bluuebunny/crossref_metadata_2025 huggingface dataset:
2182. Expression of the MadR regulon in Enterococcus faecalis OG117 is influenced by the presence of the LiaS Histidine Kinase of the LiaFSR pathway
Authors: Rizvi Samie A , Gomez Villegas Sara I , Panesso Diana , Arias Cesar A , Miller William R
Published: November 2023

Background

The MadRS pathway is a two-component signaling (TCS) system which mediates resistance to antimicrobial peptides (AP) and AP-like antibiotics in E. faecalis (Fig. 1). The system is composed of a transmembrane histindine-kinase, MadS, which is responsible for the phosphorylation of the transcriptional response regulator, MadR. This leads to increased expression of the madR regulon, containing madG, madL, and dltA, which provide resistance against APs and AP-like antibiotics. Interestingly, deletion of madS does not result in loss of expression of madG, suggesting an alternative mechanism of phosphorylation of MadR independent of MadS. We hypothesize that LiaS, of the LiaFSR pathway, may phosphorylate MadR in the presence of APs and AP-like antibiotics.Figure 1.MadRS initiates a regulatory response to defend against antimicrobial peptides.

In the presences of APs, the MadS Histidine Kinase phosphorylates the MadR response regulator, leading to transcription of downstream genes madAB, madEFG, madLM and the dlt operon.

Methods

Wild type (WT) E. faecalis OG117, OG117FΔmadS, and OG117ΔliaSΔmadS were grown to mid-exponential phase in tryptic soy broth. Each strain was grown either with or without ½ of the minimum inhibitory concentration (MIC) of bacitracin (BAC), an inducer of the MadRS system. RNA was isolated, and expression of madG was evaluated by qRT-PCR relative to the control strain, OG117, without bacitracin exposure. Values were normalized to the gyrB “housekeeping” gene. Fold-change was calculated using the Pfaffl method. Differences in gene expression were determined using two-way ANOVA with Tukey’s test for multiple comparisons.

Results

Both the control strain, OG117, and the OG117ΔmadS mutant exhibited a BAC MIC of 32 mg/L. The BAC MIC for OG117ΔliaSΔmadS decreased to 2 mg/L. In the presence of BAC exposure, OG117ΔmadS had a statistically significant increase in madG expression (p< 0.001) as compared to OG117ΔmadS without BAC exposure (Fig. 2). In contrast, OG117ΔliaSΔmadS displayed no significant change in madG expression when exposed to bacitracin (Fig 2).Figure 2.Gene expression of madG in OG117, madS, and liaSmadS knockout strains.

Conclusion

In the absence of a functional MadS histidine-kinase there is still transcriptional upregulation of madG. This effect is reversed with the deletion of both LiaS and MadS. This suggests that the LiaS histidine-kinase may lead to MadR dependent activation of the MadRS pathway in E. faecalis OG117.

Disclosures

William R. Miller, M.D., Merck: Grant/Research Support|UpToDate: Honoraria
2194. Implementation of the CDC’s Core Elements of Antibiotic Stewardship: A Survey of Long-Term Care Facilities During the COVID-19 Pandemic
Authors: Cichon Catherine (Cathy) , Preusker Jenna , Soma Mounica , Schroeder Danny , Van Schooneveld Trevor C , Bergman Scott J , Ashraf Muhammad Salman
Published: November 2023

Background

Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) is funded by the Nebraska DHHS to assist healthcare facilities with improving their antimicrobial stewardship programs (ASP). ASAP conducted a survey during the COVID-19 pandemic to learn about implementation of the CDC core elements (CE) of antibiotic stewardship in long-term care facilities (LTCF).

Methods

An online self-assessment survey of CE was created and hosted on the ASAP website. A link to the survey was shared with LTCF through ASAP’s email distribution lists, webinars, and other meetings. Data were summarized using descriptive statistics.

Results

54 of 196 licensed LTCF in Nebraska responded to the survey between 05/2021 to 12/2022. Of these, 26 (48%) had all 7 CE with reporting and education being the least likely CE to be met (Tables 1 and 2). Half (50%) of LTCF did not have a signed leadership statement of support for ASP. ASP leadership responsibility was often shared across multiple positions (physicians, directors or assistant directors of nursing [DON/ADON], pharmacists, and infection preventionists), but DON/ADON were most commonly accountable (69%). Consultant pharmacists were the most commonly identified ASP experts (74%) available to LTCF. Only 57% of LTCF reported successfully implementing at least one infection-specific intervention to improve antibiotic use (AU); addressing UTIs was the most commonly identified intervention (31%). Almost a quarter (22%) of LTCF did not monitor rates of C. difficile infection, and about a third (30%) did not track antibiotic-resistant (AR) organisms. While 78% of LTCF provided educational resources to their nursing staff on AR and opportunities to improve AU, only 48% provided these resources to their clinical providers. Out of 26 LTCF reporting areas of antibiotic misuse at their facility, 88% agreed that ASP could help address the issue. For 24 LTCF that reported barriers to starting or improving ASP, prescriber resistance and lack of time were the most commonly identified barriers (28% and 13%).

Conclusion

Implementation of the CE remains low in LTCF and was likely further impacted by the COVID-19 pandemic. The findings highlight the challenges to implementing ASP in LTCF along with opportunities for improvement.

Disclosures

Trevor C. Van Schooneveld, MD, FSHEA, FACP, AN2 Therapeutics: Grant/Research Support|Biomeriuex: Advisor/Consultant|Biomeriuex: Grant/Research Support|Insmed: Grant/Research Support|Thermo-Fischer: Honoraria Scott J. Bergman, PharmD, bioMerieux, Inc.: Honoraria Muhammad Salman Ashraf, MBBS, Merck & Co. Inc: Board Member|Merck & Co. Inc: Grant/Research Support
2204. Excess Antibiotic Therapy for 5 Common Conditions in Primary Care: Low-Hanging Fruit for Outpatient Antibiotic Stewardship
Authors: Patel Payal K , Buckel Whitney , Fletcher Rachel , Gangwer Nick , Hansen Jeni , Stanfield Valoree K , Hersh Adam , Stenehjem Eddie , Seibert Allan M
Published: November 2023

Background

Improving duration can be a key intervention in outpatient antibiotic stewardship as most conditions require only 5 days of therapy or less. Cellulitis, acute otitis media (AOM), sinusitis, community-acquired pneumonia (CAP), and uncomplicated urinary tract infections (UTI) encounters account for the majority of outpatient antibiotic prescriptions and have been associated with durations longer than necessary. We characterized the duration of antibiotic prescriptions associated with these conditions in our primary care (PC) network.

Methods

We retrospectively evaluated prescribing practices for cellulitis, AOM, sinusitis, CAP, and UTI encounters among patients ≥ 3 years-old from January 1st, 2022 – December 31st, 2022 in the Intermountain Health (IH) PC network. IH is an integrated healthcare system operating 119 PC clinics (69 family medicine, 22 internal medicine, 23 pediatric). System-specific evidence-based ambulatory guidelines for the conditions of interest during the study recommended 5-7 days of therapy. Encounters, patient characteristics, and prescription information were electronically extracted from the electronic health record. We analyzed duration of therapy by categories (≤5 days, 6-9 days, 10-14 days, or 14+ days) for each condition in pediatric (≥ 3-18 years-old) and adult (≥ 19 years-old) patients.

Results

There were 14,918 and 38,790 encounters for the studied conditions among pediatric and adult patients, respectively. The mean age of pediatric patients was 9.0 years and among adults, 56.8. Pediatric and adult patients were predominantly White, non-Hispanic, female, and preferred speaking English (Table 1). Overall, only 10.4% (8,965) of all prescriptions were ≤ 5 days and consistent with the recommended duration. Duration of prescriptions associated with each condition are presented in Figure 1. UTI exhibited the highest percentage of ≤ 5 day prescriptions (22.1% pediatrics, 29.1% adults) while sinusitis had the lowest (0.9% pediatrics, 2.6% adults).Table 1.Total encounters for all studied conditions and patient characteristicsFigure 1.Duration of antibiotic prescriptions associated with cellulitis, acute otitis media (AOM), sinusitis, community-acquired pneumonia (CAP), and uncomplicated urinary tract infection (UTI) encounters for patients 3-18 years-old (pediatric) and ≥19 years-old (adult) in the Intermountain Health primary care network.

Conclusion

Duration of therapy for cellulitis, AOM, sinusitis, CAP, and UTIs is almost always longer than the recommended 5 days of therapy in our PC network. There is substantial opportunity to improve duration for these conditions.

Disclosures

Payal K. Patel, MD MPH, qiagen: Honoraria
2205. Utilization of guiding comments imbedded within culture results to improve antimicrobial prescribing for enterococcal urinary tract infections in the ambulatory setting
Authors: Pepper Julia , Rosenberger Aundrea , Tirupathi Raghavendra , Logsdon Jarett
Published: November 2023

Background

Evaluate outcomes associated with utilizing guiding comments imbedded within the electronic health record’s (EHR) culture result to decrease the inappropriate use of cephalosporins in enterococcal urinary tract infections.

Methods

Data collected retrospectively from a regional health system from 02/01/22 to 02/28/23. Inclusion criteria was urine culture positive for enterococcus and active cephalosporin order. Exclusion criteria was cephalosporin treatment prescribed for a non-enterococcal organism and age less than 18 years. Patients were evaluated 6 months pre- and post-implementation of a microbiology comment added to streptococcus gamma and enterococcal cultures: “Enterococcus sp. are resistant to cephalosporins.” The primary outcome was rate of inappropriate prescribing of cephalosporins in enterococcal urinary tract infections in the ambulatory care setting. The secondary outcome was rate of 30-day follow-up visits required pre- and post-implementation of guiding comment. Follow-up was defined as either ambulatory visit, telephone visit, emergency department admission, or inpatient admission. Chi-Squared statistical test was utilized to compare nominal data.

Results

93 patients were not included based on inclusion and exclusion criteria. 141 patients in the pre group and 146 patients in the post group were analyzed. After guiding comment implementation, the incidence of inappropriate treatment continuation decreased from 67.4% to 43.8% (RRR=35%, p=0.001). Follow up events included patient encounters related to urinary symptoms such as emergency department admissions, inpatient admission, ambulatory visits, and telephone encounters. Total patients requiring follow-up decreased from 44.7% (63/141) to 26.0% (38/146); 41.8% relative risk reduction (p = 0.001).

Conclusion

Providers assume enterococcus sensitivity to ampicillin equates to sensitivity to all beta-lactams. The implementation of guiding comments results significantly reduced the inappropriate use of cephalosporins to treat enterococcal urinary tract infections. Total follow-up visits were also significantly reduced which has the potential to improve patient experience. Enterococcal guiding comments should be implemented at heath care facilities when possible.

Disclosures

All Authors: No reported disclosures
2224. A Novel Pediatric Antimicrobial Stewardship Program Intervention Leads to Decreased Use of Piperacillin-tazobactam in the Neonatal Intensive Care Unit at an Academic Institution
Authors: Pichilingue-Reto Patricia , Trimble Kelsey , Johnston Marissa , Dominguez-Garcia Maria G , Hill Katherine C
Published: November 2023

Background

Antimicrobial stewardship programs (ASP) were created to improve antimicrobial use without compromising patient outcomes. Nationwide, Pediatric ASPs have shown a very rapid growth during the past decade. Inpatient stewardship can present some challenges, particularly with special patient populations like newborns and premature infants.

Methods

A new Pediatric Antimicrobial Stewardship committee was established in April 2022 at Ochsner LSU Health Shreveport- St. Mary’s Hospital. The first process measurement was a medication usage evaluation (MUE) report of piperacillin-tazobactam from January 31st, 2020, to September 7th, 2021, in the Neonatal Intensive Care Unit (NICU) for early and late onset sepsis. Neonatologists received education about the recommended antibiotics for these indications. The stewardship committee obtained a report one year later to evaluate the impact of the intervention. Slicer dicer, a data extraction tool from EPIC Electronic Health Record (EHR) system was used to determine how many NICU patients received piperacillin-tazobactam.

Results

From January 31st, 2020, to September 7th, 2021, the charts of 64 neonatal patients, who were prescribed piperacillin-tazobactam, were reviewed. Out of these 64 patients, 46 (72%) were 4-28 days old when the antibiotic was received, 33 (72%) received piperacillin-tazobactam and vancomycin and 13 received additional antibiotics. Indications for the 46 patients included: Possible sepsis (15%), confirmed sepsis (6.5%), possible necrotizing enterocolitis (NEC) (2.2%) and confirmed NEC (10.9%). The report demonstrated a possible overuse of piperacillin-tazobactam for early and late onset sepsis, without the diagnosis of NEC. We reported this antibiotic’s usage in NICU patients during the years 2020, 2021 and 2022 (Figure 1).Figure 1:Piperacillin-tazobactam usage in newborns and infants admitted to the Neonatal intensive care unit (NICU).

Piperacillin-tazobactam was administered to a total of 27 patients admitted to the NICU in 2020, 46 patients in 2021, and only 15 patients in 2022. The medication usage evaluation (MUE) was presented by the Pediatric Antimicrobial Stewardship committee in April 2022.

Conclusion

Neonates and premature infants can represent a challenging patient population for Pediatric ASPs’ interventions. Before the introduction of this committee, there was no tracking of the use of broad-spectrum antibiotics in patients admitted to the NICU. We reported a possible overuse of piperacillin tazobactam for early and late onset sepsis, as well as NEC. Our interventions caused a dramatic reduction in the administration of this broad-spectrum antibiotic in the NICU.

Disclosures

All Authors: No reported disclosures
2946. Comparative Pharmacokinetics and Pharmacodynamics of Cefadroxil and Cephalexin for Pediatric Musculoskeletal Infections
Authors: Haynes Andrew , Wei Zixuan , Anderson Peter , Scheetz Marc H , Parker Sarah K , N Douglas
Published: November 2023

Background

Methicillin-susceptible Staphylococcus aureus (MSSA) is one of the leading causes of pediatric musculoskeletal (MSK) infections, such as osteomyelitis and septic arthritis. MSSA MSK infections are treated initially with an IV antibiotic, followed by prolonged oral therapy. Cephalexin is the most used oral option due to long-standing clinical experience and its well-described pharmacokinetics (PK) in children. Cefadroxil could be an attractive alternative requiring less frequent dosing, but it has minimal pediatric clinical or PK data. In this study, we describe the comparative PK of cephalexin and cefadroxil in children with MSK infections and evaluate dosing regimens to achieve effective free time above the MIC (fT >MIC) for MSSA.

Methods

Children aged 6 months to 18 years admitted with an MSK infection were enrolled in a prospective, open-label, crossover study and given single oral doses of cefadroxil (50-75 mg/kg up to 2,000 mg) and cephalexin (50 mg/kg up to 1,375 mg). During a single dosing interval, 4-5 plasma samples were obtained per patient for each drug. Antibiotic concentrations were quantified using liquid chromatography-mass spectrometry. PK models were developed, and then Monte Carlo simulations were performed using various dosing regimens to estimate the probability of target attainment (PTA) for a range of pharmacodynamic (PD) targets, across various pediatric ages and common MSSA MICs (1-4 mg/L).

Results

Concentration-time data for cephalexin (n=15) and cefadroxil (n=14) were best described using a one-compartment model with first order absorption. PK parameters were notable for cefadroxil’s longer half-life than cephalexin. Monte Carlo simulation showed that cephalexin 120 mg/kg/day divided q8hrs (max 1,000 mg per dose) and cefadroxil 100 mg/kg/day divided q12hrs (max 1,500 mg) achieved >95% PTA for fT >MIC >40% for MICs up to 4 mg/L, though cephalexin QID and cefadroxil TID dosing were required to achieve higher PD goals.

Conclusion

Among pediatric patients with MSK infections, oral cefadroxil and cephalexin both achieve PD targets for efficacy against MSSA. Twice-daily cefadroxil should be further considered as an alternative to cephalexin for oral step-down therapy given its similar PTA and possibility for less frequent dosing.

Disclosures

Marc H. Scheetz, PharmD, MSc, Abbvie: Advisor/Consultant|ASHP: Honoraria|Chambless, Higdon, Richardson, Katz & Griggs, LLP: Expert Testimony|Cidara: Advisor/Consultant|Entasis: Advisor/Consultant|F2G: Advisor/Consultant|GSK: Advisor/Consultant|Guidepoint Global: Honoraria|Hall, Booth, Smith, P.C.: Expert Testimony|Merck: Advisor/Consultant|Reminger Co., L.P.A: Expert Testimony|Spero: Advisor/Consultant|Takeda: Advisor/Consultant|Taylor, English, Duma, LLP: Expert Testimony|Third Pole Therapeutics: Advisor/Consultant Sarah K. Parker, MD, Pfizer: Grant/Research Support
2229. Impact of Elexacaftor/tezacaftor/ivacaftor on Utilization of Antibiotics at a Single Pediatric Cystic Fibrosis Center
Authors: Elson Elizabeth C , Lee Brian R , Burns Alaina N , Herigon Joshua C , Wirtz Ann , Duehlmeyer Stephanie
Published: November 2023

Background

Intravenous (IV) and oral (PO) antibiotics (ABX) are standard treatments for pulmonary exacerbations (PEx) in people with cystic fibrosis (pwCF). Frequent ABX use may lead to adverse events and ABX resistance. Cystic fibrosis transmembrane conductance regulator modulator treatments have significantly reduced PEx in qualifying pwCF, but impact on ABX use is unknown. The approval of elexacaftor/tezacaftor/ivacaftor (ETI) in 2019 makes these treatments accessible to the majority of pwCF. The primary objective was to examine utilization of ABX pre-and post-ETI in pwCF managed at Children’s Mercy Kansas City’s (CMKC) CF center.

Methods

A retrospective analysis of PO and IV ABX for CF PEx was performed at CMKC. The pre-ETI treatment period was defined as 1/1/2017-12/31/2019 and post-ETI treatment period as 1/1/2020-12/31/2022. A paired analysis including pwCF managed by CMKC during both periods was used to compare ABX courses pre- and post-ETI.

Results

A total of 293 pwCF and 110 pwCF received PO and IV ABX during the study period, respectively. Of these, 224 pwCF managed by CMKC during both periods were included. IV ABX were received by 25 pwCF in both periods whereas 138 pwCF did not receive IV ABX in either period. There were 43 pwCF who received IV ABX only in the pre-ETI period compared to 18 pwCF who received IV ABX only in the post-ETI period (p=0.0021) resulting in a discordance of 27.2%. PO ABX were prescribed for 119 pwCF in both periods whereas 35 pwCF did not have PO ABX prescribed in either period. There were 52 pwCF who received PO ABXs in the pre-ETI period only compared to 18 pwCF who received PO ABX in the post-ETI period only (p=0.0001) resulting in a discordance of 31.3%. The number of patients receiving ABX directed against Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus significantly decreased between periods. The median duration of ABX did not significantly change for IV (9.2 days vs. 8.9 days, p=0.958) or PO (14 days vs. 14 days, p=0.384) ABX during both periods.

Conclusion

CMKC pwCF experienced a dramatic decline in prescribing both PO and IV ABX following approval of ETI. Future investigations are necessary to determine this trend nationwide and ascertain the overall impact from decreased ABX exposure in pwCF.

Disclosures

All Authors: No reported disclosures
2234. Ambulatory Prescribing Trends of Azithromycin and Systemic Glucocorticoids in Patients Diagnosed with COVID-19: A Large Healthcare Network Analysis in Massachusetts
Authors: Anwar Shamsuddin , Campion Maureen , Foong Kap Sum , Doron Shira , Vazquez Gabriela Andujar
Published: November 2023

Background

Data do not support the use of azithromycin (AZ) and systemic glucocorticoids (GCS) for nonhospitalized adult patients with COVID-19. However, these two medications remain commonly prescribed in the ambulatory setting. We aimed to evaluate prescribing trends of AZ and GCS in patients diagnosed with COVID 19 at ambulatory clinics from a large Boston area healthcare network.

Methods

We performed a retrospective cohort study of all ambulatory clinics (i.e., primary care and specialty) affiliated with Tufts Medicine healthcare network from April 2020 through May 2022. These clinics were categorized into academic medical center-based (AMCB) clinic or community-based (CB) practices. We queried the system informatics database to identify all outpatient COVID-19 encounters using ICD-10-CM diagnosis code (U07.1). Demographics, treatment, and prescriber data were extracted. We performed χ2 to compare categorical variables.

Results

A total of 44,369 outpatient COVID-19 encounters were identified; 40.7% occurred in AMCB clinics and 59.3% in CB clinics. Within these encounters, 1,798 (4.1%) and 3,561 (8.0%) had prescriptions for AZ and GCS, respectively. Prescriptions varied by month, with a higher rate of prescriptions during SARS COV 2 variant surges (i.e., Winter period 2020-2021, Delta, Omicron)(Figure 1). The rates of AZ (3.6% vs 4.4%, p< .001) was significantly higher in CB clinics compared to AMCB while rates of GCS (9.5% vs. 7.0%, p< .001) prescriptions were significantly higher in AMCB.

Prescription Trends For Azithromycin And Systemic Glucocorticoids From May 2020 to April 2022

Conclusion

Despite national guidelines recommending against the use of AZ and GCS for nonhospitalized adult patients with COVID-19, we observed their use, and noted higher rates of prescription during SARS COV-2 variant surges. While the overall prescription rates for AZ and GCS were similar to national trends, we found use to be significantly varied in CB and AMCB clinics. Our study highlights opportunities for targeted intervention to reduce inappropriate prescribing practices for patients diagnosed with COVID-19 in the ambulatory setting.

Disclosures

Maureen Campion, PharmD, BCIDP, Shinoigi: Speaker
2947. Improving Access to Allergy Specialty Care in Houston through a Collaborative Penicillin Allergy Stewardship Program
Authors: Taylor Margaret G , Anvari Sara
Published: November 2023

Background

Approximately 5% of children carry a penicillin (PCN) allergy label, but less than 10% of reported reactions are IgE-mediated. Guidelines recommend formal evaluation of children with unconfirmed PCN allergy labels, but this evaluation occurs infrequently. We piloted a novel pediatric PCN allergy clinic in the infectious disease and allergy & immunology clinics, utilizing telemedicine services to provide prompt initial PCN allergy evaluation for children in the community with unconfirmed PCN allergy labels.

Methods

A collaborative PCN allergy clinic utilizing telemedicine services for initial evaluations, followed by in-person skin testing and/or oral challenge was implemented in a tertiary-care children’s hospital. Benchmark data of this piloted clinic was obtained via retrospective chart review of children evaluated between December 2021 and December 2022.

Results

Following the implementation of a collaborative PCN allergy clinic utilizing telemedicine for initial evaluations, referral rates for pediatric PCN allergy evaluations increased from an average of 15 per month to 53 per month. Of 459 referrals, 355 (77.3%) were successfully scheduled in one of the telemedicine clinics, and 348/355 (98%) completed their initial telemedicine evaluation. 89 children who completed their recommended in-person formal evaluation were de-labeled, and 23 failed their challenge and remain labeled as penicillin allergic.

Conclusion

Piloting a collaborative PCN allergy clinic within two ambulatory divisions of a tertiary care center and utilizing telemedicine services has resulted in a successful avenue to promptly evaluate and de-label children with PCN allergies. Future work will be needed to determine prescribing outcomes of children de-labeled in this PCN allergy clinic.

Disclosures

All Authors: No reported disclosures
2245. Appropriate use of antibiotics in patients with osteomyelitis due to decubitus ulcers
Authors: Dattadeen Jaraad , Aslam Sadaf
Published: November 2023

Background

Decubitus ulcers are a costly and challenging problem in the healthcare system, with an estimated 2.5 million pressure ulcers treated annually in the United States at a cost of $11 billion. Patients with decubitus ulcers may present with evidence of infection or sepsis, but the source is rarely the ulcer itself. Recent guidelines recommend evaluating patients for curative management before pursuing further testing or empiric antimicrobial treatment. This study aimed to assess the appropriateness of antibiotic usage in patients admitted to the hospital with decubitus ulcers, and to determine the rate of appropriate antibiotic use.

Methods

This study involved a retrospective review of 1678 patients records with decubitus ulcers to assess the appropriate use of antibiotics during their inpatient stay. Appropriateness was determined by one of three criteria. The 1st criteria included patients who met systemic inflammatory response syndrome with suspected infection from osteomyelitis; 2nd criteria included patients who received antibiotics due to another infection (pneumonia, urinary tract infection or bacteremia) and 3rd criteria included use of antibiotics as a bridge therapy to surgical intervention (flap closure or Incision and Drainage). The rate of consultation for infectious disease and plastic surgery was also investigated.

Results

Of the total 1678 patients, the median age was 70 yrs (IQR=21), of that 51 % were males. Based on the criteria for appropriateness, there were a significant difference in gender (p= 0.000) females were more likely to receive inappropriate antibiotics (Table 2). Similarly, the rate of inappropriate use of antibiotics was 15.9% with ID consults as compared with 84.1% who didn’t receive ID consult (p=0.000) as seen in table 1.

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Conclusion

This study contributes to a better understanding of appropriate antibiotic usage in patients with decubitus ulcers. The findings favor the importance of ID consults in the appropriate use of antibiotics. Additionally, there may be some underlying bias with prescribing antibiotics to females compared to males. Thus, the study provides clinicians with tools in order to make evidence-based decisions on the management of these patients, and for healthcare systems to optimize resource allocation

Disclosures

All Authors: No reported disclosures
2948. Pediatric Clinical Outcomes of MRSA PCR Utilization for Anti-MRSA De-escalation
Authors: Demirhan Salih , Escobar Lee Kiriam , Lee Philip J , Sy Sharlene , Anosike Brenda I
Published: November 2023

Background

Methicillin resistant Staphylococcus aureus (MRSA) remains a major infectious disease challenge often requiring empiric therapy. Rapid identification methods, such as MRSA polymerase chain reaction (MRSA PCR) have been increasingly utilized as a stewardship tool for antimicrobial de-escalation in adults. More recently, a growing, albeit small, number of pediatric studies have demonstrated similar promise. However, there remains a paucity of data evaluating clinical outcomes of using MRSA PCR as a stewardship tool in pediatrics.

Methods

Retrospective cohort study of nasal MRSA PCRs collected from hospitalized patients ≤ 21 years of age between November 1, 2021, and February 28, 2023. Indications for testing were categorized into 4 clinical syndromes defined a priori: pneumonia; skin and soft tissue infections (SSTI); head and neck infections (HNI); and bacteremia. Each MRSA PCR test was counted per single episode. Inclusion: all those who started on an anti-MRSA agent and discontinued ≤48 hours of a negative PCR. Primary endpoint: any adverse clinical outcome defined as restarting an anti-MRSA agent in 7 days (14 days for SSTI), readmission for same indication in 30 days, escalation of ventilatory support, new inotropic support and/or transfer to intensive care unit (ICU) -all in 7 days; and in-house mortality in 30 days.

Results

Total of 145 patients with 156 episodes met inclusion criteria; demographic and clinical characteristics are shown in Table 1. Pneumonia (39.1%) and SSTI (24.4%) were the most common indications for testing. 58.3%) were in the ICU at the time of testing; 48.7% received respiratory support. Vancomycin (57.0%) was the most used antibiotic. Clinical characteristics of episodes are shown in Table 2. Fifteen patients (9.6%) had any of the adverse outcomes (negative predictive value =90.4%, [95%CI: 84.6-94.5]); only 3 were restarted on an anti-MRSA agent (Table 3).

Conclusion

In this single center study of pediatric patients who had a negative MRSA PCR nasal swab, none grew MRSA from cultures. Though limited, early discontinuation of anti-MRSA antibiotics was not associated with high rates of any adverse outcome suggesting the role of MRSA PCRs as a useful clinical stewardship tool in children. Larger/prospective studies are still needed.

Disclosures

All Authors: No reported disclosures
2254. Asymptomatic Bacteriuria Underestimates True Inappropriate Prescribing for Non-Urinary Tract Infections
Authors: Hartlage Whitney , Chan Jeannie D , Bajenov Maria , Castillo Alyssa , Lynch John B , Martinez-Paz Natalia , Bryson-Cahn Chloe , Escobar Zahra
Published: November 2023

Background

Unnecessary treatment of asymptomatic bacteriuria (ASB) is an important target for antimicrobial stewardship efforts. However, patients with urine colony counts <105 colony-forming units (CFU)/mL or no growth are often excluded due to not meeting the definition of bacteriuria. We evaluated inappropriate treatment among patients without urinary tract infection (UTI) symptoms who underwent urine testing, regardless of the significance of growth in culture.

Methods

Patients who underwent urine testing during September 8, 2022 - March 11, 2023, were reviewed across ten critical access hospitals participating in the University of Washington Center for Stewardship in Medicine. Culture growth was categorized as no growth, ≤10,000 CFU/mL, 11,000-50,000 CFU/mL, 51,000-100,000 CFU/mL or >100,000 CFU/mL. Asymptomatic for UTI was defined as the absence of documented signs or symptoms of UTI, per the National Hospital Safety Network definition and Infectious Diseases Society of America Guidelines. We assessed the number of patients with a positive UA (leukocyte esterase, WBC >10, or nitrites) treated with antibiotics and the association of urine colony cutoffs on inappropriate antibiotic prescribing. Variables were compared using Mantel-Haenszel chi square test. A two-sided p-value of < 0.05 was considered statistically significant.

Results

The analysis included 616 patients- 249 were classified as asymptomatic for UTI (40%). Patients with asymptomatic pyuria (n=188) were more likely to receive treatment than those without pyuria (n=42) (79% vs 43%, p< 0.001). One hundred seventeen patients with urine colony counts < 105 CFU/mL lacked signs or symptoms of UTI. Among these 117 patients, 72 (62%) were treated with antibiotics. There was a significant trend that treatment in asymptomatic patients increases with colony count in urine culture (p< 0.001).

Conclusion

Treatment of ASB alone inadequately captures the total number of patients receiving unnecessary antibiotics for suspected UTI. A more comprehensive means of quantifying unnecessary UTI treatment may be capturing all patients who undergo urine cultures-including those with asymptomatic pyuria or asymptomatic nitrituria, even with low growth on culture.

Disclosures

All Authors: No reported disclosures
2949. Emergency Department (ED) Discharge Antibiotic Prescription Review by Hospital Pharmacists at a Large Academic Medical Center
Authors: Dubrovskaya Yanina , Merchan Cristian , Marsh Kassandra , Siegfried Justin , Major Vincent J , So Jonathan , Rodriguez James , Jhala Pradyuman , Iturrate Eduardo , Papadopoulos John , Mazo Dana , Smalley Samantha
Published: November 2023

Background

Direct patient discharge from the Emergency Department (ED) presents an ideal time to promote antimicrobial stewardship (AS). On March 1, 2021 we initiated a pilot program where ED pharmacists conduct a review of discharge antibiotic prescriptions (abx Rxs). The aim of this program is to ensure appropriate discharge abxs. Willow Pharmacy Epic Analysts, ED and AS pharmacists collaborated on this program which included Epic integration of Rx Discharge Track Board, ED Discharge InBasket, ED Discharge Rx iVent and AS-led education sessions.

Methods

Data for 2022 ED patients with discharge abx Rxs and iVents were extracted via Epic Reports. The first encounter per patient was included. We compared discharge abx Rxs and patient outcome data in Pharmacy vs No Pharmacy Review Groups (PRG, NPRG). Pharmacy iVents were used as a process measure.

Results

Among 5747 ED adult patients with discharge abx Rxs, 2638 (46%) were reviewed by pharmacy (PRG). PRG and NPRG had similar prevalence of chronic pulmonary disease (12% vs. 13%), diabetes mellitus (9% vs. 10%), malignancy (8% vs. 9%), peripheral vascular disease (6% vs. 8%), renal disease (4% vs. 5%), and HIV (1% vs. 2%) despite a difference in mean Charlson Comorbidity Index (0.64 vs 0.75, p< 0.01). The primary ED diagnosis was skin and soft tissue, urinary, intra-abdominal infections and pneumonia (25 vs 23%, 18 vs 17%, 8 vs 9%, 5 vs 6%, respectively all p=NS). In PRG, discharge abxs demonstrated an increase use of penicillin (26 vs 24%, p=0.017) and 2nd generation cephalosporin (17 vs 14%, p< 0.001). The PRG also decreased use of 3rd generation cephalosporin (11 vs 12%, p=NS), quinolones (6 vs 7%, p=NS) and clindamycin (1.7 vs 2.4%, p=NS). There was no difference in ED length of stay (LOS 4.8h in each group), C. difficile infection (CDI) within 8 weeks (0.1 vs 0.2%, p=NS), and 30 days repeat ED visit or inpatient admission with the same diagnosis as index ED encounter (2.8 vs 2.6%, p=NS). Pharmacists intervened in 10% (272/2638) of ED abx Rxs with 92% (249/272) acceptance rate. The top 3 pharmacy interventions were recommending alternative abx (42%), dose optimization (31%) and abx duration (6%).

Conclusion

Engaging pharmacists in ED discharge Rxs review resulted in use of narrower spectrum abx with lower CDI risk without any negative impact on ED LOS and clinical outcomes.

Disclosures

All Authors: No reported disclosures
2261. Impact of Antimicrobial Stewardship Program on Klebsiella pneumoniae and Escherichia coli Antimicrobial Resistance
Authors: Ferreiro Jose Luis Lamas , Otero Judith Alvarez , Rivo Ana Sanjurjo , de Salamanca Holzinger Ignacio Enriquez , Soneira Maria Fernandez , de Miguel Bouzas Jose Carlos , Conde Irene Rodriguez , Cavero Jorge , Aguado Javier de la Fuente
Published: November 2023

Background

A decrease in antimicrobial stewardship activities has been observed in our hospital since the beginning of the pandemic. The study aim was to evaluate the impact of decrease in antimicrobial stewardship activities in Klebsiella pneumoniae and Escherichia coli acquired multidrug-resistance.

Methods

The quarterly percentage of broad-spectrum antibiotic prescriptions evaluated by antimicrobial stewardship team (AMST), the quarterly consumption of broad-spectrum antimicrobials and the quarterly proportion of multidrug-resistant K. pneumoniae and E. coli were assessed between October 2016 and December 2022, with 2 periods of time, before the pandemic (October 2016-March 2020) and after the pandemic (April 2020-December 2022).Time series analysis was performed with ARIMA models to evaluate the association between decrease in AMST activities with multidrug-resistance in K. pneumoniae or E. coli. Correlation between broad-spectrum antibiotic prescriptions reviewed by AMST with broad-spectrum antimicrobials consumption and proportion of multidrug-resistance in K. pneumoniae or E. coli in urine cultures was assessed using the Pearson correlation coefficient.

Results

Percentage of broad-spectrum antimicrobials evaluated by AMST was 77% in first period and 29% in second period. The mean of broad-spectrum antibiotics consumption in first period was 13.02 DDD/100 bed-days and 15.35 DDD/100 bed-days in second period. Decrease of AMST activities was associated with an 37% increase in multidrug-resistant K. pneumoniae in second period compared with first period (p=0.02). No differences were found in E. coli. Correlation between percentage of AMST-reviewed broad-spectrum antibiotics with consumption of these antibiotics was good (correlation coefficient -0,7; p< 0,01). Correlation between ASMT-reviewed broad-spectrum antibiotics and multidrug-resistant K. pneumoniae was moderate (correlation coefficient -0.44; p=0,02). No correlation between ASMT-reviewed broad-spectrum antibiotics and multidrug-resistant E. coli (correlation coefficient 0,09; p=0,6) was found.

Conclusion

Decrease in antimicrobial stewardship activities was associated with high isolation of multidrug-resistant K. pneumoniae in urine cultures.

Disclosures

All Authors: No reported disclosures
2264. Shorter Duration of Visit Associated with Inappropriate Antibiotic Prescribing for Respiratory Tract Infections in a National Sample of Ambulatory Visits, 2009 - 2016
Authors: Mendoza Vidal M , Strey Kelsey , Reveles Kelly
Published: November 2023

Background

Due to the reported decrease in the duration of primary care visits, it is important to assess provider adherence to guidelines when treating respiratory infections that are unlikely to necessitate antimicrobial treatment. This study aimed to investigate the relationship between the duration of visit and unnecessary antibiotic prescribing while considering patient and provider factors, including age, sex, race, and diagnosis.

Methods

This retrospective, cross-sectional study used outpatient, office-based data from the National Ambulatory Medical Care Survey from 2009 to 2016. All patients with a primary diagnosis of bronchitis, viral respiratory tract infection, influenza, and viral pneumonia were included for analysis. Patients with diagnoses that almost always require an antibiotic were excluded. Diagnoses were identified using ICD-9 or ICD-10 codes. Inappropriate antibiotic use was identified using multum codes and defined as at least one prescribed oral antibiotic during the visit. Provider status was defined as physician only or other provider. Multivariate logistic regression was used to determine predictors of inappropriate antibiotic prescribing. Data weights were applied to all analyses to generate national estimates.

Results

A total of 226,250,589 patient visits were included in the analysis, of which 83,404,484 (36.9%) resulted in an inappropriately prescribed antibiotic. Patients prescribed antibiotics were older (median age 42 vs. 13 years) and more often White (82.4% vs. 79.6%). After adjustment for covariates, time spent with provider less than 15 minutes (aOR 1.866, 95% CI 1.862-1.869), patient age 18-64 years (aOR 2.408, 95% CI 2.406-2.410), other provider types only (aOR 1.790, 95% CI 1.785-1.794), and viral pneumonia diagnosis (aOR 68.432, 95% CI 66.691-69.936) were most strongly associated with inappropriate antibiotic prescribing.

Conclusion

This study found that patients who spent less time with providers, had viral pneumonia, and were aged 18-64 years old were more likely to receive inappropriate treatment. Further investigation is necessary to determine reasons for inappropriate antimicrobial prescribing among outpatients.

Disclosures

Kelly Reveles, PharmD, PhD, Ferring Pharmaceuticals: Advisor/Consultant|Ferring Pharmaceuticals: Honoraria
2265. Immunocompromised Patients, Compromised Guidelines? Practice Patterns of Managing Asymptomatic Bacteriuria in Immunocompromised Patients
Authors: Moore Jacqueline , Villanueva Daphne-Dominique , Stewart Logan
Published: November 2023

Background

Asymptomatic bacteriuria is an issue that plagues the field of medicine. Current guidelines set by the Infectious Diseases Society of America (IDSA) recommend against screening for and treating asymptomatic bacteriuria (ASB) in immunocompromised hosts. However, practice patterns of physicians may deviate from these guidelines. The goal of this study was to gather information on the practice patterns of providers in the fields of transplantation and infectious diseases and determine how closely they follow the recommended approach on managing ASB in immunocompromised hosts.

Methods

We employed the use of a computer-based survey using the REDCap software, and then disseminated the survey to several target groups. The survey was distributed from March 2023 through April 2023. There were 145 total responses. The survey included a scale to assess what participants considered to be diagnostic of urinary tract infection (UTI) (Table 1). The survey presented clinical cases which appeared after a specialty was chosen to ensure each participant was shown cases relevant to their specialty.Table 1.Demographics and Likert scale in diagnosing UTI based on urinalysis components and symptoms

Results

Infectious disease accounted for 111 of the responses. When asked if they would routinely screen for UTI in patients on immunosuppression, 5.8% of participants said yes. Thirty nine participants agreed or strongly agreed that bacterial growth of ≥100,000 CFU on culture is diagnostic of UTI, regardless of symptoms. Seventeen participants saw foul-smelling urine and cloudy urine as symptoms of UTI, 41% of which were infectious disease specialists. A larger number of those practicing more than 10 years versus fewer than 10 years agreed or were neutral regarding foul smelling urine and cloudy urine as symptoms of UTI (Table 1). Figure 1 shows 14.2% of participants chose to treat an asymptomatic neutropenic patient. Of these, 93.8% were infectious disease specialists.

How would you manage a patient with breast cancer on chemotherapy with stable neutropenia who has asymptomatic bacteriuria?Figure 1.Sixteen out of 114 respondents chose to treat in this clinical case involving an asymptomatic patient with neutropenia

Conclusion

Practice patterns in managing asymptomatic bacteriuria in immunocompromised patients vary, despite latest guidelines. Many providers agreed that foul-smelling urine and cloudy urine are indicators of UTI, and many see bacterial growth as diagnostic. This survey demonstrates room for improvement in management of asymptomatic bacteriuria in immunocompromised patients and the need for further education of providers.

Disclosures

All Authors: No reported disclosures
2266. Microbiology and Predictors of Gram-Negative Infections in Persons Who Inject Drugs with Injection-Related Infections Requiring Hospitalization
Authors: Mulbah Jessica L , Morita Kazumi , Mentzer Laura , Schultz Sara K
Published: November 2023

Background

Intravenous drug use predisposes users to life-threatening bacterial infections primarily caused by gram-positive organisms. Studies have seen an uptrend in gram-negative injection-related infections in persons who inject drugs (PWID). Therefore, this study aimed to assess the microbiology of injection-related infections in PWID and evaluate risk factors that may predispose these patients to infections caused by gram-negative organisms.

Methods

This retrospective chart review of adult PWID hospitalized with an injection-related infection (skin & soft tissue infection, bacteremia, septic arthritis, endocarditis, epidural abscess, and osteomyelitis) included patients aged >18 years with bacterial growth on specimens collected within 72 hours of admission from September 1, 2021, to March 31, 2022. Data analysis utilized descriptive statistics, chi-square tests, and Mann-Whitney U tests where appropriate.

Results

A total of 259 patients were included in the study. 243 (93.8%) patients grew gram-positive organisms, while only 16 (6.2%) grew gram-negative organisms. The majority of patients were male (60%), the median age was 38 (IQR [33-44]), and 10% had a prior infection with MRSA. The distribution of injection-related infections included SSTIs (79.9%), bacteremia (34.7%), septic arthritis (12%), infective endocarditis (10.4%), osteomyelitis (8.5%), and epidural abscess (3.5%). The most commonly observed organisms were MRSA (36%), S. pyogenes (43%), and MSSA (9%). The gram-negative organisms isolated are shown in Figure 1. Approximately 84% of patients received overtreatment with an anti-pseudomonal agent; however, only 2% required its use. SSTIs with lower extremity involvement were found to be associated with gram-negative infections within this cohort, as shown in Table 1.Figure 1.Distribution of gram-negative organisms isolated from cultures collected within 72 hours of admissionTable 1.Baseline characteristics and potential risk factors for gram-negative injection-related infections in PWID

Conclusion

In this study, despite less than 10% of patients growing gram-negative organisms on culture, approximately 80% received gram-negative treatment. Knowledge of the microbiology of infections in PWID can aid prescribers in optimizing empiric therapy for injection-related infections and preserving the core principles of antimicrobial stewardship.

Disclosures

Sara K. Schultz, MD FACP FIDSA, AbbVie: Advisor/Consultant