bluuebunny/crossref_metadata_2025 huggingface dataset:
Automatic detection of weeds: synergy between EfficientNet and transfer learning to enhance the prediction accuracy
Authors: Duong Linh T. , Tran Toan B. , Le Nhi H. , Ngo Vuong M. , Nguyen Phuong T.
Published: September 2023

The application of digital technologies to facilitate farming activities has been on the rise in recent years. Among different tasks, the classification of weeds is a prerequisite for smart farming, and various techniques have been proposed to automatically detect weeds from images. However, many studies deal with weed images collected in the laboratory settings, and this might not be applicable to real-world scenarios. In this sense, there is still the need for robust classification systems that can be deployed in the field. In this work, we propose a practical solution to recognition of weeds exploiting two versions of EfficientNet as the recommendation engine. More importantly, to make the learning more effective, we also utilize different transfer learning strategies. The final aim is to build an expert system capable of accurately detecting weeds from lively captured images. We evaluate the approach’s performance using DeepWeeds, a real-world dataset with 17,509 images. The experimental results show that the application of EfficientNet and transfer learning on the considered dataset substantially improves the overall prediction accuracy in various settings. Through the evaluation, we also demonstrate that the conceived tool outperforms various state-of-the-art baselines. We expect that the proposed framework can be installed in robots to work on rice fields in Vietnam, allowing farmers to find and eliminate weeds in an automatic manner.
How Market Intervention can Prevent Bubbles and Crashes: An Agent Based Modelling Approach
Authors: Westphal Rebecca , Sornette Didier
Published: September 2023

Using a previously validated agent-based model with fundamentalists and chartists, we investigate the usefulness and impact of direct market intervention. The policy maker diagnoses bubbles by forming an expectation of the future returns, then invests in burgeoning bubbles to develop a sufficient inventory of the risky asset in order to be able to sell adequate amounts of the overpriced asset later countercyclically to fight market exuberance. Preventing bubbles and crashes, this market intervention improves all analysed market return metrics, volatility, skewness, kurtosis and VaR, without affecting long-term growth. This increases the Sharpe ratios of noise traders and of fundamentalists by approximately 28% and 45% respectively. The results are robust even for substantially miscalibrated long-term expected returns.
Per Davidsson: recipient of the 2023 Global Award for Entrepreneurship Research
Authors: Storey David J. , Andersson Martin , Henrekson Magnus , Jack Sarah , Stenkula Mikael , Thorburn Karin , Wigren-Kristoferson Caroline , Zander Ivo
Published: September 2023

Professor Per Davidsson is the recipient of the 2023 Global Award for Entrepreneurship Research. Throughout an extraordinarily productive career, he has made invaluable contributions in building the field of entrepreneurship. His early studies on entrepreneurship and culture and his studies on the growth of small businesses played an important role in the emergence and development of entrepreneurship as a scholarly field of research. He has also, continuously, made more conceptual contributions by critically probing the development of the field, and engaged in writing foundational books that have been used extensively in higher education institutes. By probing and challenging traditional assumptions throughout his career, he has contributed to the refinement and renewal of the field.
„The same or different?“ – Effekte von Unterrichtsanalyse und Unterrichtsreflexion auf die Veränderung kognitiver und motivationaler Merkmale professioneller Lehrkompetenz
Authors: Lohse-Bossenz Hendrik , Schmitt Markus , Lenske Gerlinde , Gold Bernadette
Published: September 2023

Die Analyse von und die Reflexion über Unterricht sind zentrale Elemente universitärer Lehrkräftebildung. Dabei kann sowohl in der Lehre als auch in der Forschung begriffliche Heterogenität bzgl. Reflexion konstatiert werden. Auch fehlt eine klare Abgrenzung zwischen Analyse und Reflexion von Unterricht. Aufbauend auf der Konzeption des Selbstbezugs als ein zentrales Unterscheidungsmerkmal wird mittels eines quasi-experimentellen Prä-Post-Interventions-Kontrollgruppendesigns geprüft, inwiefern sich Unterrichtsanalysen von Unterrichtsreflexionen in ihren Auswirkungen auf die professionelle Unterrichtswahrnehmung (PUW) und die klassenführungsbezogene Selbstwirksamkeit (SW) unterscheiden. An einer Stichprobe von 194 angehenden Lehrkräften im Master of Education einer Hochschule kann gezeigt werden, dass Unterrichtsanalyse und -reflexion vergleichbar positive Effekte auf die PUW zeigten (besser als eine Kontrollgruppe ohne spezifische Intervention). Allerdings zeigt die Reflexionsgruppe eine stärkere Zunahme klassenführungsbezogener SW im Vergleich zu den anderen beiden Gruppen. Die Ergebnisse deuten somit darauf hin, dass durch den expliziten Selbstbezug selbstgerichtete Kognitionen verstärkt thematisiert werden und damit zusätzliche Aspekte professioneller Kompetenz adressiert werden können.
A Reinduction-Based Approach for Efficient High Utility Itemset Mining from Incremental Datasets
Authors: Sra Pushp , Chand Satish
Published: September 2023

High utility itemset mining is a crucial research area that focuses on identifying combinations of itemsets from databases that possess a utility value higher than a user-specified threshold. However, most existing algorithms assume that the databases are static, which is not realistic for real-life datasets that are continuously growing with new data. Furthermore, existing algorithms only rely on the utility value to identify relevant itemsets, leading to even the earliest occurring combinations being produced as output. Although some mining algorithms adopt a support-based approach to account for itemset frequency, they do not consider the temporal nature of itemsets. To address these challenges, this paper proposes the Scented Utility Miner (SUM) algorithm that uses a reinduction strategy to track the recency of itemset occurrence and mine itemsets from incremental databases. The paper provides a novel approach for mining high utility itemsets from dynamic databases and presents several experiments that demonstrate the effectiveness of the proposed approach.
Computer-Assisted Avatar-Based Treatment for Dysfunctional Beliefs and Eating-Disorder Symptomatology: A Randomized Control Pilot Study
Authors: Fey Marius , Peperkorn Nicolina , Borchert Thomas , Meyer Marie Lisa , Raacke Jan , Shiban Youssef
Published: September 2023

Dysfunctional beliefs influence the pathogenesis and maintenance of eating disorders. Cognitive-behavioral therapy (CBT) aims to modify these specific beliefs and mediate functional patterns of appraisal and thinking. The present pilot study aims to experimentally validate a computer-assisted avatar-based treatment (CAT-DB) to reduce dysfunctional body-related cognitions and symptom severity in a sample with subclinical eating disorder symptomatology. In a randomized controlled trial, 48 participants were assigned to either the control group or CAT-DB. The conviction of individual body-related cognitions and eating disorder-specific symptom expression was measured shortly before the beginning of the intervention (pre-measurement), directly after the intervention (post-measurement), and 14 days later (follow-up). There was a significant interaction effect for symptom severity, as reductions in eating disorder-specific symptomatology were significantly greater in the CAT-DB group compared to the control group at follow-up. Compared to the control group, CAT-DB resulted in non-significant but expected improvements in individual body-related automatic thoughts. The present study offers preliminary evidence suggesting that CAT-DB could be efficacious in addressing certain symptoms associated with eating disorders. Further studies with representative clinical samples diagnosed with eating disorders are needed to provide more evidence of the efficacy of CAT-DB as a support for classical CBT in a variety of therapeutic and research contexts.
Matrix Mathematics
Authors: Garcia Stephan Ramon , Horn Roger A.
Published: September 2023

Using a modern matrix-based approach, this rigorous second course in linear algebra helps upper-level undergraduates in mathematics, data science, and the physical sciences transition from basic theory to advanced topics and applications. Its clarity of exposition together with many illustrations, 900+ exercises, and 350 conceptual and numerical examples aid the student's understanding. Concise chapters promote a focused progression through essential ideas. Topics are derived and discussed in detail, including the singular value decomposition, Jordan canonical form, spectral theorem, QR factorization, normal matrices, Hermitian matrices, and positive definite matrices. Each chapter ends with a bullet list summarizing important concepts. New to this edition are chapters on matrix norms and positive matrices, many new sections on topics including interpolation and LU factorization, 300+ more problems, many new examples, and color-enhanced figures. Prerequisites include a first course in linear algebra and basic calculus sequence. Instructor's resources are available.
Evaluation of four environmental sampling methods for the recovery of multidrug-resistant organisms
Authors: Babiker Ahmed , Page Alex , Riel Julia Van , Wilber Eli , Strudwick Amanda , Bower Chris , Woodworth Michael , Satola Sarah
Published: September 2023

Background: Environmental contamination is a major risk factor for multidrug-resistant organism (MDRO) exposure and transmission in the healthcare setting. Sponge-stick sampling methods have been developed and validated for MDRO epidemiological investigations, leading to their recommendation by public health agencies. However, similar bacteriological yields with more readily available methods that require less processing time or specialized equipment have also been reported. We compared the ability of 4 sampling methods to recover a variety of MDRO taxa from a simulated contaminated surface. Methods: We assessed the ability of (1) cotton swabs moistened with phosphate buffer solution (PBS), (2) e-swabs moistened with e-swab solution, (3) cellulose-containing sponge sticks (CSS), and (4) non–cellulose-containing sponge sticks (NCS) to recover extended-spectrum β-lactamase (ESBL)–producing Escherichia coli, carbapenem-resistant Pseudomonas aeruginosa (CRPA), carbapenem-resistant Acinetobacter baumannii (CRAB), methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecium (VRE), and a mixture that contained VRE, MRSA, and ESBL organisms. A solution of known bacterial inoculum (~105 CFU/mL) was made for each MDRO. Then, 1 mL solution was pipetted on a stainless-steel surface (8 × 12 inch) in 5 µL dots and allowed to dry for 1 hour. All samples were collected by 1 individual to minimize variation in technique. Sponge sticks were expressed in PBS containing 0.02% Tween 80 using a stomacher, were centrifuged, and were then resuspended in PBS. Cotton and e-swabs were spun in a vortexer. Then, 1 mL of fluid from each method was plated to selective and nonselective media in duplicate and incubated at 35°C for 24 hours (MRSA plates, 48 hours) (Fig. 1). CFU per square inch and percentage recovery were calculated. Results: Table 1 shows the CFU per square inch and percentage recovery for each sampling method–MDRO taxa combination. The percentage recovery varied across MDRO taxa. Across all methods, the lowest rate of recovery was for CRPA and the highest was for VRE. Regardless of MDRO taxa, the percentage recovery was highest for the sponge stick (CSS and NCS) compared to swab (cotton and E-swab) methods across all taxa (Table 1 and Fig. 2).

Conclusions: These findings support the preferential use of sponge sticks for the recovery of MDROs from the healthcare environment, despite the additional processing and equipment time needed for sponge sticks. Further studies are needed to assess the robustness of these findings in noncontrived specimens as well as the comparative effectiveness of different sampling methods for non–culture-based MDRO detection.

Disclosure: None
Identifying nonprescription antibiotic users with screening questions in a primary care setting
Authors: Amenta Eva , Valentine-King Marissa , Laytner Lindsey , Paasche-Orlow Michael , Street Richard , Barning Kenneth , Porter Thomas , Mahmood Hammad , Trautner Barbara , Grigoryan Larissa
Published: September 2023

Background: Antibiotic use without a prescription (nonprescription use) leads to antibiotic overuse, with negative consequences for patient and public health. We studied whether screening patients for prior nonprescription antibiotic use in the past 12 months predicted their intentions to use them in the future. Methods: A survey asking respondents about prior and intended nonprescription antibiotic use was performed between January 2020 and June 2021 among patients in waiting rooms of 6 public clinics and 2 private emergency departments in economically and socially diverse urban and suburban areas. Respondents were classified as prior nonprescription users if they reported previously taking oral antibiotics without contacting a doctor, dentist, or nurse. Intended use was defined as answering “yes” or “maybe” to the question, “Would you use antibiotics without contacting a doctor, nurse, or dentist?” We calculated the sensitivity, specificity, and positive and negative predictive value (PPV and NPV) of prior nonprescription antibiotic use in the past 12 months for future intended nonprescription use. Bayes PPV and NPV were also calculated, considering the prevalence of nonprescription antibiotic use (24.8%) in our study. Results: Of the 564 patients surveyed, the median age was 51 years (SD, 19–92), with 72% of patients identifying as female. Most were from the public healthcare system (72.5%). Most respondents identified as Hispanic or Latino(a) (47%) or African American (33%), and 57% received Medicaid or the county financial assistance program. Prior nonprescription use was reported by 246 (43%) of 564 individuals, with 91 (16%) reporting nonprescription use within the previous 12 months. Intention to use nonprescription antibiotics was reported by 140 participants (25%). The sensitivity and specificity of prior nonprescription use in the past 12 months to predict the intention to use nonprescription antibiotics in the future were 75.9% (95% CI, 65.3–84.6) and 91.4% (95% CI, 87.8–94.2), respectively. After the Bayes’ adjustment, the PPV and NPV of prior use to predict future intention were 74.5% (95% CI, 66.7–80.9) and 92.0% (95% CI, 88.7–94.4) (Table 1). Conclusions: These results show that prior nonprescription antibiotic use in the past 12 months predicted the intention to use nonprescription antibiotics in the future (PPV of 75%). As a stewardship effort, we suggest clinicians use a simple question about prior nonprescription antibiotic use in primary-care settings as a screening question for patients at high risk for future nonprescription antibiotic use.

Financial support: HSQR-R 5R01HS026901-04

Disclosure: None
Patient and facility characteristics of an NDM-producing Acinetobacter baumannii outbreak in California, 2020–2022
Authors: Hsiao Lian , Horwich-Scholefield Sam , Mitsunaga Tisha , Holden Diana , Epson Erin
Published: September 2023

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) are bacteria that cause healthcare-associated infections and outbreaks. Most produce carbapenemases like New Delhi metallo-β-lactamase (NDM), which are more commonly found in carbapenem-resistant Enterobacterales but rarely in CRAB. In 2018, selected laboratories began participating in a public health sentinel surveillance program by routinely submitting CRAB and other antimicrobial-resistant isolates to the AR Laboratory Network for specialized testing. In May 2020, the Antimicrobial Resistance Laboratory Network detected the first NDM-CRAB case in California, triggering an investigation. Initial whole-genome sequencing of subsequent isolates indicated high relatedness. Methods: We defined confirmed cases as patients with NDM detected in CRAB isolates and probable cases as NDM detected in a screening swab from a patient epidemiologically linked to a known case(s) with specimens collected during May 2020–September 2022. We defined outbreak facilities as having (1) 1 or more newly identified cases during a point-prevalence survey in response to a known case or (2) at least 2 cases identified within 4 weeks of each other that were epidemiologically linked. We analyzed demographic and specimen characteristics, as well as healthcare exposure history using R Studio version 1.3.959 software. Results: Of 230 total patients, 176 (77%) were confirmed and 54 (23%) were probable cases; 150 (65%) were identified through colonization screening. Among 176 NDM-CRAB isolates, the most common specimen sources were respiratory (n = 29), wound (n = 28), and urine (n = 24), and 87 (49%) of 176 isolates were nonsusceptible to all antimicrobials tested. Among patients, median age was 65 years (range, 24–97), 127 (55%) were male, 37 (15%) were Hispanic or Latino, and 100 (43%) were White. We identified 37 outbreak facilities across 13 counties, including 25 acute-care hospitals (ACHs), 6 skilled nursing facilities (SNFs), 5 ventilator-equipped SNFs (vSNFs), and 1 long-term ACH. We identified 125 cases (54%) in SNFs and vSNFs and 93 cases (40%) in ACHs; among ACH patients, 43 (46%) had been SNF or vSNF residents within the prior year. No patients reported international exposure. Conclusions: The first known case of NDM-CRAB in California was detected by sentinel surveillance. In this extensive regional outbreak, most cases were identified by screening at public health and clinical laboratories. Transmission occurred across healthcare settings connected by patient sharing, underscoring the importance of communication, active surveillance, and implementation of infection prevention and control practices to mitigate spread within and between facilities. Expanding these efforts, with support and resources from public health departments, is key to detecting, characterizing, and containing future outbreaks of antimicrobial-resistant pathogens.

Disclosure: None
Sex differences in knowledge and practices regarding antibiotics and antibiotic resistance in the Puerto Rican population
Authors: Toro-Garay Yiana , Rivera-Santiago Tanialy , Ortiz-Bonilla Vilmarie
Published: September 2023

Background: Antibiotic resistance is one of the biggest threats to global health, and by 2050 it is expected to cause 10 million deaths per year globally. Sex differences depend on context and sociodemographic factors; therefore, studies addressing sex differences have been inconclusive. Furthermore, to our knowledge, sex differences in the Puerto Rican population have not been analyzed. We sought to understand whether knowledge and practices regarding antibiotic use and antibiotic resistance in the Puerto Rican population differ by sex. Methods: A convenience sampling was performed at outpatient clinics across Puerto Rico. Those who agreed to participate completed a self-report questionnaire aimed to address demographics, antibiotic knowledge, and experiences. Bivariate analyses were performed using Stata version 17.0 software. Results: In total, 252 participants received the questionnaire, and 250 completed it. Most of the participants were female (71.2%), aged >56 years (40.0%), and had a high school diploma (40.4%). Women had 2.71 (95% CI, 1.1–6.8, P). Conclusions: Women perceived themselves to be more knowledgeable regarding antibiotic use and resistance than men. However, no difference in actual knowledge could be identified. Similarly, antibiotic-related practices did not differ by sex except for using previously saved antibiotic treatment, and men had higher odds of conducting this practice. Further studies should be conducted to understand the factors that influence these behavioral practices, and educational interventions should focus on addressing misconceptions regarding antibiotics and antibiotic resistance.

Disclosures: None
Determining trends of respiratory tract infections in a long-term care facility pilot surveillance project
Authors: Adre Cullen , Patel Dipen , Reed Vicky , Velrajan Srilakshmi , Evans Christopher , Wilson Christopher
Published: September 2023

Background: Respiratory tract infections (RTIs) in long-term care facilities (LTCFs) are particularly burdensome among residents, the COVID-19 pandemic highlighted the devastating consequences of RTIs in LTCFs. This situation has prompted the need for LTCFs to have a robust, active surveillance system to assist LTCFs with RTI identification. Such a system could assist with faster implementation of appropriate antimicrobial therapy and critical infection prevention and control. The TN Emerging Infections Program worked with CDC EIP to implement a pilot project to test the feasibility of performing RTI surveillance to inform future changes to NHSN. Methods: We recruited 6 LTCFs to collect prospective RTI surveillance for 6 consecutive months from October 2021 through March 2022. Data were collected for all residents meeting the RTI surveillance definitions: pneumonia, lower respiratory tract infection, influenza-like illness (including influenza), and COVID-19. These data were entered by facility workers into a REDCap database with a prospective RTI LTCF event form. Monthly data collection summaries were submitted using a designated denominator form. Descriptive statistics were used to analyze RTI data, and analyses were performed using SAS version 9.4 software. Results: In total, 6 facilities participated in the pilot project during the capture period. The total number of RTI cases across all facilities was 195. December had the most cases (n = 50). The most common first triggers were new RTI signs or symptoms (67.69%), laboratory results (17.44%), imaging findings (6.67%), and clinician-diagnosed RTI (8.21%). The most reported symptom was new or increased cough (57.44%). Chest radiographs were performed for 50.77% of patients. Positive viral laboratory test results were documented 29.74% of the time. Antibiotic treatments were given to 70.77% of residents. The most commonly prescribed antibiotics were cephalosporins (22.56%), macrolides (17.95%), fluoroquinolones (12.31%), and doxycycline (9.23%). Also, 17.4% of cases with antibiotic regimens had cephalosporins as monotherapy. Vaccine documentation was as follows: influenza 2020–2021 (40.51%), influenza 2021–2022 (64.1%), complete COVID-19 vaccine series (82.56%), PPSV-23 vaccine (33.85%), and PCV-13 (23.59%). Conclusions: RTI surveillance was incorporated smoothly into the daily workflow for facilities; the biggest barrier to effective implementation was staff turnover. A scheduled weekly time to collect data and fill out forms proved most effective. A high percentage of cases was treated with cephalosporins as monotherapy, which, based on the latest guidelines, may be suboptimal. Individual reports were sent back to facilities with a comparison to the aggregated data. These data will be used to evaluate antibiotic appropriateness and to guide future RTI surveillance efforts in the LTCF setting.

Disclosures: None
Effect of antifungal stewardship on micafungin prescribing practices in intensive care units at a tertiary-care hospital
Authors: Arya Radhika , Norman Sarah , Daas Farah , Ramdeen Sheena
Published: September 2023

Background: Fungal diseases are associated with substantial global mortality and economic burden, especially in critically ill or immunocompromised patients. Antifungal resistance has emerged as a barrier to treating invasive fungal infections, but antifungal stewardship is still a developing effort due to limited data. Here, we describe the antifungal prescribing practices and the impact of antifungal stewardship on micafungin days of therapy (DOTs) in critical care units. Methods: This retrospective study included patients who were admitted to the intensive care unit (ICU) at a tertiary-care hospital in Washington, DC. The preintervention group included baseline micafungin use data between January 1, 2021, and May 31, 2021. The postintervention group included prospective audits, feedback on micafungin orders by a clinical pharmacist, and education on the appropriateness of the antifungal agents. The postintervention group included patients admitted between June 1, 2021, and December 31, 2021. Approval was obtained from the institutional review board. Results: The overall average of micafungin days of therapy (DOT) per 1,000 patient days present in the preintervention group versus the postintervention group was 33 versus 24 days, respectively. Moreover, 121 patients were randomly selected for a more detailed retrospective review to define micafungin prescribing practices further. Of these, 73 patients (60.3%) were male; the median age was 63 years. The most common cause for prescribing micafungin in both groups was empiric antifungal coverage (62.8%), followed by fungemia (12.4%). The most common organism isolated was Candida albicans. For other sources of infection and organisms isolated, refer to Table 1. In-hospital mortality occurred in 63 (52.06%) patients in both groups. Conclusions: Antifungal stewardship through prospective audit and feedback and education by clinical pharmacists decreased micafungin DOTs in critical care units. Empiric prescribing of micafungin is highly prevalent in the ICU despite the low incidence of invasive fungal infections. Although periodic drug utilization reviews and pharmaceutical surveillance can help reduce the prolonged duration of micafungin therapy in the ICU, more robust and routine antifungal stewardship is key to the appropriate use of micafungin to avoid the emergence of antifungal resistance.

Disclosures: None
Serotonergic agents and linezolid: Impact of exposure to more than one agent concomitantly on risk of adverse effects
Authors: Yan Xuping , McCoy Christopher , Chapin Ryan , Lee Matthew , Gold Howard , Donohoe Kendall
Published: September 2023

Background: The off-target effects linezolid have the potential to cause serotonin syndrome when given in conjunction with serotonergic agents. Despite package insert labeling as a contraindication, several postmarketing studies have demonstrated a low incidence of serotonin syndrome with the concomitant use of linezolid and other serotonergic agents. Linezolid provides a convenient oral option for gram-positive infections. However, due to concerns for serotonin syndrome, the use of linezolid is sometimes avoided. Methods: We performed a single-center, retrospective, medical record review of all adult inpatients from September 2021 to September 2022. Patients included had 1 administration of linezolid and 1 inpatient administration of a selective serotonin reuptake inhibitor (SSRI) or serotonin and norepinephrine reuptake inhibitor (SNRI) within 14 days. The primary outcome was the incidence of serotonin syndrome as defined by the Hunter serotonin toxicity criteria, which were retrospectively applied to each patient based on medical-record documentation. We compared patients receiving 1 versus multiple serotonergic agents. Secondary outcomes included duration of hospitalization and adverse outcomes based on concerns for serotonin syndrome such as need for rescue, ICU admission, or change in medication. Results: Of the 50 included patients from a convenience sample, 27 (54%) were on linezolid and >1 serotonergic agent. Patients had similar baseline characteristics (Table 1). The most common concomitant agent used was an SSRI. Other agents that predispose patients to serotonin syndrome included opioid analgesics and other classes of antidepressants (Fig. 1). Serotonin syndrome occurred within 48 hours in 1 patient on an SNRI and a continuous fentanyl drip. There was no need for rescue or ICU admission due to serotonin syndrome. No patients were readmitted due to serotonin syndrome, and no differences were observed in hospital lengths of stay. Conclusions: Exposure to a single serotonergic agent combined with receipt of linezolid was not associated with any cases of serotonin syndrome. Exposure to multiple serotonergic agents was not associated with a high incidence of serotonin syndrome. This small series supports previous reports demonstrating relative safety of linezolid given with serotonergic agents and encourages review of interruptive drug–drug interaction alerts for linezolid within the electronic ordering system.

Disclosures: None
Identifying the relationship between hospital rurality and antibiotic overuse
Authors: Hardin Hannah , Vaughn Valerie , White Andrea , Horowitz Jennifer , McLaughlin Elizabeth , Szymczak Julia , Petty Lindsay , Malani Anurag , Flanders Scott , Gandhi Tejal
Published: September 2023

Background: Antibiotic overuse and the resulting patient outcomes span all hospitals. However, although antibiotic stewardship can improve antibiotic use, effective stewardship programs require expertise and an infrastructure that are not present in all hospitals. Rural hospitals have less access to resources, infectious disease expertise, and participation in academic research. Thus, we compared antibiotic overuse at discharge between rural and nonrural hospitals for patients diagnosed with community-associated pneumonia (CAP) or urinary tract infection (UTI)—the 2 most common hospital infections. Methods: To determine whether antibiotic overuse at discharge was higher among rural versus nonrural hospitals, we analyzed data from a 41-hospital prospective cohort of patients treated for CAP or UTI between July 1, 2017, and July 30, 2019, in Michigan. Antibiotic overuse was defined as treatment that was unnecessary (ie, patient did not have an infection), excessive (ie, duration >4 days for CAP), or included suboptimal fluoroquinolone use (ie, safer alternative available). Overuse was determined based on patient risk factors, symptoms, allergies, diagnostic results, and time to stability. Hospital rurality was defined using the Rural–Urban Continuum Codes (RUCC) score. We defined rural as a score ≥4 and very rural as a score of 7–9. We used t tests to compare the mean percentage of patients with antibiotic overuse at discharge between nonrural and rural (and very rural) hospitals. Results: Across 41 hospitals, we included 23,449 patients with CAP or UTI. There were 5 rural (and 3 very rural) hospitals with 2,039 (and 1,082) patients. Antibiotic overuse at discharge was present in 43.1% of patient cases in nonrural hospitals, 52.5% in rural hospitals (P = .04 vs nonrural) and 58.1% in very rural hospitals (P = .007 vs nonrural). Compared to nonrural hospitals, the mean percentage of cases with antibiotic overuse at discharge in rural hospitals was 9.4% higher (15.1% higher in very rural hospitals). Results were similar in a subgroup analysis of only patients with UTI (47.0% in rural vs 37.5% in nonrural, mean difference, 9.5%; P = .03) but were not statistically significant in patients with CAP (53.8% vs 48.0%, respectively; mean difference, 5.8%; P = 0.23). Conclusions: In this retrospective study, rural hospitals—especially very rural hospitals, had higher rates of antibiotic overuse at discharge than nonrural hospitals. Our findings suggest that antibiotic stewardship interventions tailored toward the unique differences in infrastructure, resources, and needs of rural hospitals are essential to community health.

Disclosures: None
Diagnostic accuracy of antibiograms in predicting the risk of antimicrobial resistance for individual patients
Authors: Hasegawa Shinya , Church Jonas , Perencevich Eli , Goto Michihiko
Published: September 2023

Background: Many clinical guidelines recommend that clinicians should use antibiograms to decide on empiric antimicrobial therapy. However, antibiograms aggregate epidemiologic data without consideration for any other factors that may affect the risk of antimicrobial resistance (AMR), and little is known about an antibiogram’s reliability in predicting antimicrobial susceptibility. We assessed the diagnostic accuracy of antibiograms as a prediction tool for E. coli clinical isolates in predicting the risk of AMR for individual patients. Methods: We extracted microbiologic and patient-level data from the nationwide clinical data warehouse of the Veterans Health Administration (VHA). We assessed the diagnostic accuracy of the antibiogram for 3 commonly used antimicrobial classes for E. coli: ceftriaxone, fluoroquinolones, and trimethoprim-sulfamethoxazole. First, we retrospectively generated facility-level antibiograms for all VHA facilities from 2000 to 2019 using all clinical culture specimens positive for E. coli, according to the latest Clinical & Laboratory Standards Institute guideline. Second, we created a patient-level data set by including only patients who did not have a positive culture for E. coli in the preceding 12 months. Then we assessed the diagnostic accuracy of an antibiogram for E. coli to predict resistance for the isolates in the following calendar year, using logistic regression models with percentages in the antibiogram as dependent variables. We also set 5 stepwise thresholds at 80%, 85%, 90%, 95%, and 98%, and we calculated sensitivity, specificity, and accuracy for each antimicrobial. Results: Among 127 VHA hospitals, 1,484,038 isolates from 704,779 patients were available for analysis. The area under the ROC curve (AU-ROC) was 0.686 for ceftriaxone, 0.637 for fluoroquinolones, and 0.578 for trimethoprim-sulfamethoxazole, suggesting their relatively poor prediction performances (Fig. 1). The sensitivity and specificity of the antibiogram widely varied by antimicrobial groups and thresholds, with substantial trade-offs. Along with AU-ROC, these metrics suggest poor prediction performances when antibiograms are used as the sole prediction tool (Fig. 2). Conclusions: Antibiograms for E. coli have poor performances in predicting the risk of AMR for individual patients when they are used as a sole tool, and their contribution to the clinical decision making may be limited. Clinicians should also consider other clinical and epidemiologic data when interpreting antibiograms, and guideline statements that suggest antibiogram as a valuable tool for decision making in empiric therapy may need to be reconsidered. Further studies are needed to evaluate the contribution of antibiograms when combined with other patient-level factors.

Disclosures: None
Evaluating racial disparities in central-line–associated bloodstream infections for Tennessee hospitals, 2018–2021
Authors: Godwin Simone , Kirtz Erika , Wilson Christopher
Published: September 2023

Background: Central-line–associated bloodstream infections (CLABSIs) significantly burden the US population and healthcare system. Reporting facilities in Tennessee consistently omit race and ethnicity data in the NHSN despite having the option to enter. Racial and ethnic disparities are well documented across many health outcomes, including patient safety. CLABSIs were compared among 3 racial groups to better understand the impact of race on CLABSI incidence in Tennessee. Methods: CLABSI data from NHSN were linked with records from the TN Hospital Discharge Data System (HDDS) for 2018–2021. A multivariable linear regression model was used to determine relative risk (RR) between racial groups for contracting a CLABSI after controlling for confounding variables including Charlson comorbidity index (CCI) and social vulnerability index (SVI) scores. Statistical significance was set at P < .05. Data linkage and statistical analyses were performed in SAS version 9.4 software. Results: In Tennessee between 2018 and 2021, 342 (17.2%) of the 1,980 CLABSI events had race documented, and no ethnicity variables exist in the NHSN. The data linkage process yielded a 72% match (1,426 CLABSIs). The remaining 28% were excluded from the analysis. Per 1,000 central-line days (CL days) for all races, white patients had the highest CLABSI rate (17.5), followed by Black patients (1.36), and Native American or Alaskan Native patients (0.68). Per 1,000 admissions by race, Black patients had a higher CLABSI rate (1.26) than Native American/Alaskan Native patients (0.85) and white patients (0.75). The risk of contracting a CLABSI was 79% higher in Black patients than in white patients (RR, 1.79; 95% CI, 1.55–2.07; P < .0001) when controlling for CCI, age group, and SVI. Conclusions: These results suggest that racial disparities between Black and white patients are present in Tennessee hospitals regarding CLABSIs. Although most CLABSI events were linked to HDDS patients, there were limitations in the ability to match all cases and calculate CL days by race. This study highlights the need for complete race and ethnicity data in the NHSN. Further studies should examine infection types at the regional and facility levels to target interventions for reducing HAI inequities in Tennessee.

Disclosures: None
Examining CLABSI rates by central-line type
Authors: DiBiase Lauren , Summerlin-Long Shelley , Stancill Lisa , Vavalle Emily Sickbert-Bennett , Teal Lisa , Weber David
Published: September 2023

Background: Central-line–associated bloodstream infections (CLABSIs) are linked to increased morbidity and mortality, longer hospital stays, and significantly higher healthcare costs. Infection prevention guidelines recommend line placement in specific insertion locations over others because of the relative risk of infection. The purpose of this study was to assess CLABSI rates by line type to determine whether some central lines had a lower risk of infection and should be recommended over others given similar clinical indications. Methods: At UNC Hospitals, data were obtained on central lines across a 3-year period (FY20–FY22) from the EMR (Epic Systems). Central lines were categorized as apheresis catheters, CVC lines (single, double, or triple lumen), hemodialysis catheters, introducer lines, pulmonary artery (PA) catheters, PICC lines (single, double, or triple lumen), port-a-catheters, trialysis catheters, or umbilical lines. The line type(s) associated with each CLABSI during the same period were recorded, and CLABSI rates by line type per 1,000 central-line days were calculated using SAS software. If an infection had >1 central-line device type associated, the infection was counted twice when calculating the CLABSI rate by line type. We calculated 95% CIs for each point estimate to assess for statistically significant differences in rates by line type. Results: During FY20–FY22, there were 264,425 central-line days and 458 CLABSIs, for an overall CLABSI rate of 1.73 CLABSIs per 1,000 central-line days. Also, 16% of patients with a CLABSI had >1 type of central line in place. Stratified data on CLABSI rates by each central-line type is presented in the Figure. CLABSI rates were highest in patients with apheresis lines (6.22; 95% CI, 3.96–9.35) and PA catheters (6.22; 95% CI, 3.54–10.20), and the lowest CLABSI rates occurred in patients with PICC lines (1.44; 95% CI, 1.19–1.73) and port-a-catheters (1.14; 95% CI, 0.89, 1.45). For both CVC and PICC lines, as the number of lumens increased from single to triple, CLABSI rates increased, from 0.91 to 2.63 and from 0.57 to 1.20, respectively. Conclusions: At our hospital, different types of central lines were associated with statistically higher CLABSI rates. Additionally, a higher number of lumens (triple vs single) in CVC and PICC lines were also associated with statistically higher CLABSI rates. These findings reinforce the importance of considering central-line type and number of lumens to minimize risk of CLABSI while ensuring that patients have the best line type based on their clinical needs.

Disclosures: None
Identifying COVID-19 clusters in Tennessee long-term care facilities based on weekly staff vaccination rates
Authors: Turner Marissa , Gambrell Ashley , Hitchingham Erin , Godwin Simone
Published: September 2023

Background: In September 2021, the CMS mandated that long-term care facility (LTCF) healthcare workers be vaccinated for COVID-19 unless medically or religiously exempt. Vaccinating healthcare workers reduces transmission of COVID-19 among patients and workers, reducing the risk of illness among residents and patients. We examined the relationship between COVID-19 clusters and staff vaccination rates in Tennessee LTCFs. Methods: COVID-19 cluster data were collected using REDCap from January 3, 2021, to September 25, 2022, and LTCF vaccination rates were collected from the NHSN. Clusters were identified in facilities with 2 or more cases. The staff vaccination rate 2 weeks prior to the cluster was used, accounting for the lag time between vaccination dose and reaching full immunity. We selected 75% as the critical immunization threshold. The facility case rate was calculated per 100 beds. A test was performed to determine whether reaching the critical vaccination threshold was associated with cluster occurrence. The relationship between vaccination rate and case number was tested using Pearson correlation. Statistical analyses were conducted using SAS version 9.4 software. Results: The average staff vaccination rate when NHSN first required long-term care facilities to report rates rose from 47% in June 2021 to 83% in September 2022. In total, 806 clusters were identified with 20,868 combined weeks from all facilities being reported after merging facilities’ weekly vaccine percentage rates with cluster data. Most weeks from all facilities did not identify a cluster (n = 20,064, 96.15%) and did not meet the critical immunization threshold (n = 11,050, 52.95%). The association between a cluster occurring and a facility meeting the threshold was significant (χ2 = 5.41; df = 1; P 95% CI, .7327–.9740). The Pearson correlation coefficient between vaccination rate and case number was 0.05560 (P = .2894). Conclusions: There was a significant association between facilities not reaching the immunization threshold and presence of a COVID-19 cluster. The facility case rate was not correlated with staff vaccination rate; however, a limitation of this analysis was that resident vaccination was not tested. Another limitation was that medical and religious exemptions could not be differentiated. Healthcare staff should consider getting vaccinated, if able, to reduce the risk of COVID-19 and to keep staff and residents safe from COVID-19.

Disclosures: None
MRSA PCR improves sensitivity of detection of colonization in neonates
Authors: Hiermandi Nahid , Foster Catherine , Purnell Krystal , Dunn James , Campbell Judith , Marquez Lucila
Published: September 2023

Background: Neonates colonized with methicillin-resistant Staphylococcus aureus (MRSA) are at high risk of developing life-threatening MRSA infection. Due to lack of evidence, national guidelines do not currently recommend a specific methodology for detecting MRSA colonization. We hypothesize that surveillance for MRSA colonization via polymerase chain reaction (PCR) is superior to culture for the detection of colonization. Methods: In this retrospective study, we compared results of MRSA surveillance by 2 methodologies, culture and PCR, after implementation of an MRSA surveillance and decolonization protocol in the Texas Children’s Hospital Pavilion for Women, a 42-bed neonatal intensive care unit. MRSA colonization of 3 body sites via the 2 methodologies was assessed from June 2017 through December 2020. All neonates were screened for MRSA upon admission to the NICU and weekly thereafter until MRSA-positive or discharged. Swab specimens were initially tested by PCR (Xpert MRSA NxG, Cepheid) and when MRSA-positive reflexed to culture to recover the organism for further characterization. This study was approved through the Baylor College of Medicine Institutional Review Board. Results: During the study period, 2,351 neonates were assessed for MRSA colonization by PCR; 81 (3.4%) infants were PCR positive (Fig. 1). Of those 81, 57 (70.4%) had concordant MRSA PCR and culture results, and 24 (29.6%) were MRSA PCR positive but no isolate was recovered in culture. Also, 8 specimens were indeterminate by PCR. However, 1 infant who was negative by culture but was PCR positive developed an MRSA orbital infection. Compared to PCR, the overall sensitivity of MRSA culture was 70.4% (range, 57.7%–80.8%, depending on the year) (Table 1). Conclusions: PCR is more sensitive than culture for detecting MRSA colonization in neonates. Utilizing a PCR method enhances the ability to identify MRSA colonized infants more readily and allows for prompt initiation of infection control interventions including isolation precautions and decolonization strategies. Reflex to culture remains important for strain characterization during outbreak investigations and for additional susceptibility testing. Resource utilization and cost–benefit analyses should be done in future studies to influence changes in national guidelines for the control of Staphylococcus aureus colonization and infection in neonatal intensive care units.

Disclosures: None
Healthcare personnel with laboratory-confirmed mpox in California
Authors: Bailey Allison , Siegel Jane , Chai Shua , Bui David , Snyder Robert , Lewis Linda , Saadeh Kayla , Bertumen J.B. , Epson Erin
Published: September 2023

Objectives: Few reports have been published about the transmission of mpox in healthcare settings. During the 2022 multinational outbreak, the California Department of Public Health (CDPH) conducted a systematic review of healthcare personnel (HCP) with mpox, including their community and occupational exposures, to understand the transmission risk in healthcare settings. We also sought to inform return-to-work protocols by describing the frequency of HCP working while symptomatic for mpox and identifying occurrences of secondary transmission from infected HCP to patients. Methods: We analyzed surveillance data for laboratory-confirmed mpox cases in California with symptom onset from May 17 to September 30, 2022, collected by investigators at local health departments and reported to the CDPH. The reported data were supplemented by review of free-text variables, interview notes, and other files uploaded to state and county disease surveillance data registries. We identified HCP as all persons working in healthcare settings with potential for direct or indirect exposure to patients or infectious materials, including clinical and nonclinical staff but excluding remote workers. Results: The CDPH received reports of 3,176 mpox cases during the study period: 109 were HCP. Of the 109 HCP identified from 19 counties, 78 (72%) were aged 30–49 years, 102 (94%) were male, and 43 (39%) were Hispanic or Latino. Also, 29 HCP (27%) had received at least 1 dose of the JYNNEOS vaccine. Occupations requiring frequent physical interactions with patients were reported for 66 individuals (61%). During interviews with local health department investigators, nearly all HCP (n = 98, 90%) reported potential or confirmed sources of community exposure; 1 had confirmed occupational exposure with symptom onset 9 days after a sharps injury acquired during collection of an mpox specimen for testing. Of the 60 HCP who provided information about the days they worked, 35 (58%) worked while symptomatic, for a mean of 3.14 days (median, 2; IQR, 3). Also, 2 HCP worked for 12 days after symptom onset. No secondary cases of mpox were associated with HCP reported to the CDPH. Conclusions: This analysis suggests that HCP are more likely to be exposed to mpox in community settings than healthcare settings. The findings support recommendations against sharps use for mpox specimen collection. Although transmission between symptomatic HCP and patients was not reported, HCP can decrease opportunities for mpox transmission by closely monitoring themselves for symptoms after potential exposures and staying home from work if symptoms develop.

Disclosures: None