bluuebunny/crossref_metadata_2025 huggingface dataset:
1580. A national prospective HIV provider survey of antiretroviral therapy preferences for management of treatment naïve and experienced individuals with genotypic resistance
Authors: Krishnan Sonya , Bjerrum Stephanie , Rivera Marina B Martinez , Shah Maunank
Published: November 2023

Background

HIV clinical practice guidelines outline broad treatment principles, but offer less explicit recommendations for complex patient situations. We hypothesize there is variability in antiretroviral (ARV) decision-making among experienced providers when considering HIV drug resistance.

Methods

US HIV clinicians and pharmacists were enrolled to provide ARV recommendations for up to 36 clinical case-vignettes in a series of electronic surveys (minimum survey length, 6 cases), encompassing variations of ARV resistance. Responses were categorized for each case based on drugs and classes selected, as well as anticipated activity based on genotypic susceptibility.

Results

119 experienced clinicians from across the US participated (Table 1). In the setting of high-level viremia and an isolated M184V, 85.9% selected a regimen with 2 NRTI+INSTI, while 9.9% selected regimens with > 3 ARVs (Table 2, Case #1). Alternatively, when presented scenarios with treatment-failure and moderate to high-level NRTI resistance (Table 2, Case #2, 3) without PI or INSTI resistance, providers most frequently ( >50%) selected an NRTI-sparing regimen, while a minority recommended 2NRTI + INSTI (21/123). Following EVG/c/TAF/FTC failure (isolated M184V, potential low level INSTI resistance, Table 2, Case #4), most providers recommended a PI-based regimen (31.2%) with 2 NRTI, or an intensified regimen with > 3 drugs (32.5%), while a minority suggested a second generation INSTI (23.4%). By contrast, when low-level INSTI resistance was present with more extensive NRTI resistance (Table 2, Case #5), the majority chose an NRTI-sparing regimen (45.6%) or a regimen with > 3 drugs (e.g., 2NRTI+INSTI+PI; 36.8%).

Table 1. Characteristics of survey respondents

Conclusion

There was heterogeneity in treatment preferences among providers when presented with ARV resistance. A majority suggested INSTI-based regimens (with 2 NRTI) with limited NRTI resistance alone. By contrast, most providers recommended regimens with at least 2 active drugs (e.g., NRTI-sparing or intensified with PI and INSTI) with more extensive NRTI resistance.

Disclosures

All Authors: No reported disclosures
1598. Predictive equations for immune recovery at 48 weeks of BIC/FTC/TAF treatment in Virologically Suppressed PLWHIV.
Authors: Tomé Roberto Pedrero , Buzón Luis , Pousada Guillermo , Dueñas Carlos , Galera Carlos , Sanz Jose , Troya Jesús
Published: November 2023

Background

The possibility to anticipate immune recovery could be of great interest when a switching strategy is planned, especially among those patients with low CD4+ count as an indirect marker of potential immunological success not only in absolute CD4+ and CD8+ count but also with CD4/CD8 ratio. The objective is to provide predictive equations that allow prognostication of 48-week immune recovery in HIV-positive men and women treated with BIC/FTC/TAF based on baseline CD4+ and CD8+ cell counts.

Methods

We collected data from 1315 adult patients with undetectable HIV+ who switched to a bictegravir/emtricitabine/tenofovir triple therapy regimen (1028 men; 287 women). We studied CD4+ and CD8+ cell counts at baseline and 48 weeks. Simple linear regression models were performed to predict patient immune status at 48 weeks according to patient sex. A logarithmic transformation of each variable was performed to obtain equations with higher predictive power. Each simple linear regression model was validated by an ANOVA test (p < 0.001). In addition, the assumptions of linearity, normality of residuals (Shapiro-Wilk test), homoscedasticity (Breusch-Pagan test), and independence of residuals were verified using the Durbin-Watson test. Each model was internally validated with one-third of the dataset using a bootstrap of 5000 iterations.

Results

All four proposed equations yield good predictive values (adjusted R-squared: 0.705 - 0.835). In the case of women, the proposed formulae are as follows: [1] 48 weeks Log10 [CD8+ cells/mm3] = 0.923 + 0.671*Baseline Log10 [CD8+ cells/mm3] (adjusted R-squared = 0.835); [2] 48 weeks Log10 [CD4+ cells/mm3] = 0.702 + 0.757*Baseline Log10 [CD4+ cells/mm3]] (adjusted R-squared = 0.746). For males, the formulas are as follows: [1] 48 weeks Log10 [CD8+ cells/mm3] = 1.392 + 0.571*Baseline Log10 [CD8+ cells/mm3] (adjusted R-squared = 0.705); [2] 48 weeks Log10 [CD4+ cells/mm3] = 0.605 + 0.795*Baseline Log10 [CD4+ cells/mm3] (adjusted R-squared = 0.810). The results obtained in the bootstrap do not differ from the initial models and therefore support the equations proposed.

Conclusion

Available data on immunological recovery in patients with triple therapy are scarce, and this could be an adjunct to predicting the evolution of these patients.

Disclosures

Luis Buzón, MD, PhD, Janssen: Advisor/Consultant|Janssen: Expert Testimony|MSD: Expert Testimony|Viiv: Advisor/Consultant|Viiv: Expert Testimony Carlos Dueñas, MD, Gilead: Advisor/Consultant|Gilead: Expert Testimony|Jannsen: Advisor/Consultant|Jannsen: Expert Testimony Jose Sanz, MD, PhD, Gilead: Expert Testimony|Janssen: Expert Testimony|MSD: Expert Testimony|ViiV: Expert Testimony Jesús Troya, Staff, Gilead: Advisor/Consultant|Gilead: Expert Testimony|Janssen: Board Member|Janssen: Grant/Research Support|ViiV: Advisor/Consultant
1610. Adherence to Antiretroviral Therapy and Its Effect on Quality of Life among Persons with HIV in the United States using Real-World Data
Authors: Hennessy Fritha , Prajapati Girish , Salmon Phoebe , Holbrook Tim , Tadese Bekana K
Published: November 2023

Background

Adherence to antiretroviral therapy (ART) is critical for persons with HIV (PWH) for achieving durable virologic suppression and minimizing drug resistance. This study aimed to characterize ART adherence and its effect on quality of life (QoL) among PWH using real-world data.

Methods

Data were drawn from the Adelphi HIV Disease Specific Programme™, a cross-sectional survey of physicians and PWH in the U.S., collected between July-2021 and March-2022. At consultation, each of 60 physicians reported demographics, clinical characteristics, ART adherence and satisfaction on 10 consenting PWH. These PWH were then invited to complete questionnaires reporting QoL (PozQol, EQ-5D). Physicians categorized adherence as completely adherent (C-Adh), mostly adherent (M-Adh), or less adherent (L-Adh). Comparisons were made using Chi squared test.

Results

Of 578 PWH with physician-reported adherence status; mean [SD] age 44.9 [12.8] years, 70.4% cisgender male, 50.5% White. A total of 389 (67%) were C-Adh, 155 (27%) M-Adh, and 34 (6%) L-Adh. L-Adh (55.9%) and M-Adh (46.5%) PWH had the higher proportion of ART side effects compared to C-Adh (29.3%); p< 0.001. Also, L-Adh (75.8%) and M-Adh (50.8%) were more likely to report current HIV-associated symptoms than C-Adh PWH (29.3%); p< 0.001. C-Adh PWH were perceived as very satisfied with their ART (68.4%), compared to M-Adh 39.4% and L-Adh 23.5%; p< 0.001. Reasons for PWH skipping ART included forgetting, difficulties integrating into routine, and ART side effects (Figure 1). QOL survey was completed by 229 PWH. QoL was higher for C-Adh PWH, measured by PozQol score mean, (C-Adh;45.2, M-Adh ;40.7, L-Adh;42.0; p< 0.05) and EQ-5D score mean (C-Adh; 0.91, M-Adh;0.77, L-Adh;0.66; p< 0.001).

Conclusion

About one-third of PWH who were not fully adherent to ART, and this was correlated with having poorer QoL. These findings highlight the need to better understand factors leading to sub-optimal ART adherence, to provide targeted interventions to improve quality of life.

Disclosures

Girish Prajapati, M.B.B.S., MPH , Merck & Co., Inc.: Employee|Merck & Co., Inc.: Stocks/Bonds Bekana K. Tadese, PhD, MPH, Merck and Co Inc: Employee
1619. Epidemiology of Congenital Syphilis Infections in Northwestern (NW) Iowa Witnessing a Significant Increase- Experience of a Tertiary Care Center
Authors: Kaushik Ashlesha , Beal Kristen , Gupta Sandeep
Published: November 2023

Background

According to the CDC, STI (sexually transmitted infections) including syphilis infections in adults have recently increased in the upper Midwest. Studies evaluating epidemiology of Congenital syphilis (CS) are needed to facilitate prompt recognition to prevent sequelae.

Methods

We retrospectively studied epidemiologic, clinical characteristics and outcomes of neonates with CS at our tertiary care center which is the largest maternal/neonatal center in NW Iowa during 1/1/2021-12/31/2022 (labeled P2). Epidemiologic characteristics during P2 were compared with the period from 1/1/2019-12/31/2020 (labeled P1). Diagnosis and treatment for CS were in accordance with CDC/American Academy of Pediatrics Committee on Infectious Diseases Red Book guidelines.

Results

During P2, a total of 42 newborns were diagnosed with CS compared to 0 during P1 (p< 0.05); 64% of infected newborns were White followed by Native American (21%), Hispanic (11%) and Black (2%). All (100%) neonates with CS were born to mothers infected during or after second trimester of pregnancy with negative first trimester RPR (Rapid Plasma Reagin) testing. Maternal RPR titers ranged from 1:1-1:256. Majority (62%) of newborns were diagnosed with proven/possible CS with RPR-titers > 4-fold mother's titers /untreated or inadequately treated maternal infection and required 10 days of intravenous Aqueous crystalline penicillin G treatment and NICU care; 2 newborns had meningitis and 3 developed sensorineural hearing loss. Thirty-eight% received 1 dose of intramuscular Benzathine penicillin G. Need for cerebrospinal fluid syphilis testing and 10 days of intravenous penicillin treatment increased by > 600% from P1 to P2 (p=0.02). CS evaluation/treatment in infected Native American neonates increased by > 1000% in P2 (p< 0.001). Mean hospitalization duration was 9.5 (±1.6) days. No infant died. Only 33% of infants followed up at 2 months for repeat testing. None of the Native American/Hispanic/Black neonates compared to 52% White neonates had follow-up testing (p< 0.05).

Conclusion

Our results show an alarming increase in CS in NW Iowa and underline the need for urgent preventive measures including STI prevention education, adequate maternal/ neonatal testing and follow-up, especially among marginalized populations.

Disclosures

All Authors: No reported disclosures
1635. Assessing the Potential Reduction in Morbidity and Mortality Attainable by Delayed Influenza Vaccine Strain Selection
Authors: Kissler Stephen M , Joshi Keya , Van de Velde Nicolas , Vicic Nevena , Park Yoonyoung , Rudin Deborah , Ghaswalla Parinaz
Published: November 2023

Background

To allow time for production, seasonal influenza vaccine target strains must be chosen up to 8 months before the start of the influenza season. Antigenic drift during these months can lead to mismatch between the circulating and vaccine strains, negatively impacting vaccine effectiveness (VE). mRNA vaccines can be produced more quickly than standard vaccines, raising the possibility of delaying influenza vaccine strain selection by up to 3 months, thus potentially improving VE. This is especially important for the H3N2 subtype, which is generally more severe than other subtypes and causes most human infections. The potential reductions in morbidity and mortality attainable by delayed influenza vaccine strain selection, especially for H3N2 subtype, have not yet been examined.

Methods

We assessed the match between circulating and vaccine strains (only H3N2 subtype) using influenza phylogenetic data and associated predictions of antigenic distance (difference in log-2 HI titer) from 2011-2019 obtained from GISAID and analyzed using NextStrain. We then developed a mathematical model to estimate the potential reduction in symptomatic cases, hospitalizations, and mortality attainable by a 3-month delay in influenza vaccine strain selection. A direct estimation of final epidemic size, trained to historical data on influenza burden from the US Centers for Disease Control and Prevention, was used to parametrize the model.

Results

In 2011-2019, a 3-month delay in strain selection could have detected the emergence of antigenically distinct H3N2 strains ( > 2 predicted log-2 HI titer difference from the vaccine) on 3 occasions: Mar (June) 2012, Sep (Dec) 2014, and Sep (Dec) 2017 (Figure). Improved strain selection in 2012 and 2017 may have had only a limited impact: VE in the NH 2012-13 season remained high despite the suboptimal match, and circulation of influenza in the SH in 2018 was low. However, in 2014, improved strain selection could have yielded substantial benefits, with model-estimated reductions in hospitalizations and mortality between 15-20%.

Conclusion

Delayed seasonal influenza vaccine strain selection, made possible by mRNA vaccine technology, could improve vaccine strain match and potentially yield reductions in hospitalizations and mortality in some seasons.

Disclosures

Stephen M. Kissler, PhD, ModernaTx: Advisor/Consultant Keya Joshi, PhD, Moderna, Inc.: Employee|Moderna, Inc.: Stocks/Bonds Nicolas Van de Velde, PhD, Moderna, Inc.: Salary|Moderna, Inc.: Stocks/Bonds Nevena Vicic, MSc, Moderna, Inc.: Employee|Moderna, Inc.: Stocks/Bonds Yoonyoung Park, ScD, Moderna, Inc.: Employee|Moderna, Inc.: Stocks/Bonds Deborah Rudin, MD, Moderna, Inc.: Employee|Moderna, Inc.: Stocks/Bonds Parinaz Ghaswalla, PhD, Moderna, Inc: Employee|Moderna, Inc: Stocks/Bonds
1640. Acyclovir use in infants and children (0-18 years) in Pediatric hospitals in Australia and New Zealand for suspected herpes simplex virus infection
Authors: Berkhout Angela , Clark Julia , Jones Cheryl , McMullan Brendan , Lim Selina , Yeoh Daniel , Britton Philip , Wong Shirley , Grimwood Keith , Cheng Daryl , Palasanthiran Pamela , Gwee Amanda , Cross Jack , Nguyen Tran , Jeffs Emma , Walls Tony , Mahony Michelle , Yan Jennifer , Nourse Clare
Published: November 2023

Background

Non-specific presentations of severe herpes simplex virus (HSV) infections and high risk of adverse outcomes have driven empiric acyclovir use. We therefore audited acyclovir prescribing in Australia and New Zealand for suspected HSV infection.

Methods

All children (0-18 years) prescribed intravenous (IV) acyclovir for suspected HSV infection in eight paediatric hospitals in Australia and New Zealand between 1 January 2019 and 31 December 2019 were included. Clinical data were extracted from patient records.

Results

IV acyclovir was prescribed for 1426 suspected cases, of whom 114 (8%) subsequently had proven HSV infection; 0.8% severe (9 encephalitis, 3 disseminated) and 7.2% (102) non-severe. Median age of the 1426 suspected cases was 4-months (IQR 0-49, range 0-223); 30% being neonates (<28 days), 17% aged 29 days-to-3 months and 53% aged >3-months. Suspected encephalitis (55%) and disseminated disease (29%) were the most common indications for prescribing acyclovir. 88% lacked risk factors and 90% had no potential identifiable source. 57% had CSF obtained, 25% and 13% had >1 surface swab and blood sent for HSV PCR testing respectively, whilst 20% had no HSV investigations. 34% were admitted to an intensive care unit. Median IV acyclovir duration was 1-day (IQR 1-2; range 0-81); 0.5% experienced nephrotoxicity and 2% had an extravasation injury. The median length-of-hospital stay was 4-days (IQR 2-9, range 0-307), 92% were well at discharge. Non-HSV infections (47%) and seizure disorders (15%) were the most common discharge diagnoses.

Conclusion

This study suggests frequent unnecessary empiric acyclovir use, with 8% of children having proven HSV infection; minority severe (0.8%) and 20% of children not having any HSV investigations.

National algorithms identifying high-risk age groups and clinical features of neonatal HSV infection and HSV encephalitis are needed to better guide acyclovir use and limit unnecessary treatment.

Disclosures

All Authors: No reported disclosures
1649. Tracking and reporting antibiotic use: Rising antibiotic prescriptions for URI illness in children during the COVID-19 pandemic.
Authors: Clemons Emily , Whiteman Matthew , Garavaglia Lisa , Gupta Shipra
Published: November 2023

Background

During COVID-19 there was an increase in antibiotic utilization across all settings. West Virginia has the highest outpatient antibiotic prescribing rate in the country. As part of our outpatient antibiotic stewardship initiative, we developed and utilized a dashboard to track and report prescribing data in two pediatric clinics in a large health system.

Methods

We reviewed prescribing data from Oct 2020- Mar 2022 in two outpatient pediatric clinics using a dashboard within the electronic medical record. Both clinics are affiliated with a large health system but clinic A was academic and clinic B was non-academic clinic. We also collected data on total number of visits and visits that had antibiotics prescribed. We reviewed prescription data on visits that were diagnosed with upper respiratory tract illness (URI) like acute otitis media, acute sinusitis, acute pharyngitis etc. We compared URI antibiotic prescriptions in Jan 2021-Mar 2021 with Jan 2022- Mar 2022.

Results

There were more than 15,000 visits during the study period. A steady increase in antibiotic prescriptions written per visit was noted in both clinics (Figure 1). There was a significant increase in percentage of prescriptions for URI in the respiratory season for 2021 and 2022 (30.2% vs. 47.7%, p< 0.0001). The most common diagnosis for antibiotic prescription in both clinics was acute otitis media (67 and 72%, respectively). However, clinic B wrote cefdinir prescriptions for 38 % cases of otitis media vs. 12% in clinic A.

Conclusion

There was an increase in overall prescriptions for antibiotics and prescriptions for URI in both clinic sites. This was most likely due to the prolonged viral season following cessation of COVID-19 mitigation measures. There were significant differences noted in prescribing practices, like cefdinir overuse for treatment of otitis media, which will guide our antimicrobial stewardship interventions in future.

Disclosures

All Authors: No reported disclosures
1650. Caregiver Perspectives on Educational Materials Used for Paediatric Community-Acquired Pneumonia and Antibiotic Stewardship in the Emergency Department: A Qualitative Study
Authors: Huang Nelson , Murphy Lara , Kandasamy Sujane , Wahi Gita , Pernica Jeffrey
Published: November 2023

Background

The objective of this study was to determine the best modality for educating caregivers on paediatric community-acquired pneumonia (CAP) and antibiotic stewardship within the emergency department (ED) setting. This was to inform the design of educational materials used in a prospective study (PIONEER study, NCT 05114161) testing a novel care pathway for treating non-severe paediatric CAP that aims to reduce unnecessary antibiotic prescriptions.

Methods

This was a phenomenologically-informed qualitative study involving interviews with caregivers of young children in Hamilton, Ontario. Caregivers were presented with four educational materials on appropriate antibiotic prescribing for paediatric pneumonia management. The four materials included: a video of a physician presenting the information, a caregiver discussing her own experiences with antibiotic use for her children, an animated video with audio alongside written information and illustrations, and a brochure. Following this, participants were asked open-ended questions about how they felt about the effectiveness of the materials shown.

Results

Eleven caregivers were interviewed. Most caregivers preferred the combination of the animated video and brochure to the use of either the didactic physician or caregiver video. Participants reported that the stress of the ED environment may hinder their ability to easily process information in the moment. As such, some participants preferred the simpler visuals of the animated video as well as the brochure which they could refer to following their child’s discharge. One caregiver expressed a desire for increasing the diversity of racial identities represented in the educational materials. Although our study focused on paediatric CAP, these findings may have implications in the larger context of caregiver education in the ED.

Conclusion

The findings from this study emphasize the importance of providing clear and concise information to caregivers in the ED environment. Educational aids with simple visuals and concise information which can be referenced following the ED visit are preferred. Additionally, increasing diversity in educational materials can help promote a more inclusive care experience.

Disclosures

Jeffrey Pernica, MD, MSc, FRCPC, DTMH, MedImmune: Grant/Research Support|Merck: Grant/Research Support
1657. Evaluating the Effectiveness of Biofire® FilmArray® BCID2 Sepsis Panel in Pediatric Antibiotic Stewardship Program: Less time and more control
Authors: Londono-Ruiz Juan Pablo , Betancur Juan Pablo , Casadiego-Payares Stephanie , Castellanos-Leguizamon Daniela , Gutierrez-Tobar Ivan Felipe
Published: November 2023

Background

The use of molecular biology tools has allowed for a decrease in the time required for effective therapy in bacteremia. Integrating these tools into Antimicrobial Stewardship Programs (ASP) can improve clinical outcomes. The aim of this study is to describe the impact of using a molecular biology platform for sepsis as part of an ASP in a pediatric hospital.

Methods

This descriptive study collected data from positive blood cultures that underwent Biofire® FilmArray® BCID2 testing for sepsis from January 2021 to February 2023. In our hospital, taking this molecular test is indicated in all blood cultures positive for Gram-negative bacilli, in Gram-positive cocci only when there is a pyogenic focus or both sets are positives, additionally in patients with immunosuppression or who present with septic shock. Clinical and microbiological characteristics of the samples were described, along with the impact of the ASP after receiving the test results. Data analysis was performed using the R program.

Results

A total of 119 positive blood culture bottles were included in the study, in which the molecular test was performed. Gram-positive cocci were identified in 82 (68.9%) bottles, while Gram-negative bacilli were identified in 37 (31.1%). The mean detection time for Gram-positive cocci was 13 hours and 33 minutes (range: 11-18 h), while for Gram-negative bacilli it was 11 hours and 30 minutes (range: 9-13 h). The most frequently detected germs are presented in Table 1. Among the 119 patients, the FilmArray test result prompted a change in antibiotic therapy in 54 cases (45.3%). In an additional 28 cases (23%), a change was made after the final culture result. Only 6 patients (5%) experienced clinical deterioration after the FilmArray® test, requiring changes prior to the definitive culture result.Table 1:Different microorganisms, diagnosis times and concordance with the definitive culture

Conclusion

In conclusion, our study demonstrates that the use of molecular tools in positive blood culture bottles, guided by an ASP, allowed for rapid changes in nearly half of the cases. Few patients experienced deterioration after the completion of the FilmArray® test, requiring empirical changes in the antibiotic. These findings suggest that incorporating molecular tests into ASPs can significantly improve the management of bacteremia, leading to more effective and timely treatment decisions.

Disclosures

All Authors: No reported disclosures
1667. Patterns of Inpatient Antibiotic Use by Race and Ethnicity at US Children's Hospitals
Authors: Wattles Bethany , Campbell Jeffrey I , Feygin Yana , Jawad Kahir S , Stevenson Michelle D , Davis Deborah , Porter Jennifer , Jones V Faye , Smith Michael J
Published: November 2023

Background

Racial and ethnic variations in antibiotic prescribing to children are well-reported in outpatient settings. However, little is known about racial prescribing patterns in hospital settings. We sought to describe national inpatient antibiotic utilization among children by race and ethnicity.

Methods

We utilized Pediatric Health Information System (PHIS) data from 49 children’s hospitals across the US. All inpatient and observation-status visits from 2022 for children < 18 years were included. An “antibiotic visit” was defined as any inpatient admission in which an oral, parenteral, or intramuscular antibiotic was prescribed. Antibiotic visits, severity, length of stay, and cost of stay were stratified by patient race and ethnicity (as collected by each hospital). Diagnoses and severity were classified by All Patients Refined Diagnosis Related Groups (APR-DRG).

Results

Antibiotic visits by race-ethnicity ranged from 38.4% (Non-Hispanic [NH] Black children) to 45.0% (NH American Indian) (Table 1). NH White children made up the largest group (45.2% of all visits) and had an antibiotic visit rate of 42.4%, followed by Hispanic (27.1% of all visits) and NH Black (19.2%). Antibiotic visits for children < 2 months ranged from 19% (Asian) to 39.4% NH American Indian. The largest gap in antibiotic visits between NH White and NH Black children was in ages 5 to 11 years (49% and 40.6%, respectively). Differences between NH White and NH Black children were highest in the northeast (44.7% vs. 36.6%, respectively), and lowest in the south (40.1% vs. 38.9%, respectively). In NH White and Hispanic children, antibiotic visits decreased with increasing income and Child Opportunity Index; for NH Black children, a reverse relationship was observed. Severity was similar for NH White, Hispanic and NH Black children. NH Black children had the highest proportion of stays >14 days (6.6%) but lower cost of stays. Antibiotic visits and diagnoses of interest are reported in Table 2.Table 1.Demographics and Antibiotic Visits by Race and Ethnicity. NH = Non-Hispanic; Child Opportunity Index (a neighborhood measure of resources and conditions for healthy development) and Income were assigned using patient zip code.Table 2.Antibiotic Visits and Outcomes by All Patients Refined Diagnosis Related Groups (APR-DRG). All Visits, Antibiotic Visits = row %; Severity = column %

Conclusion

Antibiotic utilization in children’s hospitals differs by race and ethnicity. Antibiotic stewardship programs should stratify antibiotic use data by race-ethnicity and examine policies and practices that may contribute to disparities in treatment for hospitalized children.

Disclosures

Bethany Wattles, PharmD, MHA, Merck: Grant/Research Support Michael J. Smith, M.D., M.S.C.E, Merck: Grant/Research Support|Pfizer: Grant/Research Support
1674. 10 Year p-OPAT Experience In A Tertiary Pediatric Center In Singapore
Authors: Aoyama Rie , Chan Si Min , Leow Olivla , Ang Samantha , Quek Belinda
Published: November 2023

Background

Outpatient parental antibiotic therapy is safe and effective. Our institution is one of two tertiary public hospital pediatric centers in Singapore. We aim to describe characteristics and outcomes of pediatric OPAT (p-OPAT).

Methods

We retrospectively reviewed p-OPAT patients from May 2013-Dec 2022. Clinically stable inpatients were referred to the pediatric infectious disease team for assessment, caregiver training, and weekly review. Two main delivery models were used; daily bolus/short infusion at an outpatient unit, and home self-administration via elastomeric device. Electronic medical records were analyzed for demographics, clinical and microbiological data, treatment, and outcomes. Institutional review board approval and written informed consent were waived.

Results

219 patients completed 249 p-OPAT episodes; 46.6% female, 53.3% male. Median age was 8 years 5 months (range 11 days-29 years). Patient ethnicities were 53.9% Chinese, 12.3% Indian, 20.5% Malay, 13.3% others.

53/219 (24.2%) patients were immunocompromised; three had primary immunodeficiency, 50 had acquired immunodeficiency. 89/219 (40.6%) patients had chronic illness.

176/249 (70.7%) episodes had only one pathogen identified (Tab 1). Pathogens were gram positive (21.7%), gram negative (38.2%), fungal (5.2%), mycobacterial (5.6%) (Tab 2). 18.9% episodes were culture-negative, 1.6% episodes had no cultures. Infection sites varied considerably; osteoarticular infection +/- bacteremia were most common (Tab 3). Ceftriaxone was the most frequent antimicrobial (105, 42.3% episodes). Peripherally inserted central catheter was most commonly used (138, 55.4% episodes).

Complete success, partial success, and failure were seen in 174 (69.9%), 43 (17.3%) and 32 (12.8%) episodes respectively. Main adverse events (AE) were vascular site dermatitis, infection, and line dislodgement. 235 (94.4%) episodes achieved infection cure. Mean p-OPAT duration was 16.9 days (range 1-177 days), saving 4208 admission bed days.

Conclusion

We describe one of the largest series of children receiving p-OPAT over 10 years and report good outcomes for a broad spectrum of infections. Vascular access issues were common AEs despite preventive measures.

Disclosures

All Authors: No reported disclosures
1681. Persistent Increased Invasive Pediatric Streptococcus pyogenes (Group A Streptococcus) Infections with Correlated Increase in Superficial Infection and Pharyngitis
Authors: Dowling Jameson , Werz Daphne , Smith Kenneth , Harris Rebecca , Smathers Sarah , Harrison-Long Cecelia , Sammons Julia , Hayes Ericka
Published: November 2023

Background

Children's Hospital of Philadelphia (CHOP) clinicians observed an increase in invasive group A Streptococcus infections (iGAS) in November 2022. In December 2022, the Centers for Disease Control and Prevention published an investigation of increased iGAS. At CHOP iGAS remain increased, even after peak respiratory viral season. Our objective was to compare pre-pandemic and current case counts and to investigate if the increase in iGAS correlates with an increase in non-invasive GAS infections (nGAS).

Methods

Data for positive Streptococcus pyogenes results at CHOP from January 2018 to April 2023 was collected from the electronic medical record (n=466). Results were classified by source and specimen type as pharyngitis, superficial, and invasive, then further classified as non-invasive (pharyngitis and superficial) or invasive. For infection events with multiple results only one result was included, giving preference to the most aggressive classification (invasive >pharyngitis >superficial). Fisher's exact test was used to assess association between the increase in nGAS and iGAS prior to and after the start of the COVID-19 pandemic (2018-2019 vs. 2021-2023). Fisher's exact test, with Monte Carlo simulation, was used to assess association between the increase in nGAS and iGAS infections by year.

Results

There was a statistically significant association in the increase in pharyngitis, superficial, and invasive group A Streptococcus infections (GAS) (p-value < 0.0001) and in nGAS and iGAS (p-value = 0.0001), when comparing pre- and post-2020. We found statistically significant associations in the increase of pharyngitis, superficial, and invasive GAS cases (p-value = 0.0005) and of nGAS and iGAS cases (p-value = 0.0005).

Conclusion

Our data shows a significant increase in cases from pre-pandemic years for nGAS and iGAS infections. iGAS is correlated with nGAS, even with further stratification of nGAS into pharyngitis and superficial. Notably, increases in nGAS were significantly more than the increase in iGAS, which has unexpectedly persisted beyond the typical winter viral infection peak. Continued monitoring or GAS, particularly iGAS, is justified.

Disclosures

All Authors: No reported disclosures
1692. Increasing incidence of Streptococcus anginosus group intracranial complications of sinusitis, otitis media and mastoiditis in a pediatric population
Authors: Hoyer Elisabeth , Joseph Marritta , Dunn James , Weiner Howard , Dimachkieh Amy , Flores Anthony R , Kaplan Sheldon L , Vallejo Jesus G , McNeil Jonathon C
Published: November 2023

Background

The Streptococcus anginosus group (SAG) pathogens (S. anginosus, S. intermedius, and S. constellatus) are oral flora with the potential to cause head and neck space infections including brain abscesses. Several centers noted an increase in intracranial abscesses in children in the SARS-CoV-2 era, prompting a CDC health alert in May 2022. Notably, a large proportion of such reported cases were associated with SAG and/or sinusitis. We examined the epidemiology of pediatric intracranial abscesses with a focus on SAG in the pre- and post-pandemic periods.

Methods

Cases of intracranial abscesses (parenchymal, subdural, epidural) of any microbiologic etiology from January 1, 2011 to December 31, 2022 were identified at Texas Children's Hospital by ICD10 codes. Subjects were cross referenced with culture results of the microbiology laboratory. Cases included were those associated with either otitis media, mastoiditis, or sinusitis. Temporal trend in these infections was investigated with linear regression.

Results

157 cases were identified and 59.9% were due to SAG. The incidence of all sinogenic/otogenic intracranial infections (p=0.006), and SAG specific infections (p=0.01), increased from 2011 to 2022 (Figure 1). SAG infection was more often associated with multiple surgeries and these subjects were specifically more likely to require craniotomy or craniectomy (Figure 2). Among sinogenic abscesses, S. intermedius was the most common pathogen while among otogenic cases S. pyogenes predominated (Figure 3). There were 8 cases of craniectomies and one relapse (due to SAG) after replacement of autologous bone flap. After March 2020, 6/46 cases tested positive for SARS-CoV-2 (13%); the severity of infection was not significantly different with concomitant COVID and intracranial abscess. The proportion of SAG-associated infections was similar prior to and after the COVID pandemic.

*- p= 0.01- <0.05 ** p< 0.01

Conclusion

Over the last decade, intracranial complications of sinusitis/otitis have been increasing, and specifically those caused by SAG. This observed trend clearly predated the COVID pandemic. SAG cases were associated with greater need for surgical intervention and specifically neurosurgery. Further work is necessary to determine the explanation for these rising infections.

Disclosures

Sheldon L. Kaplan, MD, MeMed: Grant/Research Support|Pfizer: Grant/Research Support|Pfizer: Honoraria Jonathon C. McNeil, MD, Allergan: Grant/Research Support|Nabriva Therapeutics: Grant/Research Support
1710. Clostridioides difficile Bundle Implementation Reduces Unnecessary Testing in Pediatric Patients
Authors: Sietsema Lydia , Maples Holly , Honeycutt Michele , Boyanton Bobby , Forbus John , Snowden Jessica
Published: November 2023

Background

Failure to follow proper guidelines can lead to inappropriate Clostridioides difficile infection (CDI) testing in pediatric patients, resulting in incorrect diagnoses and antibiotic overuse. The Infectious Diseases Society of America and Society for Healthcare Epidemiology of America recommend a 2-step testing algorithm incorporating restrictions based on age, exposure, and underlying conditions. With these recommendations, a CDI bundle was implemented to reduce unnecessary testing in pediatric patients. Outcomes were measured via National Healthcare Safety Network (NHSN) LabID reporting.

Methods

An interdisciplinary team reviewed the CDI ordering process in a 24-bed community pediatric hospital with an Emergency Department (ED). Previous testing only used toxigenic C. difficile PCR without order restrictions. In September 2021, a CDI bundle was implemented, including a 2-step algorithm (toxigenic C. difficile PCR, toxin A/B immunoassay), a physician guidance pathway, and Epic order restrictions (Table 1).

Outcomes were measured by examining NHSN LabID data before and after bundle implementation. Inpatient and ED data were reported under the appropriate NHSN patient safety module. CDI rates were calculated by the number of infections/1000 inpatient days and number of infections/1000 ED encounters. There was a 12-month pre-implementation period (August 2020-July 2021), a 3-month implementation period (August 2021-October 2021), and a 12-month post-implementation period (November 2021-October 2022).

Results

A statistically significant decrease in the CDI incidence was seen after CDI bundle implementation (P< 0.05 for both inpatient and ED using test of proportions). The average CDI incidence decreased from 2.24 to zero infections/1000 inpatient days (Figure 1) and from 0.58 to 0.02 infections/1000 ED encounters (Figure 2).

Conclusion

CDI diagnostic bundle implementation effectively decreased the number of abnormal CDI test results, and positively impacted data reported to NHSN. Further analysis is warranted to delineate the impact of CDI bundle implementation on patient treatment, antimicrobial stewardship, and healthcare costs.

Disclosures

Jessica Snowden, MD, MHPTT, Pfizer: Advisor/Consultant
2878. A Regional Antimicrobial Stewardship Collaboration to Address Fluoroquinolones
Authors: Adenew Ayne , McKnight Angela Y , Ketema Pawlose , Cole Mirella , Callahan Patricia , Laake Ann , Huffman Patrick , Dave Rohini , Bork Jacqueline , Tripathi Ravi , Allman James , Gaynor Cecilia , Cork Travis , Liappis Angelike P
Published: November 2023

Background

Geographically associated Antimicrobial Stewardship Programs (ASPs) may benefit from working in collaboration. Independent ASPs can coordinate efforts with other programs to address high-yield targets for quality improvement and share in experience and knowledge to meet both local goals and fulfill national regulatory standards.

Methods

In 2016 ASPs from six neighboring urban/rural VA Medical Centers serving 800K veterans agreed to target fluoroquinolone (FQ) use with shared messaging on preferred indications and reducing avoidable FQ toxicity. All sites had an established ASP and dedicated ASP Champions; two sites lacked FT ID trained MD and ASP FTE allocation varied per site. Sites pooled antibiograms 2018-22 and national metrics for FQ use in outpatient (OP) 2017-22, inpatient (IP) 2020-22 and the pandemic period (PP). Electronic platforms sustained communication and regular teleconferences facilitated planning and coordination. Local decisions determined interventions to target based on resources and patterns of use. FQ-targeted prospective audit/feedback, peer-peer reports and modified EMR- order entry were supplemented with shared educational materials. Messaging with reinforced with bi-annual regional events used targeted email campaigns and teleconferenced talks, including throughout the PP.

Results

Over six years FQ total OP fills sustainably fell 13.6K to 4.3K with annual pharmacy visits 25K (1.5-7K site/year) and DOT/1,000 unique OP visits fell by nearly 70% in the same period across all sites urban/rural (P=.01). In the 522 (28-175) acute, 594 (50-275) LTC beds FQs fell 22.3 to 10.8 DOT/1,000 patient days by 2022. Regional-trends did not increase in PP, but decline slowed. In the region E. coli resistance was unchanged but in sites reporting FQs, suscepblity improved for isolates of MRSA (n 1294) and MSSA (n 1931); with sustained gains in the PP.

Conclusion

Despite differences in hospital size, settings and resources, sustained outcomes can be achieved through efforts developed with regional partners. Coordinated regional stewardship initiatives facilitated by shared metrics are effective, support local efforts, allow for program autonomy and lessen the overall workload through shared experience.

Disclosures

All Authors: No reported disclosures
2882. Impact of a Tele-Antimicrobial Stewardship Program at Two Small Community Hospitals in Partnership with an Academic Medical Center: 2 Years of Experience
Authors: Ross Jennifer , Chandorkar Aditya
Published: November 2023

Background

Community and rural hospitals often lack resources for infectious diseases (ID) specialists. Tele-antimicrobial stewardship programs (TASPs) have emerged as a method for health systems to meet regulatory requirements. We analyzed the impact of a fully remote TASP at two small community hospitals in partnership with an academic medical center over a two-year period.

Methods

A TASP, co-led by an ID physician and ID pharmacist, was implemented at a 21-bed hospital in Princeton, MN, and 49-bed hospital in Wyoming, MN, in August 2020. Figure 1 outlines daily TASP workflows in which the ID physician and ID pharmacist were located at an academic medical center. Frequently encountered restricted antimicrobial agents included vancomycin (intravenous and enteral), piperacillin-tazobactam, cefepime, meropenem, ertapenem, micafungin, and remdesivir. Antimicrobial stewardship interventions were tracked monthly. Restricted antimicrobial days of therapy per 1000 patient days (DOT/1000 PD) mean averages two years pre- and post-implementation were compared. Annual antimicrobial expenditures were followed.

Results

For the first two TASP years (8/1/2020 to 7/31/2022), a total of 789 antimicrobial interventions were made with 85.6% being accepted. Each site boasted similar TASP intervention acceptance rates, 85% for the Princeton hospital and 86% for Wyoming (Figure 2 and Table 1). Restricted antimicrobial use trended down from 141.97 to 113.97 DOT/1000 PD at Princeton. A smaller decrease from 106.3 to 103.12 DOT/1000 PD was seen at Wyoming. Annual antimicrobial costs per total patient days also decreased (Figure 3). Princeton hospital’s annual antimicrobial expenditures per total patient days fell from $18.89 in 2019 (pre-implementation) to $6.64. Wyoming showed a reduction in antimicrobial costs per total patient days by decreasing from $11.20 to $5.36.

Conclusion

A fully remote TASP in partnership with an academic medical center for two small community hospitals resulted in a rapid increase in the rates of accepted interventions. These high rates were sustained over two years. Restricted antimicrobial use and antimicrobial costs trended down. Consistent communication with tele-hospital physicians and pharmacists helped establish trusting relationships.

Disclosures

All Authors: No reported disclosures
1763. Attendance and Learning Outcomes of Statewide Infection Prevention and Control Education and Support Webinars Initiative During the COVID-19 Pandemic: The Nebraska Experience
Authors: Martinez Rebecca , Soma Mounica , McConville Josette , Tyner Laura "Kate" , Donahue Matthew , Ashraf Muhammad Salman , Brailita Daniel M
Published: November 2023

Background

In October 2020, the Nebraska Infection Control Assessment and Promotion program (ICAP), funded by the Nebraska Department of Health and Human Services (DHHS) through a CDC grant, launched a statewide initiative providing infection prevention and control (IPC) education and guidance through weekly webinars to long-term care (LTC) facilities. In March 2021, this was expanded to include a twice monthly webinar for acute care (AC) and outpatient facilities. ICAP infection preventionists (IPs) and medical directors developed the content of webinars in collaboration with Nebraska DHHS. Webinar recordings and slides were posted for reference. Webinar reminders were shared with facilities through the ICAP email distribution list. We investigated factors driving attendance and learning outcomes for this initiative.

Methods

Attendance was recorded for each webinar and compared between LTC and AC considering webinar focus and known denominators of Nebraska LTC and acute facilities. A comprehensive survey regarding learning outcomes and factors driving participation was sent to webinar contacts in early 2023. Responses from IPs working in AC and LTC were compared by independent two-sample T-Test with Pooled and Satterthwaite distribution using SAS version 9.04.01

Results

On average, 69 (range 42 to 110) facility IP leaders attended AC webinars and 160 (range 123 to 526) attended LTC webinars since the inception. Of the 96 AC and 429 LTC operational facilities, 50% AC and 25% LTC facilities responded to the survey. Of the 51 AC and 170 LTC respondents, IPs constituted 86% (n=44) and 25% (n=42) respectively. LTC IPs were more likely than AC IPs to join the webinars to learn about changes in regulatory requirements and national IPC guidance. More than 60% of IPs in both settings implemented a new policy or procedure based on the webinar, with LTC IP’s implementing 5% more general IP and 9% more COVID-19 specific policies. 83.3 % of LTC IPs and 52.3% of the AC IPs reported attending almost all webinars. IPs self-rated learning outcomes were high (AC 4.5-4.6 and LTC 4.3-4.6 on a 1-5 scale)

Conclusion

A statewide initiative to provide infection prevention education and guidance was well received by Nebraska facilities and led to just-in-time policy and procedure changes during COVID-19 pandemic.

Disclosures

Muhammad Salman Ashraf, MBBS, Merck: Grant/Research Support
1768. Engaging Clinically and Socially Vulnerable Populations to Understand Their Perceptions of mRNA Vaccines
Authors: D’Silva Chelsea
Published: November 2023

Background

One of the COVID-19 pandemic’s greatest silver linings has been the success of mRNA-based vaccines. While successful, the public has had many questions and even concerns about these vaccines as the pandemic is the first time they were clinically used. Both clinically and socially vulnerable populations have borne a hugely disproportionate burden of the pandemic. It is a public health imperative to ensure vaccine uptake in these groups are as high as possible. This project aimed to understand vulnerable populations perspectives on mRNA vaccines and immunizations to inform the development and dissemination of educational materials.

Methods

We conducted semi-structured qualitative descriptive interviews with clinically vulnerable (e.g., 50+, those living in LTC and congregate settings, having immunocompromising conditions/treatments) and socially vulnerable (e.g., racialized, newcomer and indigenous) populations across Canada. We thematically analyzed the data to identify patterns of meaning across the interviews.

Results

Fourteen people participated in interviews. Themes include: 1) clinically vulnerable populations view mRNA vaccines as safe and important for protecting themselves against COVID-19 and wish for the general public to get vaccinated to protect those who are most vulnerable; 2) socially vulnerable populations felt that there was a lack of accessible and concise information about who is high risk for COVID-19, timing of vaccination and how natural immunity to COVID-19 impacts the need for vaccination; and 3) vulnerable populations felt that the general public no longer views getting vaccinated as important since they do not view themselves as at-risk of hospitalization or severe adverse events.

Conclusion

These findings suggest that vulnerable populations view the vaccine as safe but perceive that getting vaccinated is not a priority for the general public. Our team is developing educational resources for vulnerable populations and the public to promote vaccine uptake. With more mRNA vaccines being developed for other infectious diseases, these findings can help inform vaccine promotion efforts and increase confidence in mRNA vaccines.

Disclosures

All Authors: No reported disclosures