season
Authors: Kato Mikiro , Kunkel Tori , Bram David , Newman Jessica , Lopez Angela , Santana Pheadra , Clough Lisa A , Hinthorn Daniel , El Atrouni Wissam
Published: January 2021

Background

Antibody response after high dose influenza vaccine (HDIV) approved for age ≥ 65 years, is superior to a standard-dose vaccine in HIV-infected persons. We report the effectiveness data of HDIV compared to the standard dose quadrivalent vaccine (SDIV) in our HIV clinic.

Methods

We conducted a retrospective cohort study at the University of Kansas Medical Center to evaluate the effectiveness of HDIV in HIV-infected patients during the 2017–2018 influenza season. A phone survey was utilized to verify vaccination status and interval development of influenza-like illness (ILI). A modified CDC definition of ILI (mCDC ILI = fever and cough, sore throat or shortness of breath (SOB)) and a broader protocol defined ILI (PD ILI = sore throat, cough or SOB with either fever, chills, headache or myalgia) were utilized. The electronic medical record was reviewed to confirm vaccine type and influenza testing when available.

Results

Of 560 HIV-infected patients in the clinic, 219 (39.1%) were available and willing to participate (197 males, 21 females, 1 transgender female). The median age was 53 years and BMI 27.2 kg/m2. Five percent had CD4< 200 cells/uL, and 13.7% had an HIV viral load > 40 copies/mL. HDIV was given to 119 (54.3%), SDIV to 77 (35.2%) and 23 (10.5%) were not vaccinated (Table 1). A mCDC ILI occurred in 8 (10.4%) in the SDIV group compared to 6 (5.0%) in the HDIV group (p=0.16). A PD ILI was reported in 16 (20.8%) in the SDIV group compared to 12 (10.1%) in the HDIV group (p=0.04). There was no difference in confirmed influenza cases between the two groups (Table 2). On logistic regression only vaccine dose (SDIV OR 2.34 95% CI 1.04–5.37, p=0.04) and age in years (OR 0.97, 95% CI 0.94–1.0, p=0.045) were associated with PD ILI. HDIV remained protective after adjustment for age. Vaccine side effects were mild and occurred in 11/77 (14.3%) in the SDIV group compared to 13/119 (10.9%) in the HDIV group (p=0.5).

Conclusion

During the 2017–2018 winter season, the CDC reported an influenza attack rate of 14.7% in adults in the US and overall vaccine effectiveness of 38%. Our study demonstrated a 50% reduction in ILI with the HDIV compared to the standard-dose vaccine in HIV-infected patients. A larger prospective randomized control trial is warranted.

Disclosures

Wissam El Atrouni, MD, ViiV (Advisor or Review Panel member)
34. Oops, I Didn’t Follow My Post Vaccinaton Instructions
Authors: Manandhar Sabina , Ramsey Keith , Buffaloe Valerie
Published: January 2021

Background

Smallpox vaccine is derived from vaccinia virus, a large, double-stranded DNA virus. With the worldwide eradication of smallpox, routine vaccination with vaccinia virus is no longer performed. However, at-risk laboratory and health care personnel continue to be vaccinated against smallpox, and large numbers of military personnel in the United States resumed smallpox vaccination after the anthrax bioterrorism in 2001. Two available smallpox vaccines are part of the strategic stockpile in the United States; one is a replication-deficient modified vaccinia Ankara vaccine (MVA), and the other is a replication-competent smallpox vaccine (ACAM2000). Among others, one of the potential complications of smallpox vaccine is an accidental autoinoculation or accidental inoculation of close contacts.

Methods

A 27-year-old female presented to the employee health clinic at Vidant Medical Center with a 7-day lesion on her right upper extremity. She denied any fever, chills, pets at home, insect bites or trauma to the area. She was using inhaled nebulizers for her asthma and lived in Greenville, NC, with her boyfriend. The lesion was non itchy, approximately 5 mm blister like rash that ulcerated with a grayish, white center and had a surrounding red border. On further questioning, she disclosed that her boyfriend was a marine, who was recently vaccinated against smallpox two weeks before she developed the skin lesion, but he did not cover the site as instructed. Her lesion was unroofed and a sample was collected and sent to NC State Laboratory of Public Health for identification. It was also reported to the NC State Department of Health for possible contact transmission of smallpox. In the meantime, the patient was instructed to cover the area while at work, keep the lesion open to air at home, and avoid skin-to-skin contact.

Initial Lesion

Lesion after Unroofing

Results

The sample returned positive for Orthopoxvirus DNA by PCR.

Conclusion

Recipients of smallpox vaccine have a potential for autoinoculation and inoculation of close contacts. Hence, the vaccine recipients should be well educated about proper care of the vaccination site for preventing possible contact transmission of the virus. These include covering the vaccination site, proper hand washing after bandage changes, and avoiding skin-to-skin contact.

Disclosures

All Authors: No reported disclosures
35. Pneumococcal Vaccination in High-Risk Adults: An Initial Analysis Incorporating Social Determinants of Health
Authors: Gatwood Justin , Chiu Chi-Yang , Shuvo Sohul A , Ramachandran Sujith , Hohmeier Kenneth , Hagemann Tracy
Published: January 2021

Background

Despite CDC’s recommendation, vaccination rates for adults at high-risk of invasive pneumococcal disease are below HealthyPeople 2020 goals. Comparatively little is known about influencers on vaccine-seeking behavior in this population, particularly related to social determinants of health. To address this gap, this study assessed the potential influence of select social determinants on uptake of and time to pneumococcal vaccination among a high-risk, insured US population.

Methods

Using the MarketScan commercial claims databases between 2013–2016, adult patients (aged 18–64 years) were followed from their first diagnosis for a condition deeming them high-risk for invasive pneumococcal disease through one year following the diagnosis and observed for pneumococcal vaccination in outpatient clinics and pharmacies. Publicly-available data on select social determinants of health were incorporated into analyses, guided by the WHO vaccine hesitancy matrix. Logistic regression determined predictors of vaccination and a generalized linear model compared days to being vaccinated while controlling for baseline demographic and clinical characteristics.

Results

A total of 173,712 patients were analyzed of which 25.3% were vaccinated against invasive pneumococcal disease within the first year of being deemed high risk, nearly all of which (98.5%) were received in outpatient clinics. The odds of vaccination were higher in urban areas (OR: 1.18; 95% CI: 1.144–1.223), areas of higher health literacy (OR: 1.02; 95% CI: 1.019–1.025), and more liberal-voting communities (OR: 1.5; 95% CI: 1.23–1.88). Conversely, the odds of vaccination were particularly low in areas of higher poverty (OR: 0.14; 95% CI: 0.068–0.304) and with more limited Internet access (OR: 0.14; 95% CI: 0.062–0.305) as well as among adults who did not also get a seasonal influenza vaccine (OR: 0.05; 95% CI: 0.048–0.052). Time to vaccination was longer in rural areas (B=8.3, p< 0.0001) and communities with less Internet access (B=75.6, p< 0.001).

Conclusion

Results suggest that some social determinants may be influencing pneumococcal vaccine-seeking behavior among those deemed high-risk. A more formal framework must be assessed to determine the full impact of these factors across vaccines recommended in adults.

Disclosures

Justin Gatwood, PhD,MPH, AstraZeneca (Grant/Research Support)GlaxoSmithKline (Grant/Research Support)Merck & Co. (Grant/Research Support) Tracy Hagemann, PharmD, GSK (Grant/Research Support)Merck (Grant/Research Support)
36. Safety and Reactogenicity of the Adjuvanted Recombinant Zoster Vaccine after Allogeneic Hematopoietic Stem Cell Transplantation
Authors: Baumrin Emily , Izaguirre Natalie E , Bausk Bruce P , Feeley Monica M , Bay Camden P , Ho Vincent T , Issa Nicolas C , Baden Lindsey R
Published: January 2021

Background

Herpes zoster (HZ) is common after allogeneic hematopoietic stem cell transplantation (HCT) and associated with high morbidity. While antiviral prophylaxis reduces incidence, increased risk remains after discontinuation and vaccination strategies are needed. A non-live adjuvanted recombinant zoster vaccine (RZV) has been developed but not yet studied in this population.

Methods

In this single center prospective observational cohort study, allogeneic HCT recipients ³18 years old and 9–24 months from HCT were eligible to receive 2 doses of RZV separated by ³8 weeks as part of revised institutional vaccination guidelines. The primary endpoint was safety and reactogenicity in the total vaccinated cohort (TVC). The secondary endpoints were incidence and severity of chronic graft versus host disease (cGVHD) in the TVC compared to historical controls and incidence rates of HZ in the TVC and modified total vaccinated cohort (mTVC).

Results

Of the 158 participants (mean age 55 years, 91 [58%] male) in the TVC, 150 (95%) received second vaccine. 92.1% had solicited reactions with 87.3% injection site reactions (18.7% grade 3) and 82.8% general reactions (26.5% grade 3). In the subgroup receiving first vaccine at 9–12 months after HCT, cumulative incidence of cGVHD was similar to historical controls at predefined time points between 9–15 months (unadjusted incidence rate ratio [IRR] 1.1 [95% CI 0.84–1.44], adjusted IRR 1.05 [95% CI 0.8–1.38]); there was also no difference in severity of cGVHD, or incidence of death or disease relapse. There were 4 (2.5%) HZ cases during the study period with IR 28.34/1000 person-years over median follow up 281 days (IQR 190, 354) in the mTVC. All cases occurred after antiviral prophylaxis discontinuation and one case resulted in death.

Conclusion

Two doses of RZV after allogeneic HCT was safe and acceptable despite high rates of reactogenicity. There was no evidence of an increase in cGVHD, relapse, or death compared to historical controls and overall low rates of breakthrough HZ similar to those reported after autologous HCT. Immunogenicity studies and placebo-controlled trials are needed to determine vaccine response and efficacy so that timing of RZV and its potential impact on discontinuation of antiviral prophylaxis can be determined.

Disclosures

Nicolas C. Issa, MD, AiCuris (Scientific Research Study Investigator)Astellas (Scientific Research Study Investigator)GSK (Scientific Research Study Investigator)Merck (Scientific Research Study Investigator)
40. The Role of Health Literacy in Vaccination Disparities: Do Patients Understand the Health Messages?
Authors: Kricorian Katherine , Lopez Daniel , Seu Michelle , Pham Tuyen , Kigoonya Rita , Equils Ozlem
Published: January 2021

Background

Numerous public health campaigns are organized with the goal of improving immunization rates. However, vaccination uptake remains low among certain racial/ethnic minority groups including Hispanic patients. The level of health literacy (HL), ability to recognize the words used, may impact patients’ understanding of health-related messages and consequently health behavior and vaccination.

Methods

We conducted a HL survey among adult female attendees of a health fair in an underserved area of Los Angeles. Attendees visiting a youth education booth were surveyed using an electronic tool. Respondents were surveyed on their familiarity with and recognition of specific words including: measles, shingles, pertussis, hepatitis, meningitis, stroke, diabetes, pneumonia, and human papilloma virus (HPV). Comparisons were analyzed using chi-squared tests.

Results

Forty-three women (n=28 Hispanic; n=15 Non-Hispanic) completed the survey. The mean ages of Hispanic and non-Hispanic (predominantly Caucasian and Asian) respondents were 35.4 ±14 years and 29.9 ±12 years, respectively. A significantly lower percentage of Hispanic vs. Non-Hispanic women reported recognition of words associated with vaccine-preventable diseases: “meningitis” (15% vs. 60%, p< .01), “hepatitis” (18% vs. 69%, p< .01), and “HPV” (33% vs 67%, p< .05). Substantially lower recognition was also reported for “pneumonia”, although this did not reach statistical significance (46% vs 77%, p=.06). The percentage reporting recognition of “diabetes” did not differ significantly between groups (68% vs 60%, p=0.43).

Conclusion

Immunization campaigns often use words that patients may not understand, potentially impacting patients’ relationship with the healthcare system and health behavior change. We found a lower level of recognition (health literacy) of words associated with vaccine-preventable diseases among Hispanic vs. Non-Hispanic women attending a community health fair. These findings have implications for developing culturally-tailored communication tools and educational strategies using a language easily recognized by a specific community to help reduce racial disparities in vaccination uptake.

Disclosures

All Authors: No reported disclosures
42. A Pharmacist-Led Intervention to Decrease Anaerobic Coverage for Hospitalized Patients with Community-Acquired Pneumonia
Authors: Enzmann Maxx O , Pagels Courtney M , Perry Emily J , Jones Justin , Carson Paul
Published: January 2021

Background

Community-acquired pneumonia (CAP) is frequently mis-categorized as aspiration pneumonia, prompting the addition of anaerobic coverage to the antibiotic regimen. In our institution, this usually takes the form of adding metronidazole to ceftriaxone. The 2019 American Thoracic Society and Infectious Diseases Society of America CAP guidelines recommend anaerobic coverage only for hospitalized patients with a suspected lung abscess or empyema. The objective of this study was to determine if a pharmacist-led workflow could increase adherence to the 2019 CAP guideline recommendations by limiting anaerobic coverage to those rare occasions.

Methods

The hospital antimicrobial stewardship committee approved a pharmacist workflow and guidance document which outlines criteria to evaluate appropriateness of anaerobic coverage for hospitalized patients with CAP and no other indications for antibiotics. If anaerobic coverage is not indicated, the pharmacist submits a standardized message to the treating provider via the electronic medical record, recommending discontinuation of metronidazole. This workflow was implemented on October 3, 2019. Metronidazole days of therapy (DOT) per 1000 patient days in quarters 1 through 4 of 2019 and quarter 1 of 2020 were collected as well as percent acceptance of documented pharmacist interventions from October 3, 2019 until March 31, 2020.

Results

Between October 3, 2019 and March 31, 2020, a total of 221 interventions were made by pharmacists to discontinue metronidazole in hospitalized CAP patients where anaerobic coverage was not indicated. Out of those 221 interventions, 164 (74%) were accepted by providers and only 57 (26%) were rejected.

The DOT per 1000 patient days of metronidazole was assessed for the three quarters prior to our intervention and the two quarters after the intervention. Compared to the three quarters prior, metronidazole DOT per 1000 patient days decreased by 26.6% for the two quarters following implementation of the pharmacist-led intervention (Figure 1).

Figure 1: Metronidazole DOT per 1000 patient days from January 1, 2019 through March 31, 2020. Vertical line indicates when pharmacist workflow was implemented.

Conclusion

A pharmacist antimicrobial stewardship intervention at our institution increased adherence to CAP guidelines and decreased unnecessary antibiotic exposure in hospitalized CAP patients when anaerobic coverage was not indicated.

Disclosures

All Authors: No reported disclosures
43. A Pharmacoepidemiologic Evaluation of Echinocandin Use
Authors: Jo Jinhee , Hendrickson Joshua , Gonzales-Luna Anne J , Beyda Nicholas D , Garey Kevin W
Published: January 2021

Background

Invasive candidiasis (IC) is a common healthcare-associated infection. Rates of IC caused by drug-resistant Candida spp., designated by the CDC as a serious threat, are increasing, and Candida auris alone was recently added as an urgent threat. Echinocandins are guideline-preferred for the treatment of invasive candidiasis due to in vitro potency, a favorable toxicity profile, and convenient dosing. The purpose of this study was to perform a pharmacoepidemiologic analysis on patterns of echinocandin use at a large, quaternary care medical center.

Methods

Data reporting echinocandin use, pharmacy data, and clinical microbiologic data obtained from 2017–19 were pooled. Monthly days of therapy (DOT) per 1,000 patient days were calculated during the study period along with number of unique orders. Investigators evaluated the proportion of echinocandin-treated patients with or without positive Candida cultures; the relationship between echinocandin use and hospital admission and discharge dates was also evaluated.

Results

Echinocandin monthly DOT/1,000 patient days present averaged 26 (± 5) DOT and did not change appreciably during the study period. Of the patients with microbiologic evidence of Candida, 842 (51%) received echinocandin courses. Length of echinocandin therapy was significantly longer for patients with positive Candida cultures (5.5 ± 5.9 days) compared to those without positive cultures (3.9 ± 5.0 days; p< 0.001). Of 1,659 echinocandin courses evaluated, 549 courses (33%) were initiated within 2 days of hospital admission and the average time from hospital admission to echinocandin start was 9 (± 13) days. A total of 505 (24%) echinocandin courses were continued until the day of discharge.

Conclusion

The rate of echinocandin use did not change appreciably during the study period. A significant proportion of echinocandin courses were either started upon hospital admission or were continued until the day of discharge. Further studies to evaluate antifungal stewardship opportunities for the echinocandin pharmacologic class are warranted.

Disclosures

Nicholas D. Beyda, PharmD, BCPS, Astellas (Advisor or Review Panel member)Cidara (Grant/Research Support, Scientific Research Study Investigator) Kevin W. Garey, PharMD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator)
45. Antimicrobial Stewardship for Urinary Tract Infection in Three Emergency Departments Across a Health System
Authors: Shoff Christopher , Funaro Jason , Fischer Kristen M , Boreyko John , Shroba Jenny , Mando-Vandrick Jennifer , Liu Beiyu , Lee Hui-Jie , Spires Steven S , Turner Nicholas A , Theophanous Rebecca , Staton Catherine , Moehring Rebekah W , Wrenn Rebekah
Published: January 2021

Background

Broad spectrum antibiotics are often prescribed to patients presenting to the emergency department (ED) for evaluation of urinary tract infection and pyelonephritis (UTI). We evaluated the effect of a target-specific antibiogram, education, and feedback on UTI diagnosis and antibiotic prescribing in this setting.

Methods

We created a urine-specific antibiogram from patients seen and treated without admission at three ED locations (one academic and two community hospitals). We then provided a treatment algorithm and supplemental educational content to ED providers in November 2019. Educational content highlighted appropriate diagnosis, antibiotic selection, and treatment duration for UTI. Adult encounters with appropriate ICD-9/10 codes within twelve months prior to content delivery comprised the preintervention cohort. The postintervention cohort consisted of adult visits following educational intervention until April 17, 2020. During the postintervention phase (November 2019 to April 2020), summary data regarding UTI diagnoses and guideline-concordant prescriptions were fed back routinely to ED providers through email. Guideline-concordant prescriptions were defined as those adhering to first or second-line therapy in the treatment algorithm. The proportion of prescriptions meeting this definition fulfilled the primary outcome. An interrupted time series analysis measured changes in guideline concordance.

Results

Data from 6,713 distinct encounters were analyzed across the three sites. While guideline concordant prescribing increased following intervention at all locations (30.9% to 38.8%, 48.1% to 49.1%, and 48.2% to 59.6%), these increases were not statistically significant (Figures 1, 2, and 3). The proportion of all ED encounters with a UTI diagnosis did not differ following the intervention. Interestingly, guideline concordance was greater in the academic ED, compared to the community hospitals.

Conclusion

Although guideline concordant prescribing for UTI increased in all three ED settings with education and email correspondence feedback, these results were not statistically significant. A variety of methods may be required to realize improved antibiotic prescribing across a diverse group of clinicians.

Disclosures

Rebekah W. Moehring, MD, MPH, Agency for Healthcare Quality and Research (Grant/Research Support)Centers for Disease Control and Prevention (Grant/Research Support)
46. Antimicrobial Stewardship’s Selective Antibiotic Suppression Does Not Lead to Adverse Outcomes in Neutropenic Patients with Gram-Negative Bacteremia
Authors: Witt Anna , Harper Mason G , Crescencio Juan Carlos Rico , Dare Ryan K , Burgess Mary
Published: January 2021

Background

An antimicrobial stewardship program (ASP) strategy to minimize the use of overly broad antimicrobials is to suppress specific antimicrobial susceptibility results when isolates are sensitive to narrow antibiotics. There is limited data on possible adverse outcomes of this method. Patients with febrile neutropenia (FN) and gram-negative bacteremia (GNB) whose culture is sensitive to non-pseudomonal antibiotics still require broader pseudomonal coverage to treat the syndrome of FN. We evaluated if ASP suppression of anti-pseudomonal antibiotics adversely affects patients with FN and GNB.

Methods

In February 2018, our institution’s ASP began suppressing cefepime and meropenem susceptibility results from E. coli, Klebsiella spp, and Proteus spp when sensitive to cefepime (MIC ≤ 2), ceftriaxone and ceftazidime. We performed a retrospective analysis of patients with FN and GNB from 2016 – 2020 to evaluate the appropriateness of antibiotic regimens before and after the ASP intervention. Antibiotic regimens were deemed inappropriate if the patient was de-escalated to a narrow-spectrum, non-pseudomonal agent while neutropenic. Of 338 inpatient encounters identified with any bacteremia and FN, 49 were due to non-Pseudomonas, non-ESBL GNB, 20 before and 29 after the intervention. Sixteen of the 29 post-intervention patients were excluded, as their isolates did not meet suppression criteria. This resulted in a total of 13 patients in the post-intervention group.

Results

After culture susceptibility reports were released, 3 out of 20 patients in the pre-intervention group (15%) and 4 out of 13 patients in the post-intervention group (30.8%) were inappropriately tailored to narrow-spectrum antibiotics (p=0.39). There was no significant difference in 30-day mortality, 10.0% pre- and 0% post-intervention (p=0.50), or amount of meropenem prescribed, 45% pre- and 38.5% post-intervention (p=0.74).

Conclusion

These data show no significant difference in inappropriate antibiotic regimens prescribed for patients with FN and GNB after ASP antibiotic suppression was implemented. 30-day mortality was also not affected. The ASP intervention did not decrease meropenem prescriptions in this patient group, which may be appropriate. Larger studies are needed to verify these findings.

Disclosures

Ryan K. Dare, MD, MS, Accelerate Diagnostics, Inc (Research Grant or Support) Mary Burgess, MD, Pfizer Inc (Grant/Research Support)
47. Assessing Viability and Outcomes following the Redistribution of Antibiotic Stewardship Tasks to the Clinical Pharmacist Team
Authors: Do Stephanie L , Shahzad Saboor , Lok Terence , An Hye Hyun , Arnone Suzanna
Published: January 2021

Background

Methodist Hospital and Cardinal Health determined that the TJC-mandated ASP program could be further improved. In February 2018, the program was restructured and ASP responsibilities were extended to all Clinical Pharmacists. Changing the ASP structure can improve the program efficiency via increased number of interventions/day, antibiotics’ days of therapy (DOT)/1000 patient-days, total antibiotics’ cost, and antibiotics’ cost/patient day.

Methods

A retrospective review was conducted for before and after data. The primary endpoints included number of ASP interventions/day, antibiotics DOT, and antibiotics’ cost/adjusted patient day. The secondary endpoints included effect on resistance of antibiotics for Pseudomonas aeruginosa, 48-hours antibiotic stop review, number of cultures reviewed, 7-days antibiotics review, and restricted antibiotics review.

Reports were obtained from Cardinal Health’s Drug Cost Opportunity Analytics program and Electronic Medical Record (EMR). Intervention types analyzed included: de-escalation, 48-hours review, 7-days review, cultures review, and restricted antibiotics review. Efficiency between pre and post implementation was compared via adjusted interventions/day. Resistance pattern of Pseudomonas aeruginosa, was also trended.

Interventions were trended and mean/day (SD) was calculated using Wilcox Rank Sum Test.

Results

The results showed improved efficiency with ASP interventions/day of 9.87 versus 4.73 (P≤0.0001). The DOT/1000 PD decreased from 1098 to 989 days. Antibiotics’ costs/adjusted patient day reduced from $16.62 to $9.16.

For secondary endpoints: improvement in sensitivity of different antibiotics for P.aeruginosa was noticed. Increased 48-hours antibiotic stop review (2 vs 722), increased number of cultures reviewed (380 vs 518), increased 7-days antibiotics review (24 vs 78), and increased restricted antibiotics (142 vs 432) were observed.

Conclusion

Transforming the ASP program at MHSC with Cardinal Health from resulted in improved efficiency, increased number of ASP-related interventions/day, decreased antibiotics DOT, decreased antibiotics-related cost/patient day, and increased sensitivities of drugs against Pseudomonas aeruginosa.

Disclosures

Stephanie L. Do, PharmD, Cardinal Health (Employee) Saboor Shahzad, BS. PharmD, Cardinal Health (Employee) Terence Lok, PharMD, MS, Cardinal Health (Employee) Hye Hyun An, PharMD Candidate 2022, Cardinal Health (Employee) Suzanna Arnone, PharMD, Cardinal Health (Employee)
50. Comparative Incidence of Acute Kidney Injury in Septic Patients Treated with Vancomycin in Combination with Piperacillin/Tazobactam vs. Cefepime
Authors: Deja Erin , Schmidt Monica , Frens Jeremy J , Nanavati Ankit
Published: January 2021

Background

Empiric antibiotic therapy for sepsis of unknown origin is typically broad spectrum and covers P. aeruginosa and methicillin-resistant S. aureus (MRSA). Nephrotoxicity is a well-known adverse event of IV vancomycin and literature suggests that combination with piperacillin/tazobactam may increase risk for acute kidney injury (AKI) as compared to combination with other beta-lactams. However, evidence is conflicting. The primary outcome of this study was to compare incidence of AKI in septic patients treated with IV vancomycin and piperacillin/tazobactam (VZ) vs. cefepime (VC). Secondary outcomes include hospital length of stay, inpatient mortality, and impact to direct variable cost.

Methods

Adult patients discharged with a sepsis diagnosis code who received VZ or VC for ≥24 hours in 2012–2019 were retrospectively identified. AKI was defined using RIFLE criteria. Patients were excluded for ESRD on HD, AKI occurring < 48 hours after treatment initiation or >7 days after discontinuation, pregnancy, febrile neutropenia, or meningitis. Statistical analysis controlled for many factors including age, race, gender, Elixhauser comorbidity burden, hours to first antibiotic dose, length of stay, and receipt of concomitant nephrotoxins.

Results

A total of 12,405 patients were evaluated; 7,818 received VZ and 3,096 received VC. Patients given VC had a 40% reduction in risk of AKI compared to those given VZ (IRR 0.600; 95% CI 0.46–0.78). These patients also had a 4% reduction in risk of having one additional inpatient day (IRR 0.961; 95% CI 0.937–0.985). Patients who received VZ and experienced AKI were 82.3% more likely to die inpatient compared to patients that did not (IRR 1.822; 95% CI 1.50–2.21). Patients treated with VC incurred less in average direct variable cost than those treated with VZ (p = 0.034) and those who suffered AKI also incurred more on average than those without AKI (p = 0.005).

Conclusion

Compared to septic patients treated with VZ, those treated with VC had significantly decreased risk of AKI as defined by RIFLE criteria. Patients who received VZ were at higher risk for a longer hospital stay and, if they also experienced AKI, inpatient mortality. VZ was associated with higher direct variable cost and patients with AKI incurred more dollars per encounter than those without AKI.

Disclosures

All Authors: No reported disclosures
51. Development and Assessment of a Process to Describe the Timing of Antibiotic Changes in Adult Inpatients
Authors: Livengood Spencer J , Drew Richard H , Moehring Rebekah W , Wilson Dustin , Spivey Justin
Published: January 2021

Background

Hospital antimicrobial stewardship programs (ASP) perform prospective audit and feedback to optimize use of antimicrobials; however, workflow inefficiency continues to be a distinct challenge. We developed a method to describe the volume and timing of antimicrobial changes to inform decisions on optimal timing of ASP review and intervention.

Methods

This retrospective study was performed at Duke University Hospital using anonymized antibiotic administration records from the DASON central database. Eligible antibiotic courses were administered to inpatients ≥ 18 years of age and had received ≥ 2 antibiotics administrations for ≥ 24 hours of treatment. A 2-month exploratory cohort (September to October 2017) was used to develop an antibiotic spectrum ranking (Table 1) and decision algorithm which was applied to a 1-year cohort (November 2017 to October 2018) for analysis of total change in antibiotic orders by day of the week. For each interval, the sum of antibiotic ranks was calculated and applied using specified definitions (Table 2) to determine the type of change occurring. The primary outcome was the number of total antibiotic changes that occurred on each day of the week. Secondary outcomes included the number and type (initiations, discontinuations, de-escalations, and escalations) of change. Descriptive statistics were used to describe the outcomes by day of the week.

Table 1: Antibiotic Spectrum Ranking

Table 2: Key Definitions

Results

The ranking and decision algorithm were applied to 16,993 unique antibiotic courses. Total changes occurred most on Wednesday (14,971, 16.2% [95% CI 15.7–17.1%]) and Friday (14,349, 15.6% [95% CI 15.0–16.2%]). Compared to intervals on weekdays (0.407 mean changes per patients on antibiotics [95% CI 0.401–0.413]), weekends had a lower number of changes (0.363 mean changes per patients on antibiotics [95% CI 0.349–0.377]). Initiations occurred most frequently on Tuesday (3,078, 18.1% [95% CI 16.3–19.9%]), and discontinuations on Wednesday (3,179, 18.7% [95% CI 17.4–20.5%]) (Figure 1).

Figure 1: Types of Changes per Day

Conclusion

We developed and applied a method to characterize antimicrobial changes. In our institution, the reductions in the number of changes observed on weekends provide an opportunity for ASP involvement to be incorporated and help facilitate appropriate antimicrobial changes.

Disclosures

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