bluuebunny/crossref_metadata_2025 huggingface dataset:
1401. Infliximab for Immune Reconstitution Inflammatory Syndrome (IRIS) in Tuberculous Meningitis; A Treatment Paradox
Authors: Azeem Ahad , Ahmad Faran , Velagapudi Manasa
Published: December 2021

Background

Tumor necrosis factor (TNF)-α inhibitors are known for the reactivation of latent tuberculosis (TB). As a paradox, it has been reported to have a role in the treatment of immune reconstitution inflammatory syndrome (IRIS) from anti-TB therapy.

Methods

We report a case of paradoxical worsening of central nervous system TB after initiation of anti-TB medications, which was treated successfully with infliximab (TNF-α inhibitor).

Results

A 34-year-old man from Nepal with a history of untreated latent TB presented with complaints of occipital headache, slurred speech, and witnessed seizure. His physical exam was consistent with hyperreflexia. MRI of the brain revealed multiple small contrast-enhancing lesions in cerebral hemispheres. CT Chest showed bilateral centrilobular nodules suggestive of miliary TB. Cerebrospinal fluid (CSF) analysis showed pleocytosis, high protein, and low glucose. He was started on isoniazid, rifampin, ethambutol, and pyrazinamide along with high-dose dexamethasone for TB meningitis. Later, MTB DNA probe from bronchioalveolar lavage and CSF detected Mycobacterium Tuberculosis which was pan-susceptible. Repeat MRI of the brain 6 months into therapy revealed worsening of brain lesions. Moxifloxacin and linezolid were added to the regimen given clinical progression on first-line therapy. 6-months into this enhanced regimen he started experiencing blurring of vision. Visual field mapping showed left homonymous hemianopia. Repeat MRI of the brain confirmed extensive changes of basilar meningitis completely enveloping the optic chiasm. IRIS from TB was suspected. His prednisone dose was increased, and 3-doses of infliximab infusion were, 2-weeks apart were administered which showed clinical and radiological improvement.

MRI Brain

MRI Brain (axial T2/flair sequence) shows hyperintensities in multiple locations including the involvement of the left optic nerve and the left occipital region.

Conclusion

Exacerbation of pre-existing clinical symptoms, formation of new lesions, or cavitation of prior pulmonary infiltrates is known as tuberculosis IRIS or paradoxical reaction. Despite the clinical and radiological exacerbation, mycobacterial cultures usually stay negative. Continuation of anti-TB medications and high-dose corticosteroids are the backbone of treatment but in refractory cases, immune modulation is needed with anti-TNF-α agents.

Disclosures

All Authors: No reported disclosures
1404. Tuberculosis and HIV Coinfection: A Review of 135 Cases Experience of the Infectious Diseases Department- CHU Mohamed VI- Marrakech
Authors: Alaoui Zahid Talibi , Raiteb Mohammed , Ihbibane Fatima , Soraa Nabila , Tassi noura
Published: December 2021

Background

Tuberculosis is a health problem in Morocco, which is increasingly indicative of human immunodeficiency virus (HIV) infection.

Objective

To determine the epidemiological, clinical and paraclinical, therapeutic and evolutionary aspects of tuberculosis and HIV co-infection.

Methods

we report 135 cases co-infected with HIV and tuberculosis, collected by the infectious diseases department at the Mohammed VI University Hospital in Marrakech. This is a 12-year retrospective study (2007 to 2020) that involved all HIV-infected patients hospitalized for tuberculosis regardless of its location.

Results

The mean age of the patients was 40 years (17-73 years). A male predominance was noted in 69% of cases. In 74.6% of cases, tuberculosis was indicative of HIV infection. Nine patients were receiving antiretroviral (ARV) treatment at the time of the discovery of tuberculosis. There were 24% pulmonary tuberculosis, 25.3% extrapulmonary tuberculosis and 49% disseminated tuberculosis. Tuberculosis was confirmed in 31.7% of cases. At the time of tuberculosis diagnosis, the average CD4 count was 86 cells / mm. Quadruple therapy with isoniazid, rifampicin, pyrazinamide and ethambutol was started in 83% of patients. The average time to start ARVs was 7 weeks. All patients who received ARVs received a combination therapy comprising the combination of 2 nucleoside analogs and one non-nucleoside analog. At the end of our work, the evolution was favorable in 53% of cases, death occurred in 25% of cases, 18.6% of patients were lost to follow-up, two cases of failure and another of relapse. Immune restoration syndrome was noted in 8 cases. Drug toxicity was observed in 24.5% of patients, 73% of which was related to hepato-toxicity of antibacillary drugs.

Conclusion

Tuberculosis is the most common opportunistic infection in people with HIV. Despite the advent of highly active triple therapy, tuberculosis is still a major cause of death in HIV positive people.

Disclosures

All Authors: No reported disclosures
1406. Hepatitis B and C Prevalence in Patients with Active and Latent Tuberculosis in an Ethnically Diverse Area of London, UK
Authors: Duret Amedine , Thorley Emma , Eni-Olotu Ayolola , Sikdar Oishi , Papineni Padmasayee
Published: December 2021

Background

North West London has one of the highest tuberculosis (TB) rates in the UK, at 24.8 per 10,000. The UK prevalence of hepatitis B virus (HBV) is 0.1-0.5% and for hepatitis C virus (HCV) is 0.5-1%. Chronic infection with HBV or HCV can lead to an increased risk of adverse treatment outcomes, such as drug-induced liver injury (DILI) in patients with active or latent TB. National guidelines recommend routinely screening for HBV/HCV prior to initiating TB treatment. Our objectives were to 1) evaluate the HBV/HCV screening practice in local TB clinics, 2) establish the prevalence of HBV/HCV in patients receiving TB treatment.

Methods

Retrospective analysis of laboratory and medical records of patients treated for active or latent TB identified from the London TB register and clinic records from 01/01/2018 to 31/12/2020 from London North West NHS Trust.

Results

1409 patients received treatment for TB during the time period of interest; 574 (40.7%) had active disease and 835 (59.3%) had latent infection. 966/1409 patients (68.56%) were screened for HBV and HCV. 55.9% of the active TB group and 77.2% of the latent infection group were tested. 66 (6.8%) patients had isolated anti-HBc positivity, 22 (2.3%) were HBV surface antigen positive and 8 (0.8%) were HCV-antibody positive. HBV surface antigens were more prevalent in active TB patients: 9/321 (2.80%) with active TB versus 13/645 (2.02%) with latent TB. 36/321 (11.21%) active TB patients had HBV core antibodies compared to 30/645 (4.65%) latent TB patients (p < 0.001). Three patients started antiviral treatment following their viral hepatitis diagnosis (one with HBV, two with HCV).

Conclusion

The prevalence of chronic HBV in the study population was higher than the estimated UK prevalence. Fifteen diagnoses of hepatitis were new, allowing specialist referral for monitoring of fibrosis and development of hepatocellular carcinoma. Three patients required hepatitis treatment. 6.8% of patients were positive for anti-HBc and therefore identified as being at future risk of HBV reactivation if requiring immunosuppressive therapies.TB disproportionately affects marginalised communities; screening for viral hepatitis in TB clinic represents an opportunity to target these hard-to-reach groups to maximise the impact of public health interventions.

Disclosures

All Authors: No reported disclosures
1409. Pulmonary Non-tuberculous Mycobacterium Infection (PNTMI) and COVID-19: Characterization of the National COVID Collaborative Cohort (N3C)
Authors: Figueroa Castro Carlos E , Hersh William
Published: December 2021

Background

Establishing whether a low-prevalence clinical condition is a risk factor for COVID-19 infection, or serious adverse outcomes, is difficult due to a limited number of patients, and lack of access to patient’s data by researchers. The National COVID Collaborative Cohort (N3C), a centralized national data resource to study COVID-19, provides access to structured clinical data derived from electronic health records. As of June 2021, N3C contains data on 6,193,738 patients (2,090,138 with COVID-19, 33.7%) from 55 participating sites (Figure 1). We describe the characteristics of patients with PNTMI based on COVID-19 infection status.

Figure 1

N3C Basic Demographic Data

Methods

COVID-19 is defined by positive lab result (PCR, antigen, or antibody) or COVID-19 coding diagnosis, as defined by N3C. PNTMI phenotype was built with N3C Data Enclave concept set tool, and ATLAS (https://atlas.ohdsi.org/). We limited analysis to adults (18 years-old or older). We used de-identified data sets stripped of protected health information (PHI). We used N3C Data Enclave analytical tools for exploratory data analysis, and descriptive statistics.

Results

We identified five hundred and eighty six individuals from 19 sites fulfilling the PNTMI phenotype (9.46 cases per 100,000 people). After our age limit, 555 individuals were included for analysis (Figure 2). 340 were females (61.3%), 447 of white race (80.5%), and 30 were Hispanic (5.4%). Additional descriptive statistics and statistical significance testing are provided (Table 1). The most common concept were "Non-tuberculous mycobacterial pneumonia", and "Pulmonary Mycobacterium avium complex infection". Four sites accounted for more than 50% of identified patients (Figure 2). We identified 24 individuals with COVID-19 (4.32%), and 44 deaths in this cohort (7.9%). Deaths were unrelated to COVID-19 event.

Figure 2. Basic demographic data of pulmonary non-tuberculous Mycobacterium infection phenotype in N3C

Figure 3. Concepts and data sources of pulmonary non-tuberculous Mycobacterium infection phenotype in N3C

Conclusion

In N3C, the PNTMI cohort has a lower proportion of COVID-19 infection than the general population, and it was not a cause of mortality. Further analysis to study impact of comorbidities, and differences in race and geographical location are warranted. N3C is a powerful research platform to study the impact of COVID-19 in special populations with low prevalence, and it can be used to study other populations of interest.

Disclosures

All Authors: No reported disclosures
1412. Clinical Epidemiology and Characteristics of Pulmonary Nontuberculous Mycobacterial Isolates from a Large Academic Military Treatment Facility
Authors: Ford Mary B , Okulicz Jason , Salinas Jesse , Kiley John
Published: December 2021

Background

Non-tuberculous mycobacteria (NTM) are ubiquitous in the environment and include pathogenic and nonpathogenic species. Although prevalence appears to be increasing in the US, diagnosis and treatment can be challenging. This study describes the epidemiology and clinical characteristics of pulmonary NTM (pNTM) isolates at Brooke Army Medical Center (BAMC).

Methods

BAMC pulmonary NTM isolates from 2012-2020 were included. Corresponding electronic health records were reviewed for epidemiologic, microbiologic, and clinical data. Pulmonary NTM infection (pNTMi) was defined using 2020 NTM guidelines and patients were divided into 2 groups based on whether guideline criteria for pNTMi were met. Demographic, microbiologic, and clinical characteristics were compared between groups.

Results

A total of 813 isolates from 225 patients were analyzed (median 2 [IQR 1-4] isolates per patient). Approximately half (49.7%) were female with a median age of 71 years (IQR 62-79, Table 1), and the majority were current or former smokers (57.3%). Compared to those not meeting criteria (n=116; 51.6%), pNTMi patients (n=109; 48.4%) more commonly had bronchiectasis (47.7% vs 27.6; p=0.002) but were less likely to have solid organ malignancy (11.9% vs 23.3%; p=0.036). A higher proportion of pNTMi patients were female (58% vs 42%; p=0.005) and had lower median Body Mass Index (BMI, 22.6 vs 25.1; p=0.001). M. avium complex (MAC) was more common among pNTMi patients (75.2% vs 35.3%; p=0.001). In contrast, M. simiae and M. gordonae were more likely to be isolated from those not meeting criteria (25.9% vs. 10.1%; p=0.003 and 16.4% vs. 1.8%; p=0.001, respectively). Among pNTMi patients, 60 (55%) were offered therapy and were more likely to be younger (70 [IQR 63-76] vs. 73 [IQR 65-82] years; p=0.049), have chronic obstructive pulmonary disease (COPD; 51.7% vs 24.5%; p=0.006) and MAC (88.3% vs. 59.2%; p=0.001) compared to untreated patients (Table 2).

Conclusion

Approximately half of pNTM isolates were observed in patients who did not meet criteria for pNTMi diagnosis. Female patients, lower BMI, bronchiectasis, or MAC isolation were more likely to meet pNTMi criteria. Management of pNTMi remains a challenge, with younger patients with COPD and MAC more likely to receive treatment.

Disclosures

All Authors: No reported disclosures
1413. Effect of Automated Identification of Antimicrobial Stewardship Opportunities for Urinary Tract Infections
Authors: Deri Connor , Wrenn Rebekah , Moehring Rebekah W , Spivey Justin , Yarrington Michael E
Published: December 2021

Background

The treatment of asymptomatic bacteriuria (ASB) does not improve clinical outcomes in most patients and may be associated with an increased risk of adverse events such as Clostridioides difficile infection. A best practice alert (BPA) was created to identify patients with possible ASB for antimicrobial stewardship (AS) review. We aimed to determine whether automated identification of ASB improved the timing of stewardship intervention.

Methods

An electronic health record BPA message to inpatient AS pharmacists was activated on 01/19/2021. The BPA identified inpatients with a new antibiotic order with an associated genitourinary indication and a preceding urinalysis with 0 to 5 WBC/hpf. BPAs were reviewed by an AS pharmacist during weekdays and normal business hours. We retrospectively evaluated the impact of the BPA on time from order to stewardship intervention between a cohort of pre-BPA (01/2020 to 12/2020) and post-BPA (01/20/2021 to 04/10/2021) patients. Included patients met the BPA criteria and had an AS intervention within 7 days of the antibiotic order. We specified interventions that were UTI-related. The median time from antibiotic order entry to any AS intervention was compared pre- to post-BPA using the Mann Whitney U test. Rates of UTI-related interventions were compared with Fisher’s Exact test.

Results

327 antibiotic orders met BPA criteria and were analyzed: 245 and 82 in the pre- and post-BPA group, respectively. Groups had similar baseline characteristics (Table 1). A total of 33 (27 UTI-related) pre-BPA group and 24 (17 UTI-related) post-BPA group interventions were documented by the AS team. The median time to any intervention was 28 hours (IQR 18-64.5) in the pre-BPA group compared to 13.5 hours (IQR 3.5-28.75) in the post-BPA group (p = 0.03, Figure). The pre-BPA group had a lower rate of UTI-related interventions compared to the post-BPA group (11.0% vs 20.7%, p = .04).

Conclusion

Automated identification of antibiotics targeting UTI with urinalysis showing absence of pyuria reduced the time to stewardship intervention and increased rate of UTI-specific interventions. The use of clinical decision support may aid in efficiency of AS review and syndrome-targeted AS impact.

Disclosures

Rebekah W. Moehring, MD, MPH, UpToDate, Inc. (Other Financial or Material Support, Author Royalties)
1415. Allergies to Antimicrobial Agents Among US Females with Uncomplicated Urinary Tract Infection
Authors: Thompson Jeffrey , Marijam Alen , Mitrani-Gold Fanny S , Wright Jonathon , Joshi Ashish V
Published: December 2021

Background

Uncomplicated urinary tract infections (uUTI) are generally treated empirically with antibiotics. However, antibiotic (AB) allergies limit the available oral treatment options for some patients. We assessed the proportion of self-reported AB allergies among US females with uUTI.

Methods

We performed a cross-sectional survey of US females ≥ 18 years of age with a self-reported urinary tract infection (UTI) in the 60 days prior to participation and a prescription of oral AB. Participants were further screened for evidence of a complicated urinary tract infection and, after exclusions, participants with a uUTI completed an online questionnaire about their most recent episode. Participants were from the Northeast (20%), Midwest (44%), South (20%), and West (16%) US. Descriptive self-reported allergy data were stratified into subgroups by whether the participant had recurrent UTI (defined as ≥ 2 uUTIs in the past 6 months or ≥ 3 uUTIs in past 12 months including index UTI), the number of different ABs given for the index episode (1, 2, ≥ 3), and whether the treatment was clinically appropriate according to Infectious Diseases Society of America uUTI guidelines.

Results

Overall, 375 female participants completed the questionnaire. The most commonly prescribed ABs for participants’ most recent uUTI were trimethoprim-sulfamethoxazole (TMP-SMX; 38.7%), ciprofloxacin (22.7%), and nitrofurantoin (18.9%) (Table 1). Most participants received only 1 AB for their uUTI (62.7%) and the majority were classified as having a non-recurrent uUTI (56.5%). No AB allergies were reported for most participants (69.3%); overall, 24.0% reported 1 AB allergy and 6.7% reported ≥ 2. A higher proportion of participants reported ≥ 2 allergies in the recurrent uUTI, ≥ 3 AB, and multiple AB subgroups (Table 2). The most common allergy was to TMP-SMX (15.7%), followed by amoxicillin-clavulanate (8.3%) and ciprofloxacin (5.3%) (Table 2). Similar allergy trends were seen across subgroups, except higher rates of ciprofloxacin allergy were seen in participants given multiple ABs (Table 2).

Table 1. Antibiotics used to treat most recent uUTI

Table 2 . Frequency of antibiotic allergies across cohort subgroups

Conclusion

AB allergies were relatively frequent in this uUTI cohort and the most common allergy was to TMP-SMX, which was the most prescribed AB. Allergies to ABs reduce the available treatment options for uUTI in some patients.

Disclosures

Jeffrey Thompson, PhD, Kantar Health (Employee, Employee of Kantar Health, which received funding from GlaxoSmithKline plc. to conduct this study) Alen Marijam, MSc, GlaxoSmithKline plc. (Employee, Shareholder) Fanny S. Mitrani-Gold, MPH, GlaxoSmithKline plc. (Employee, Shareholder) Jonathon Wright, BSc, Kantar Health (Employee, Employee of Kantar Health, which received funding from GlaxoSmithKline plc. to conduct this study) Ashish V. Joshi, PhD, GlaxoSmithKline plc. (Employee, Shareholder)
1416. Medicare Spending on Urinary Tract Infections: A Retrospective Database Analysis
Authors: Sulham Kate , Hammelman Eric
Published: December 2021

Background

Medical visits for UTIs represent 1%-6% of all healthcare visits (~7 million visits) and are estimated to cost the United States (US) healthcare system at least &1.6 billion annually. UTIs are associated with significant morbidity; particularly among the elderly, where UTIs are most prevalent. Little is known about the specific costs to Medicare of UTI; here, we seek to examine overall Medicare spending on UTI.

Methods

We conducted a retrospective multicenter cohort study of the Medicare fee-for-service (FFS) data. Patients were included for analysis if the following criteria were met: (1) enrolled in Medicare FFS from January 1, 2016 through December 31, 2019, (2) not enrolled in Medicare Advantage during that time period, (3) did not have any UTI diagnoses in 2016, and (4) enrolled in Medicare Part D. Individuals were categorized as having uncomplicated UTI (uUTI), complicated UTI (cUTI), or those who first had a uUTI that progressed to a cUTI (uUTI to cUTI). Medicare spending in the 12 months post-diagnosis was calculated, and patients were stratified by home- or institutionally-based (eg, nursing home, long-term care facility, etc.).

Results

2,330,123 patients were included for analysis; 92% were home-based, 8% were institutionally-based. Mean Charlson Comorbidity Index (CCI) across all patients was 2.16. In the 12 months after initial diagnosis, average Medicare spend was &33,984, &9,941 of which was UTI-related. Annual UTI-related costs were approximated &9,000 for home-based vs. &21,444 for institutionally-based patients. Mean drug spend per patient on antibiotics was &872. Broadly, uUTI patients were least expensive, followed by cUTI patients, with uUTI to cUTI patients being most expensive. Higher costs for were observed for institutionally-based patients, largely due to more frequent acute hospitalizations and more Part A-paid skilled nursing stays.

Conclusion

UTI-related spending represents approximately one-third of total annual Medicare spend for patients diagnosed with a UTI. Given average Medicare spending of approximately &12,000 per person in 2019, UTI is associated with substantially increased per patient cost and represents a significant source of spending for Medicare.

Disclosures

Kate Sulham, MPH, Spero Therapeutics (Consultant) Eric Hammelman, MBA, AbbVie Pharmaceuticals (Consultant)Edwards Lifesciences (Consultant)Genentech (Consultant)Spero Therapeutics (Consultant)Vertex Pharmaceuticals (Consultant)
161. The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use: Antibiotic Stewardship Intervention in 389 United States Ambulatory Practices during the COVID-19 Pandemic
Authors: Keller Sara C , Caballero Tania M , Tamma Pranita , Tamma Pranita , Miller Melissa A , Dullabh Prashila , Ahn Roy , Shah Savyasachi V , Gao Yue , Speck Kathleen , Cosgrove Sara E , Cosgrove Sara E , Linder Jeffrey A
Published: December 2021

Background

The AHRQ Safety Program for Improving Antibiotic Use aimed to improve antibiotic use by engaging clinicians and staff to incorporate antibiotic stewardship (AS) into practice culture, communication, and decision making. We report on changes in visits and antibiotic prescribing in AHRQ Safety Program ambulatory practices during the COVID-19 pandemic.

Methods

The Safety Program used webinars, audio presentations, educational tools, and office hours to engage clinician champions and staff leaders to: (a) address attitudes and culture that pose challenges to judicious antibiotic prescribing and (b) incorporate best practices for the management of common infections into their workflow using the Four Moments of Antibiotic Decision Making framework. Total visits (in-person and virtual), acute respiratory infection (ARI) visits, and antibiotic prescribing data were collected. Using linear mixed models to account for random effects of participating practices and repeated measurements of outcomes within practices over time, data from the pre-intervention period (September-November 2019) and the Ambulatory Care Safety Program (December 2019-November 2020) were compared.

Results

Of 467 practices enrolled, 389 (83%) completed the program, including 162 primary care practices (42%; 23 [6%] pediatric), 160 urgent care practices (41%; 40 [10%] pediatric), and 49 federally-supported practices (13%). 292 practices submitted complete data for analysis, including 6,590,485 visits. Visits/practice-month declined March-May 2020 but gradually returned to baseline by program end (Figure 1). Total antibiotic prescribing declined by 9 prescriptions/100 visits (95% CI: -10 to -8). ARI visits/practice-month declined significantly in March-May 2020, then increased but remained below baseline by program end (Figure 2). ARI-related antibiotic prescriptions decreased by 15/100 ARI visits by program end (95% CI: -17 to -12). The greatest reduction was in penicillin class prescriptions with a reduction of 7/100 ARI visits by program end (95% CI: -9 to -6).

Conclusion

During the COVID-19 pandemic, a national ambulatory AS program was associated with declines in overall and ARI-related antibiotic prescribing.

Disclosures

Pranita Tamma, MD, MHS, Nothing to disclose Sara E. Cosgrove, MD, MS, Basilea (Individual(s) Involved: Self): Consultant Jeffrey A. Linder, MD, MPH, FACP, Amgen (Shareholder)Biogen (Shareholder)Eli Lilly (Shareholder)
1419. High Prevalence of Fluoroquinolone-Resistant Urinary Tract Infection Among US Emergency Department Patients Diagnosed with UTI, 2018-2020
Authors: Faine Brett , Rech Megan A , Vakkalanka Priyanka , Talan David A
Published: December 2021

Background

Uropathogen resistance, Fluoroquinolone-resistance (FQR) and Extended spectrum beta-lactamase (ESBL), has been observed to be emerging worldwide with prevalences above recommended thresholds for routine empirical treatment. We sought to determine recent resistance prevalence from a geographically diverse sample of US Emergency Departments (ED).

Methods

We conducted a multi-center, observational cohort study utilizing a network of 15 geographically diverse US EDs. Patients ≥ 18 years of age with the primary international classification of diseases (ICD-10) diagnosis code of cystitis, pyelonephritis, or urinary tract infection (UTI) and were discharged home from the ED from 2018-2020 were included. We calculated descriptive statistics for uropathogens and susceptibilities. Logistic regression analysis was used to identify antimicrobial resistance risk factors associated with fluoroquinolone (FQ)-resistant Escherichia coli.

Results

Among 3,779 patients who met inclusion criteria, median age was 62.9 years (IQR: 41-77.6) and 76.3% were female. The most common diagnoses were complicated (40.9%) and uncomplicated cystitis (39.4%). Six hundred and forty-five (17%) patients reported receiving antimicrobials in the previous 90-days. E. coli was the most common pathogen (62.9%), followed by Klebsiella pneumoniae (13%) and Enterococcus species (5.8%). Across all sites, overall E. coli FQ-resistance prevalence was 22.1%, ranging from 10.5 to 29.7% by site. The prevalence of ESBL-producing uropathogen was 4.4%, ranging from 2.3% to 8.6% by site. Previous IV or oral antimicrobial use in the last 90-days and complicated vs. uncomplicated UTI were associated with FQ-resistant E. coli (OR 1.69, 95% CI: 1.33-2.14, and OR 1.60, 95% CI: 1.26-2.02, respectively). Of the most prescribed oral antibiotics upon patients discharged from the ED, E. coli resistance to nitrofurantoin and cephalexin was 1.8% and 0.9%, respectively.

Conclusion

FQ-resistant E. coli is widely prevalent and ESBL-mediated resistance appears to be emerging across US sites highlighting the need for ongoing monitoring of antimicrobial resistance and, at some locations, modification of empirical treatments.

Disclosures

Brett Faine, PharmD, Spero Therapeutics (Research Grant or Support) Megan A. Rech, PharmD, MS, BCCCP, FCCM, Spero (Research Grant or Support) David A. Talan, MD, AbbVie (Consultant)GSK (Consultant)SPERO Therapeutics (Grant/Research Support)
1420. Descriptive Epidemiology of UTI Hospitalizations in the US, 2018
Authors: Zilberberg Marya , Nathanson Brian , Sulham Kate
Published: December 2021

Background

In parallel with an increase in antimicrobial resistance, urinary tract infections (UTI), one of the most common diagnoses among hospitalized patients in the US, have been on the rise. Though mostly emphasized as a hospital-acquired complication among patients with an indwelling catheter, quantification of the full contemporary burden of UTI-associated hospitalizations is limited.

Methods

We conducted a cross-sectional multicenter study within the National Inpatient Sample (NIS) database, a 20-percent stratified sample of discharges from US community hospitals, from 2018, to explore characteristics of patients discharged with a UTI diagnosis. We divided UTI into mutually exclusive categories of complicated (cUTI), uncomplicated (uUTI), and catheter-associated (CAUTI). We applied survey methods to develop national estimates.

Results

Among 2,837,385 discharges with a UTI code, 77.9% were uUTI, 17.6% cUTI, and 4.4% CAUTI. Compared to patients with uUTI (mean age 69.0 years), those with CAUTI and cUTI were older (70.1 and 69.7 years), but had same comorbidity burden (mean Charlson 4.3) as cUTI (4.3) and lower than CAUTI (4.6). Compared to other geographic regions, the Northeast had the lowest proportion of uUTI (74.6%) and highest of cUTI (20.8%) while the South had highest uUTI (80.2%) and lowest cUTI (15.7%). Over 60% of all UTI, regardless of type, were in large, and nearly ½ in urban teaching, institutions, and >80% came through the emergency department. Antimicrobial resistance codes were infrequent, but extended spectrum beta-lactamase organisms were more common in CAUTI (2.7%) and cUTI (2.1%) than in uUTI (1.6%). Among the 83.0% of discharges whose UTI was a secondary diagnosis, sepsis was the most common principal diagnosis, ranging from 17.7% in uUTI to 22.3% in cUTI. Although relatively low across the board, hospital mortality was lowest in cUTI (2.8%) and highest in uUTI (3.9%). Discharges to a chronic care facility were most common in CAUTI (46.7%) and least common in cUTI (33.3%).

Conclusion

There are nearly 3 million hospital admissions with a UTI, comprising fully 8% of all annual admissions in the US. Though most are considered uncomplicated, there are few differences in characteristics or outcomes across the categories.

Disclosures

Marya Zilberberg, MD, MPH, Cleveland Clinic (Consultant)J&J (Shareholder)Lungpacer (Consultant, Grant/Research Support)Merck (Grant/Research Support)scPharma (Consultant)Sedana (Consultant, Grant/Research Support)Spero (Grant/Research Support) Brian Nathanson, PhD, Lungpacer (Grant/Research Support)Merck (Grant/Research Support)Spero (Grant/Research Support) Kate Sulham, MPH, Spero Therapeutics (Consultant)
1421. Empiric Fluoroquinolone Prescribing Trends for Cystitis in Primary Care
Authors: Brueggen Kaitlin , Revolinski Sara , Hart Mickey , Wrzesinski Magdalena , Daniels Anne R
Published: December 2021

Background

Understanding outpatient antibiotic prescribing practices for urinary tract infections (UTIs) is vital in guiding future stewardship initiatives. Focusing on fluoroquinolones (FQs) is of value as FQs are commonly prescribed, but not recommended as first line therapy by the Infectious Diseases Society of America (IDSA) cystitis treatment guidelines and are also associated with multiple adverse effects. Boxed warnings state FQs should be reserved for patients with no alternative treatment options, due to risk of aortic dissection, C. difficile infection, antimicrobial resistance as well as tendon, joint, muscle, and nervous system damage.

Methods

This descriptive study assessed rates of guideline concordant empiric FQ prescribing from March 1 to June 30, 2019. Adult women prescribed an oral FQ for acute uncomplicated cystitis at a primary care clinic were included. Men, pregnant or breastfeeding women, and patients with pyelonephritis, urologic abnormality, or antibiotic use in the past 30 days were excluded. The primary outcome was the incidence of IDSA guideline concordance among FQs empirically prescribed. Guideline concordant empiric FQ therapy was defined as correct drug, dose, duration and frequency per IDSA guidelines when no first line drug is indicated due to allergy, adverse effect, previous treatment failure or most recent previous urine culture showing bacterial resistance. Secondary outcomes were mean dose (mg), mean duration (days) and incidence of adverse effects.

Results

Of 95 FQ prescriptions included, none met the primary outcome definition. Rates of guideline concordance for each component of the primary outcome definition were 6% for drug selection, 38% for dose, 37% for duration, and 99% for frequency. Mean daily doses exceeded guideline recommended doses by 62% and 100% for ciprofloxacin and levofloxacin, respectively. Mean duration was 5 days, 66% longer than 3 days as recommended by IDSA guidelines. Of 66 patients with documented follow up within 30 days, 3 (5%) experienced an adverse effect, and none developed C. difficile infection.

Conclusion

Current outpatient FQ prescribing for acute uncomplicated cystitis does not align with IDSA guidelines. Multifaceted antimicrobial stewardship initiatives are required to improve appropriate FQ use.

Disclosures

All Authors: No reported disclosures
1423. Overview of Paediatric Urinary Tract Infections in the Gulf Co-operation Council (GCC) Countries, A Literature Review
Authors: Albarrak May , Alhashami Hilal , Alzomor Omar A , Ghatasheh Ghassan , Habashy Nervana , Hassanien Ashraf , Kurdi Ayman
Published: December 2021

Background

Urinary tract infections (UTIs) are among the most frequent infections in the pediatric population, occasionally associated with concealed renal anomalies. Hence, early treatment is pertinent to reduce morbidities for better patient outcomes. The study aimed to review published literature from the gulf region in the last decade on UTIs etiology, common risk factors, current antimicrobial management, outcomes, and common resistance patterns.

Methods

This narrative literature review was conducted by evaluating articles published for a 10-years period from 2011 to 2021 using “Google Scholar” and “PubMed” databases. The search included regional clinical practice guidelines, systematic review and meta-analysis conducted across Gulf Cooperation Council countries (GCC). The search was limited to English literature and patients below 18 years old.

Results

The prevalence of UTIs among pediatrics in the age group of 0 to18 years ranged from 9.9% to 50.8% across the region. Data obtained from 11,092 children revealed that Escherichia coli was the primary cause of UTI (26% to 93.5%), followed by Klebsiella pneumoniae (3.8% to 76.4%). Furthermore, Extended-spectrum beta-lactamases (ESBLs) producing pathogens were observed in 7% to 35.2%. Higher ESBL rates were observed in patients with recurrent UTIs. Ampicillin and Co-trimoxazole, and 3rd generation cephalosporins were mainly prescribed as first-line antibiotics. Increased resistance to Ampicillin, Co-trimoxazole, and 3rd generation cephalosporins while low resistance to Nitrofurantoin, Amikacin, and Meropenem was documented. Vesicoureteral reflux was the most common risk factor for UTIs. Renal abnormalities were also observed to provide a nidus for bacterial growth. There is an evident lack of data in the region on antimicrobial treatment duration, possible predictors of treatment failure, and epidemiological data on multidrug resistance.

Conclusion

Urinary tract infections (UTIs) in pediatrics are a common therapeutic challenge in the region. Larger scale multicenter national and regional epidemiology studies are a prerequisite in the region. There is a need to monitor antimicrobial resistance in pediatrics & enhance surveillance for the advancement of management.

Disclosures

Nervana Habashy, B. Pharm, Pfizer (Employee) Ashraf Hassanien, MD, Pfizer (Employee) Ayman Kurdi, MD, Pfizer (Employee)
1425. Revisiting β-Lactams for Treatment of Uncomplicated Urinary Tract Infections: Evaluation of Twice-daily Cephalexin for Empiric Treatment of UTIs
Authors: Benning Molly , Acosta Dominic , Sarangarm Preeyaporn , Walraven Carla
Published: December 2021

Background

Current IDSA guidelines for the treatment of UTIs discourage oral β-lactams based on lack of adequately powered studies to assess efficacy compared to fluoroquinolones or TMP-SMX. However, increasing E. coli and Klebsiella spp. resistance to first-line antibiotics has necessitated the need for alternative agents.

Methods

This was a single-center retrospective chart review of adult patients discharged from the University of New Mexico ED with twice-daily cephalexin for the treatment of uncomplicated UTIs from January 1, 2019 to December 31, 2019. Patients were excluded if < 18 years of age, received ≥ 10 days of cephalexin, received antibiotics for other indications, received antibiotics within 60 days prior to ED visit, or had structural abnormalities. The primary outcome of this study was the proportion of patients with clinical success 30 days after discharge from the ED. Patients not meeting criteria for clinical failure were classified as clinical success. Clinical failure was defined as return of patient within 30 days due to non-resolving or worsening UTI symptoms or change in antibiotic therapy after discharge based on urine culture and susceptibilities.

Results

A total of 264 patients were included for evaluation. The average age was 56.0 ± 20.2 years and 82.6% were female. Patients received an average 5.6 ± 0.9 days of antibiotic therapy including IV therapy. Of the 264 patients included for evaluation, 81.1% met criteria for clinical success. Of the patients with clinical failure, 29 (13.6%) required a change in antibiotics based on cultures and sensitivities, 17 (6.4%) returned for non-resolving or worsening symptoms, and 4 (1.5%) required both a change in antibiotics and returned for non-resolving or worsening symptoms.

Conclusion

Short courses of twice-daily cephalexin appear to be safe and effective for empiric treatment of uncomplicated UTIs. Adding β -lactams back to the antibiotic armamentarium for UTI treatment may delay the development of resistance to non- β -lactam antibiotics, ensuring their future utility.

Disclosures

All Authors: No reported disclosures
1427. Healthcare Resource Utilization During Hospitalizations with UTI in the US, 2018
Authors: Zilberberg Marya , Nathanson Brian , Sulham Kate
Published: December 2021

Background

Urinary tract infection (UTI) as the reason for hospitalization costs the US healthcare system nearly &3 billion annually, and is on the rise. We set out to explore the full burden of UTI hospitalizations in the US, including admissions both for UTI and with UTI.

Methods

We conducted a cross-sectional multicenter study within the National Inpatient Sample (NIS) database, a 20% stratified sample of discharges from US hospitals, from 2018, to explore hospital resource utilization of patients discharged with a UTI diagnosis. We divided UTI into mutually exclusive categories of complicated (cUTI), uncomplicated (uUTI), and catheter-associated (CAUTI), in addition to healthcare-associated (HAUTI). We calculated unadjusted hospital charges, costs, average reimbursements, and length of stay (LOS) associated with these infections.

Results

Among 2,837,385 discharges with a UTI code, 77.9% were uUTI, 17.6% cUTI (80.2% HAUTI), and 4.4% CAUTI; UTI was principal diagnosis in only 17.0%. Median [interquartile range, IQR] LOS ranged from 4 [3-8] days in uUTI and cUTI to 5 [3-9] days in CAUTI. Overall median [IQR] hospital charges and costs were lowest in uUTI (&36,335 [&19,920-&70,745] and &8,898 [&5,408-&16,092], respectively) and highest in cUTI (&39,690 [&21,997-&75,739] and &9,713 [&5,923-&17,423], respectively), with the HAUTI subgroup being most costly (&44,650 [&24,642-&85,628] and &10,945 [&6,573-&19,634], respectively). “Septicemia or Severe Sepsis without MV >96 Hours with MCC” was the most common DRG in uUTI (13.2%) and cUTI (14.2%), with the corresponding median [IQR] reimbursements of &11,057 [&7,028-&17,757] and &12,226 [&7,889-&19,216], respectively. In contrast, CAUTI was most commonly (44.7%) reimbursed under “Kidney and Urinary Tract Infections without MCC” at &8,635 [&5,693-&13,718].

Conclusion

The nearly 3 million hospital admissions with a UTI represent 8% of all annual admissions in the US. Though the majority are considered uncomplicated, all categories are nearly equally costly. Given that over 80% of all UTI-associated admissions are with UTI as a secondary diagnosis, annual estimates of primary UTI costs likely significantly underrepresent the true economic burden of UTI on the US healthcare system.

Disclosures

Marya Zilberberg, MD, MPH, Cleveland Clinic (Consultant)J&J (Shareholder)Lungpacer (Consultant, Grant/Research Support)Merck (Grant/Research Support)scPharma (Consultant)Sedana (Consultant, Grant/Research Support)Spero (Grant/Research Support) Brian Nathanson, PhD, Lungpacer (Grant/Research Support)Merck (Grant/Research Support)Spero (Grant/Research Support) Kate Sulham, MPH, Spero Therapeutics (Consultant)
1428. Increased Consumption of Pivmecillinam in Primary Care for Uncomplicated Urinary Tract Infection (uUTI) Is Not Associated With Increased Resistance Rates
Authors: Larsen Anders Rhod , Henriksen Anne Santerre , Frimodt-Møller Niels
Published: December 2021

Background

The evolution of antibiotic resistance in Escherichia coli (E. coli) hampers the treatment of UTIs, mirroring the global public health concerns around antimicrobial resistance. Pivmecillinam, an oral prodrug of mecillinam (a β-lactam antibiotic), is used as first-line treatment for uUTIs in Denmark. Here, we examine the use of, and the prevalence of resistance to, mecillinam in Denmark in the primary care setting.

Methods

Nationwide data on the use of and resistance to pivmecillinam (reported as its active form, mecillinam) was extracted and examined from the Danish Integrated Antimicrobial Resistance Monitoring and Research Programme (DANMAP) 2019 report (www.danmap.org). Prevalence estimates of resistance reported by DANMAP 2019 were obtained from the Danish Microbiology Database (MiBA).

Results

In 2019, pivmecillinam accounted for about 27% of penicillins and 75% of penicillins with extended spectrum consumed in primary healthcare in Denmark. Pivmecillinam usage has increased primarily due to changes in recommendations for the treatment of uUTIs. Between 2010 and 2019, pivmecillinam usage in Denmark increased by 45% from 1.67 to 2.43, defined as daily doses per 1,000 inhabitants per day. In 2019, analysis of 83,850 urinary isolates from patients in the primary care setting with E. coli revealed a 5.3% resistance rate to mecillinam. Time-trend analysis using data from a 10-year period showed a small but significant decrease from the 5.5% resistance rate recorded in 2010 (p=0.001). In general, in spite of increasing use in Denmark, the development of resistance to pivmecillinam has remained low. In fact, a slight decline in pivmecillinam resistance was observed over the past decade.

Conclusion

Despite the rising number of UTIs and the increasing use of pivmecillinam for uUTI in Denmark, over the past decade, the development of resistance to pivmecillinam remains low.

Disclosures

Anne Santerre Henriksen, MS, Advanz (Consultant)Shionogi BV (Consultant)UTILITY Therapeutics (Consultant)
1431. Evaluating Physician Decision Making in Inpatient Antibiotic Prescription for Suspected Urinary Tract Infection
Authors: Arar Celine , Reyna Valerie , Glesby Marshall J , Choi Justin J
Published: December 2021

Background

Physicians are constantly asked to evaluate inpatients for possible antibiotic treatment. As part of antibiotic stewardship it is imperative to understand the decision-making process behind a physician’s choice to prescribe antibiotics appropriately in an inpatient setting. Fuzzy Trace Theory (FTT) suggests that physicians use one of two methods in medical decision making; verbatim, employing a comprehensive risk benefit analysis, and gist, considering a bottom line analysis.

Methods

Seventy-six hospitalists at Weill Cornell Medicine in Manhattan, New York received a survey with two reminders to evaluate their decision-making process. Five basic demographic questions regarding participant gender, race, background, age, and years in practice were asked. A clinical vignette describing an inpatient with a possible urinary tract infection (UTI) was followed with statements framing hypothetical antibiotic prescription. A seven point Likert scale with response choices from Strongly Disagree scored as one to Strongly Agree scored as seven was used to assess degree of participant agreement with each statement. Questions were presented in a random order to eliminate possible effects of questions clusters or question order.

Results

Twenty-six hospitalists completed the survey. Consistent with previous literature, the hospitalists surveyed displayed a gist interpretation of the risks and benefits of antibiotics, with a mean Likert scale score of 5.54 agreeing that there are benefits to antibiotic prescription, and a mean Likert scale score of 6.04, agreeing that there are risks to antibiotic prescription. . However, the clinicians surveyed ultimately found antibiotics to be a necessary risk given the possible benefit of improving patient health. The hospitalists surveyed also did not view antibiotic prescription to be a product of pressure from patient families, agreeing by a mean Likert scale score of 5.08 that the patient’s family will trust their physician to prescribe antibiotics if needed.

Conclusion

These findings suggest that physician education to reduce overprescribing of antibiotics should underscore possible antibiotic risk, despite potential benefit.

Disclosures

Marshall J. Glesby, MD, Enzychem (Consultant)Gilead (Grant/Research Support)ReAlta Life Sciences (Consultant)Regeneron (Consultant, Grant/Research Support)Sobi (Consultant)Springer (Other Financial or Material Support, Royalties)UpToDate (Other Financial or Material Support, Royalties) Justin J. Choi, MD, Allergan (Consultant, Grant/Research Support)Roche (Consultant, Grant/Research Support)
1432. Patient-Reported Urinary Tract Infection Symptoms Among Veterans with Neurogenic Bladder
Authors: Fitzpatrick Margaret A , Wirth Marissa , Suda Katie J , Burns Stephen , Weaver Frances , Collins Eileen , Safdar Nasia , Kartje Rebecca , Evans Charlesnika T
Published: December 2021

Background

Urinary tract infections (UTIs) and asymptomatic bacteria (AB) are common in patients with neurogenic bladder (NB) but differentiating between the two is challenging because laboratory tests cannot distinguish AB from UTI. This diagnostic uncertainty can lead to antibiotic overuse. Characterization of patient-reported symptoms from large cohorts of patients with NB can inform interventions to improve appropriate UTI diagnosis and management.

Methods

Retrospective cohort study of 1,797 adults with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis (MS), and/or Parkinson’s Disease (PD) accounted for 568 patients with UTI encounters (via ICD10) at 4 Veterans Affairs (VA) medical centers between 2017-2018. Demographic and clinical data were collected from national VA datasets. Medical record review was performed on a random sample of 198 encounters. Chi-square/Fisher’s exact test were used to compare symptoms by patient and encounter characteristics.

Results

Among the 198 encounters (mean age=65 years), 33% of patients had SCI/D, 29% PD, 20% MS, and 17% had more than one diagnosis. Most encounters were for men (88%) in inpatient or long-term care settings (62%). 76% of patients used bladder catheters; most indwelling (n=92). Fever was the most frequent symptom (30%), followed by change in urine odor, color, and/or consistency (26%) and lethargy/malaise (21%). Only 38% of encounters had a urinary tract-specific symptom recorded (e.g., dysuria); 81% had non-specific symptoms (e.g., fever, lethargy). 64% of encounters were deemed an appropriate UTI diagnosis. Characteristics in red in Figure 1 were significantly associated with non-specific symptoms (p< 0.05).

Patient and encounter characteristics found to be significantly associated with non-specific symptoms, p < 0.05.

Conclusion

Symptoms not specific to the urinary tract are the most frequently reported symptoms in patients with NB and encounters with a UTI diagnosis. Change in urine odor/color were reported often; however, guidelines recommend against using these for UTI diagnosis. Providers should ensure that alternate sources of non-specific symptoms are evaluated prior to attributing them to UTI. Antibiotic stewardship interventions targeted to physical medicine and rehabilitation (PM&R) and primary care providers in inpatient settings may improve UTI diagnosis in patients with NB.

Disclosures

Charlesnika T. Evans, PhD, MPH, BioK+ (Consultant)