bluuebunny/crossref_metadata_2025 huggingface dataset:
159. Characterization of Suboptimal Discharge Antimicrobial Prescriptions and Effect of Inpatient Audit and Feedback on Quality of Antimicrobial Prescribing
Authors: Puckett Lauren M , Bio Laura , Cornell Sean , Joerger Torsten , Schwenk Hayden T , Schwenk Hayden T
Published: December 2021

Background

Approximately 30% of children are discharged from the hospital with an antimicrobial prescription; nearly a third of these prescriptions are suboptimal. Although the best approach to antimicrobial stewardship of discharge prescriptions remains uncertain, prospective audit and feedback (PAF) has improved inpatient antimicrobial use. We aimed to identify and characterize suboptimal discharge antimicrobial prescribing and assess the impact of inpatient PAF on the quality of discharge antimicrobial prescribing at a free-standing children’s hospital.

Methods

A retrospective review of enteral discharge antimicrobial prescriptions between 12/1/20-5/31/21 and parenteral antimicrobial prescriptions sent to our hospital’s infusion pharmacy between 3/1/21-5/31/21 was performed to determine if suboptimal or not. A prescription was determined to be suboptimal if the antimicrobial choice, dose, frequency, duration, formulation, or indication was not consistent with institutional and/or national guidelines. Data collection included the antimicrobial, indication, and prescribing medical service. Prescriptions were evaluated for a corresponding inpatient PAF for the same drug and indication and then stratified based on inpatient PAF completion.

Results

A total of 1192 discharge prescriptions for 698 unique patients over 834 hospital encounters were reviewed. Overall, 243 (20%) prescriptions were identified as suboptimal; reasons were duration (16%), dose (8%), frequency (5%), or antimicrobial choice, formulation, or route (≤1%). Prescriptions for cephalexin had the highest rate of suboptimal prescribing (80/167, 48%), followed by amoxicillin-clavulanate (89/203, 44%). A corresponding inpatient PAF was identified for 675 (57%) of discharge antimicrobial prescriptions. Inpatient PAF prior to discharge resulted in fewer suboptimal discharge prescriptions for the same antimicrobial (8% vs. 36%, p < 0.001).

Conclusion

Antimicrobial prescribing at inpatient discharge was suboptimal in 1 of every 5 prescriptions. Inpatient PAF was associated with improved antimicrobial prescribing at hospital discharge. Antimicrobial stewardship programs should continue to explore ways to capture and intervene on antimicrobials prescribed at discharge.

Disclosures

Hayden T. Schwenk, MD, MPH, Nothing to disclose
160. Urgent Care Prescriber Perspectives on Antibiotic Prescribing During the COVID-19 Pandemic
Authors: Betts Brooke , Ha David R , Holubar Marisa , Holubar Marisa , Artandi Maja , Onguti Sharon , Nelligan Ian
Published: December 2021

Background

Urgent care practices were significantly impacted by the COVID-19 pandemic. Studies conducted early in the pandemic demonstrated dramatic decreases in outpatient antibiotic prescribing, particularly amongst agents typically used for respiratory infections. We observed a 33% decline in urgent care antibiotics prescribing during the COVID-19 pandemic in our urgent care clinics. We investigated the prescriber experience to elucidate factors influencing antibiotic use for respiratory conditions during the COVID-19 pandemic at two academic urgent care clinics.

Methods

We employed a mix method approach, first distributing a survey to all full-time prescribers. We then followed up with qualitative interviews (12 of 22 prescribers) which was conducted by a single, trained interviewer using a standardized guide. Interviews were recorded and transcribed verbatim. Each transcription was independently reviewed and coded by two blinded investigators using standardized themes and adjudicated by a third investigator for stability, robustness, and interrater reliability. Individually, researchers identified and coded key themes and statements. These themes were then discussed as a group and combined where they shared meaning. This project was reviewed and deemed to be non-human subjects research by the Stanford University School of Medicine Panel on Human Subjects in Medical Research.

Results

A total of 20 of the 22 prescribers (13 MDs and 9 APPs) completed the survey (91% response rate). Notably, only 25% of prescribers agreed that COVID-19 had changed their antibiotic prescribing practices for patients with respiratory infections despite objective data that all prescribed less. In the qualitative interviews, we identified four major themes impacting the appropriateness of antibiotic prescribing practices as shown in Table 1.

Conclusion

Urgent care prescribers attributed a decrease in antibiotic prescribing during COVID-19 to changes in patient expectations and knowledge base, a switch to telemedicine-based encounters, and changing epidemiology. These shifts could be utilized by outpatient antimicrobial stewardship efforts to sustain low prescribing rates for conditions in which antibiotics are generally not indicated.

Disclosures

Marisa Holubar, MD, MS, Nothing to disclose
161. Flucytosine Utilization and Dosing Practices at an Academic Medical Center
Authors: Miller Molly M , Kreikemeier Emily , Stohs Erica J , Van Schooneveld Trevor C , Van Schooneveld Trevor C , Alexander Bryan , Bergman Scott J , Bergman Scott J
Published: December 2021

Background

The typical dose of flucytosine is 25 mg/kg/dose every 6 hours for severe infections due to Candida and Cryptococcus. Many hospital protocols use ideal body weight (IBW) for initial dosing to achieve a goal peak serum concentration of 30-80 mcg/mL, but this is supported by very limited data. Our objective was to evaluate flucytosine dosing strategies, describe safety concerns, and explore financial benefits associated with using IBW.

Methods

All inpatient flucytosine orders for adults from 1/1/2015 through 10/31/2020 were retrospectively evaluated. Doses, weight used, flucytosine levels, adverse events, and potential cost savings associated with IBW dosing were characterized.

Results

During this period, 35 patients received flucytosine. The most common indications were cryptococcal meningitis (73%), pulmonary cryptococcosis (14%), and candidiasis (11%). Most patients were receiving concurrent liposomal amphotericin B (92%). Based on body mass index, most patients were overweight or obese (60%). Actual body weight was used for initial dosing in most cases (81%). Flucytosine peak monitoring was performed in 51% of cases. Initial peak levels were supratherapeutic in 10/19 cases (53%). Of those 10 patients, 70% were overweight/obese, and 60% would have received a lower initial dose if IBW had been used with dose rounding to the nearest 500mg capsule. Adverse events for all patients included new onset cytopenias, hepatic and renal dysfunction, occurring in 20%, 11%, and 60% respectively. Those with supratherapeutic levels had higher rates of new onset hepatic and renal dysfunction, 30% and 90% respectively. In 32% of cases, using IBW would have resulted in a lower daily dose, with an average dose reduction of 1888 mg, resulting in a mean cost savings per patient of &640/day using average wholesale price.

Conclusion

Most flucytosine orders were not dosed using IBW, which may have led to supratherapeutic levels. Using IBW for dosing in overweight patients may lead to reduced toxicity and potential cost savings. The default dosing weight for flucytosine in our electronic medical record will be set to IBW to encourage change.

Disclosures

Trevor C. Van Schooneveld, MD, FACP, BioFire (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Insmed (Individual(s) Involved: Self): Scientific Research Study Investigator; Merck (Individual(s) Involved: Self): Scientific Research Study Investigator; Rebiotix (Individual(s) Involved: Self): Scientific Research Study Investigator Bryan Alexander, PharmD, Astellas Pharma (Advisor or Review Panel member) Scott J. Bergman, PharmD, FCCP, FIDSA, BCPS, BCIDP, Merck & Co., Inc (Grant/Research Support) Scott J. Bergman, PharmD, FCCP, FIDSA, BCPS, BCIDP, Merck & Co., Inc (Individual(s) Involved: Self): Research Grant or Support
163. MIC Shifts in Response to Increased Antibiotic Utilization During COVID-19 Pandemic
Authors: Byrd Jonathan , Thomas-Gosain Neena , Eason Jane V , Bennett Jessica , Bowden Jarred
Published: December 2021

Background

Multiple studies have shown that antibiotic utilization increased during the COVID-19 pandemic. However, the impact of this increased utilization has not been well established. The aim of this study is to describe the trends in minimum inhibitory concentrations for various antibiotics against common gram-negative pathogens observed since the start of the COVID-19 pandemic as compared to previous years.

Methods

This retrospective study was conducted at the Memphis VA. All respiratory, urine, and blood culture MicroScan results run from October 2017-March 2021 were analyzed. Only inpatient and emergency department data was included. The MIC50 and MIC90 of seven antibiotics for four of the most common pathogens were trended by quarterly intervals.

Results

MIC50 and MIC90 were compared using standardized breakpoints. As compared to previous years, Pseudomonas aeruginosa was noted to have the most sustained increase in MIC90 across various antibiotics. In the last 3 quarters of the study time frame, piperacillin-tazobactam mean MIC90 increased from 32 to 64, cefepime from 8 to > 16, and meropenem from 4 to > 8. Escherichia coli had a sustained increase in ceftriaxone MIC90 from < 1 to > 8 in the final quarter of 2020 and beginning of 2021. Klebsiella pneumonia was also found to have a sustained increase in cefepime mean MIC90 from < 1 to > 16 during the year of 2020, with return to previous MIC90 the following quarters.

Conclusion

Previous studies have clearly demonstrated a widespread increase in antibiotic utilization during the COVID era. Our study demonstrates how even short-term increases in antibiotic use can lead to shifts in MIC, if not outright resistance. This was demonstrated across multiple common gram-negative pathogens and to various broad-spectrum antibiotics which were commonly used more frequently during COVID-19. Further analysis will be needed to determine whether these trends continue or whether the decrease in antibiotic utilization in the recent months will lead to similar decrease in MIC.

Disclosures

All Authors: No reported disclosures
165. Decreased Antimicrobial Consumption and Decreased Rates of Multi-drug Resistant Organisms Following Onset of the COVID-19 Pandemic: Experience from an Australian Tertiary Hospital
Authors: Moso Michael , Cairns Kelly , Peel Trisha , Macesic Nenad
Published: December 2021

Background

Current guidelines recommend empiric antibiotics be used only for severe cases of coronavirus disease 2019 (COVID-19) or in cases where there is high clinical suspicion for bacterial co-infection. Level of adherence to guideline-recommended prescribing is unknown and high rates of antimicrobial prescribing may lead to increased development of resistance.

Methods

We reviewed antimicrobial prescribing patterns for patients with COVID-19 managed at The Alfred Hospital in Melbourne, Australia in 2020. Adherence to World Health Organization (WHO) guideline-based prescribing was assessed by manual review of case notes. Monthly hospital-wide antibacterial consumption April-Dec 2020 (post-pandemic period) was compared to Jan 2019-Mar 2020 (pre-pandemic period), measured as days of therapy (DOT) per 1000 patient-days. Rates of multi-drug resistant organisms (MRO) (including MRSA, VRE, CPE, ESBL) were compared between months in 2019 and 2020 after pandemic onset (April 2020) and expressed as isolates per 1000 patient-days.

Results

147 patients were managed for COVID-19 in 2020 at our centre. 101 patients required hospital admission and 58 (39%) were classified as either severe or critical in severity. 80 (54%) patients received empiric antimicrobial treatment, including 78/101 (77%) of hospital inpatients and 24/26 (92%) of ICU-admitted patients. 59 (73%) of antimicrobial prescriptions were adherent to WHO guidelines. Monthly antibacterial consumption was significantly lower post-pandemic than in the pre-pandemic period (mean 853 vs 902 DOT/1000 patient-days, P=0.0065). Antimicrobial use patterns varied, with significant decreases in commonly used antibiotics such as ceftriaxone, piperacillin-tazobactam, azithromycin and ciprofloxacin but no change in vancomycin or meropenem (Figure 1). There was a mean decrease of 0.77 MRO isolates/1000 patient-days (P=0.026) when each month in 2020 was compared with the corresponding month in 2019 (Figure 2).

Antibacterial consumption in 2019 and 2020 by month, expressed as days of therapy/1000 patient-days.

Rates of isolated multi-drug resistant organisms in 2019 and 2020 by month, expressed as isolates/1000 patient-days.

Conclusion

A high proportion of admitted patients with COVID-19 received empiric antibiotics. In spite of this, we observed a significant reduction in total antimicrobial consumption and reduced rates of MRO isolation in the post-pandemic period.

Disclosures

All Authors: No reported disclosures
166. Evaluation of Daptomycin Prescribing Practices Based on Microbiologic Susceptibility Determination of “Susceptible-Dose Dependent” (SDD)
Authors: Rowley Amy , Marx Ashley H , Weber David J , Weber David J
Published: December 2021

Background

Recent changes in CLSI microbiologic interpretations of daptomycin and enterococci include the “susceptible-dose dependent” (SDD) category. The effectiveness of SDD for directing clinicians to employ higher dosing of daptomycin is unknown. The study objective was to determine if implementation of SDD paired with a comment recommending higher doses of daptomycin (8-12mg/kg) and ID consultation in 2019 was associated with changes in rates of daptomycin use and prescribed doses for enterococcal bloodstream infections (BSI).

Methods

Single-center, retrospective cohort study of adult inpatients with enterococcal BSI and daptomycin susceptibility results reported from Aug 2016-Jul 2020. Chart review was performed to collect demographics, source of infection, and clinical management strategy. Rate of daptomycin use for definitive therapy (antimicrobial on day 4 after final susceptibilities) and median prescribed dose were compared for BSI caused by S and SDD isolates. Annual (Aug 1-Jul 31) trends in infections and daptomycin use were tabulated.

Results

189 blood cultures were reviewed, yielding 56 unique episodes of enterococcal BSI. Patients had a mean age of 59 years and majority had an immunocompromising disease or medication. Of the cases in which it was a clinically appropriate option, clinicians selected daptomycin for definitive treatment in 81% of S and 71% of SDD cases (p = 0.46, Chi-square). Median daptomycin dose prescribed was 10mg/kg for both interpretations; dose range was 6-12mg/kg for S and 9.5-12mg/kg for SDD isolates. No temporal trend in prescribed dose noted over the 4-year study period. Repeat blood cultures performed in 50/56 (89%). Within 90 days, rates of relapse were low but mortality was 26/56 (46%).

Table 1. Infection and Treatment Characteristics

Chart 1. Frequency of prescribed daptomycin dose (mg/kg) for susceptible (A) and SDD (B) enterococci BSI isolates.

Conclusion

No difference detected in rate of daptomycin use nor median prescribed dose based on microbiologic interpretation. While the majority of doses were adequate (10mg/kg) based on current guidance for enterococcal BSI, the use of a directive comment to guide dosing and ID consultation may have recused outliers. Additional data is needed to characterize the impact of specific microbiologic interpretations on clinician prescribing and determine the most effective messaging strategies.

Disclosures

David J. Weber, MD, MPH, PDI (Consultant)
167. Incidence of Acute Kidney Injury with Aminoglycoside Impregnated Foreign Body Implantation
Authors: Royster Kelly , Chan Dominic
Published: December 2021

Background

During orthopedic surgeries, antibiotic impregnated cement is sometimes used to prevent infection. Elution from these cements can lead to systemically detectable levels of aminoglycosides, a known adverse effect of which is nephrotoxicity. The purpose of this study is to determine if the implantation of aminoglycoside impregnated cement is associated with subsequent development of Acute Kidney Injury (AKI).

Methods

A retrospective chart review from 1/1/2018-1/1/2021 was conducted to identify a relationship between aminoglycoside impregnated cement and subsequent development of AKI. Data were extracted from Electronic Health Records (Epic) and SAP Business Objects WebI. All patients with knee or hip arthroplasty or hardware removal procedures conducted at a Legacy Health facility during the specified time frame were included. Patients were excluded from the study if < 2 serum creatinine levels were drawn during that hospitalization, AKI occurred prior to the procedure, or dialysis was required at baseline. The primary outcome was development of AKI, a > 150% increase from baseline serum creatinine according to the Acute Kidney Injury Network (AKIN) criteria. The power level was set to 80% with an alpha level of 0.05. A multiple regression analysis was conducted to control for confounding variables

Results

A total of 2229 patients were included (591 received aminoglycoside cement,1638 did not). Aminoglycoside impregnated cement implantation was not associated with an increased incidence of AKI (1.5% versus 2.3%, P = 0.25). After controlling for covariates, aminoglycoside cement was not associated with development of AKI (adjusted OR 0.68, P = 0.32).

Conclusion

The results of this study suggest aminoglycoside impregnated foreign body implantation was not associated with a greater incidence of AKI development compared to implantation of foreign bodies lacking aminoglycosides. It is possible that development of AKI post-discharge was not identified in patients with uncomplicated procedures due to omission of lab draws once discharged. Patients admitted for longer durations were more likely to have multiple serum creatinine labs drawn during hospitalization, and likely had multiple comorbid conditions or complications, innately biasing and predisposing AKI development.

Disclosures

All Authors: No reported disclosures
168. Syndrome-Based Analysis of Oral Antimicrobial Stewardship Opportunities at Hospital Discharge
Authors: Cunningham Jessica , Binkley Shawn , Uritsky Tanya , Saw Stephen , Patel Sonal , Lee Tiffany , Hamilton Keith W , Degnan Kathleen , Dutcher Lauren , Athans Vasilios
Published: December 2021

Background

Suboptimal oral antibiotic prescriptions (OAPs) are prevalent at discharge and contribute to treatment failure, resistance, toxicity, and excess costs. Syndrome-specific prescribing patterns have not been widely described at discharge, nor have specific reasons for excessive treatment durations (the most commonly cited prescribing error).

Methods

Retrospective cohort of patients discharged from a general medicine service at an academic hospital with ≥1 OAP for urinary tract infection (UTI), skin and soft tissue infection (SSTI), or lower respiratory tract infection (LRTI). Study period varied to include a random sample of encounters occurring after the most recent institutional guideline update for each syndrome. Exclusions: multiple infectious indications, discharge against medical advice, parenteral antibiotics at discharge, pregnancy, cystic fibrosis, and immunocompromising conditions. Discharge OAPs were assessed for suboptimal selection, dose, frequency, or duration according to institutional guidelines (with secondary adjudication).

Results

Analysis included 160 encounters: 70 UTIs, 66 SSTIs, and 24 LRTIs. Of 71 (44%) culture-positive infections, Enterobacterales (61%) and Streptococcus spp. (15%) were most often identified. In total, 180 OAPs were issued – most commonly cefpodoxime (21%), cefadroxil (18%), and doxycycline (17%). Overall, 99 (62%) encounters were associated with a suboptimal discharge OAP. Of 138 suboptimal characteristics identified, suboptimal duration was most frequent (57%), specifically excessive duration (45%). Proportion of suboptimal OAPs and their underlying reasons are analyzed by syndrome in Figures 1 and 2, respectively. Miscalculation (39%), intentional selection of guideline-discordant duration (29%), and omission of inpatient antibiotic days (19%) were the most frequent reasons for suboptimal duration (Fig. 3).

Conclusion

Suboptimal discharge OAPs were common for all studied syndromes, most notably SSTI. Excessive duration was a key driver, with reasons for inappropriate duration previously undescribed. Duration miscalculation and selection of appropriate treatment duration are key areas to focus electronic health record enhancements, provider education, and antimicrobial stewardship efforts.

Disclosures

All Authors: No reported disclosures
169. Prevalence and Associated Patient Characteristics of Multi-Drug Resistant Organisms and Antibiotic Prescribing Patterns in Hospitalized Patients with Community-Acquired Pneumonia
Authors: Rodriguez Leah , Morita Kazumi , Tencza Elizabeth , Mueller Daniel
Published: December 2021

Background

The 2019 Infectious Diseases Society of America/American Thoracic Society community-acquired pneumonia (CAP) guidelines eliminated the term healthcare-associated pneumonia (HCAP), and recommends to guide the use of broad-spectrum antibiotics by locally validating the prevalence and risk factors of multi-drug resistant organisms (MDROs). The objective of this study is to determine the prevalence and associated patient characteristics of MDROs, and to characterize antibiotic prescribing patterns.

Methods

This was a retrospective, cohort study in adult patients hospitalized from 1/1/19 to 12/31/19. Patients were randomly selected from a patient list of diagnosis codes suggestive of pneumonia. We excluded patients with antibiotic therapy < 48 hours, bacterial co-infections from another site, or transferred from another hospital with length of stay >24 hours. Endpoints evaluated include the percentage of MDRO isolated from a respiratory or blood culture collected within 2 days of admission, comparison of patient characteristics associated with MDROs with those who did not, treatment regimen and duration, and rate of overtreatment and undertreatment.

Results

A total of 220 patients were included. Prevalence of overall MDRO, methicillin-resistant Staphylococcus aureus (MRSA), and Pseudomonas aeruginosa (PSA) was 8%, 3%, and 5%, respectively. Patient characteristics associated with MDROs from are shown in Table 1. Prior MDRO history or recent intravenous (IV) antibiotic exposure during hospitalization was present in 39% of the MDRO cohort. Over half (58%) of the patients were initiated on antibiotics with MRSA and/or PSA coverage. Rate of overtreatment and undertreatment was 89% and 5%, respectively. Mean antibiotic duration was 9 ± 3 days.

Conclusion

The low prevalence of MDROs, coupled with the high overtreatment and low undertreatment rate suggests most patients hospitalized with CAP at our institution can receive an antibiotic regimen targeting standard CAP pathogens. Antibiotic stewardship intervention to shorten the duration of therapy should be considered. In addition to microbiology history and recent IV antibiotic exposure during hospitalization, further studies are needed to validate other patient characteristics at risk for MDROs.

Disclosures

All Authors: No reported disclosures
170. Antimicrobial Use Before and During COVID-19 – Data from 108 VA Facilities
Authors: Goetz Matthew B , Goetz Matthew B , Willson Tina M , Stevens Vanessa W , Graber Christopher J , Rubin Michael
Published: December 2021

Background

Increased antibiotic prescribing rates during the early phases of the COVID-19 pandemic have been widely reported. We previously reported that while both antibiotic days of therapy (DOT) and total days present (DP) declined in the first 5 months of 2020 at Veterans Affairs (VA) acute care facilities nationwide relative to the comparable period in 2019, antibiotic DOT per 1000 DP increased by 11.3%, largely reversing declines in VA antimicrobial utilization from 2015 – 2019. We now evaluate whether these changes in antibiotic use persisted throughout the COVID-19 pandemic.

Methods

Data on antibacterial use, patient days present, and COVID-19 care for acute inpatient care units in 108 VA level 1 and 2 facilities were extracted through the VA Informatics and Computing Infrastructure; level 3 facilities which provide limited acute inpatient services were excluded. DOT per 1000 DP were calculated and stratified by CDC-defined antibiotic classes.

Results

From 1/2020 to 2/2021, care for 34,096 COVID-19 patients accounted for 13% of all acute inpatient days of care in the VA. Following the onset of COVID-19 pandemic, monthly total acute care antibiotic use increased from 533 DOT/1000 DP in 1/2020 to a peak of 583 DOT/1000 DP in 4/2020; during that month COVID-19 patients accounted for 13% of all DP (Figure). In subsequent months, total antibiotic use declined such that for the full year the change of antibiotic use from 2019 to 2020 (a decrease of 18 DOT/1000 DP) was similar to the rate of decline from 2015 to 2019 (mean decrease of 13 DOT/1000 DP; Table). The decreased DOT/1000 DP from 5/2020 to 2/2021 occurred even as the percentage of all DP due to COVID-19 peaked at 14 - 24% from 11/2020 to 2/2021.

Conclusion

Although rates of antibiotic use increased within the VA during the early phases of the COVID-19 pandemic, rates subsequently decreased to below previous baseline levels even as the proportion of COVID-19 DP spiked between 11/2020 and 02/2021. Although the degree to which the initial increase in antibiotic use is attributable to concerns of bacterial superinfection versus changes in case-mix (e.g., decreased elective admission) remains to be assessed, these data support the continued effectiveness of antimicrobial stewardship programs in the VA.

Disclosures

Matthew B. Goetz, MD, Nothing to disclose
171. A Multicenter Analysis of Inpatient Antibiotic Use During the 2015-2019 Influenza Season in the US: Untapped Opportunities for Antimicrobial Stewardship
Authors: Amiche Amine , Kabler Heidi , Weeks Janet , Yu Kalvin , Gupta Vikas
Published: December 2021

Background

Inappropriate antibiotic (AB) use for viral respiratory illnesses remains widespread in the United States (US) with strong seasonal fluctuations. In contrast to outpatient AB use, the seasonality inpatient AB utilization (IAU) and its correlation with the influenza season are not well understood. We sought to describe trends, seasonality, and the association between IAU use and the 2015-2019 influenza seasons.

Methods

We used the BD Insights Research Database (Franklin Lakes, NJ USA) to identify IAU that were prescribed in patients >17 years old from up to 236 US acute care facilities from July 2015 to December 2019. We included the following AB categories: extended spectrum cephalosporins (ESCs), macrolides, β-lactam inhibitor combination (BLIC), fluoroquinolones, carbapenems, glycopeptides, lipopeptide, tetracyclines, and others. We defined IAU use as days of therapy (DOT) per 1000 patient days present. We used influenza laboratory data to identify facility-level positivity ratio per 100 tests. We used random effect models to estimate IAU: 1) trends overtime, 2) seasonality, and 3) association with influenza positivity rate.

Results

For IAU from 2015 to 2019, BLICs, ESCs, and glycopeptides were the most used [average 91, 107, and 96 DOT/1000 days presents, respectively]. Visually, we observed strong seasonality that matches the influenza season for macrolide, ESC, and quinolone use (See Figure). Unadjusted bivariate results showed ascending trends over time for BLICs [β= 3.8, p= .003], ESCs [β= 11.0, p= .005], and macrolides [β=1.5, p= .005]. Unadjusted bivariate results showed descending trends with quinolones [β= -10.9, p< .001] and others [β= -2.060, p< .001]. In the adjusted analysis, increased influenza positivity rate was associated with use of ESCs, glycopeptides, lipopeptides, macrolides, fluoroquinolone, and tetracyclines (see Table). No correlation was observed with BLICs, carbapenems, lipopeptides, and Others.

IAU (DOT/1000 days presents) and Flu Rate (% Positive) Trends Over Time

Conclusion

Our study shows that IAU is on the rise for the ESC and BLIC classes. ESC and macrolide use was strongly correlated with influenza season. Monitoring influenza signals may provide more insights that can inform the interpretation of IAU trends and be incorporated into antimicrobial stewardship programs.

Disclosures

Amine Amiche, PhD, Sanofi (Employee, Shareholder) Heidi Kabler, MD, Sanofi Pasteur (Employee) Janet Weeks, PhD, Becton, Dickinson and Company (Employee) Kalvin Yu, MD, BD (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)
172. Inpatient Antibiotic Prescribing Patterns Using the WHO Access Watch and Reserve (AWaRe) Classification in Okinawa, Japan: A Point Prevalence Survey
Authors: Patel Payal K , Satoh Naoyuki , Narita Masashi , Cho Yoshiaki , Oshiro Yusuke , Suzuki Tomoharu , Fowler Karen E , Todd Greene M , Tokuda Yasuharu , Kaye Keith S
Published: December 2021

Background

Few studies have been done on inpatient antibiotic use in Japan and antibiotic stewardship programs with dedicated full-time equivalents are rare. We sought to better understand inpatient antibiotic use in Okinawa, Japan. We applied the World Health Organization (WHO) Access, Watch and Reserve (AWaRe) Classification to compare our findings to international literature. Access antibiotics are common front-line antibiotics, Watch antibiotics are high-priority antibiotics with toxicity or resistance concerns, and Reserve antibiotics are last-line treatments for multi-drug resistant infections.

Methods

A point prevalence study was conducted in five hospitals in Okinawa, Japan on Oct 1, 2020. Physicians conducted chart reviews of all patients receiving intravenous antibiotics. Type of antibiotic, reason for use, duration, and microbiologic data was collected. The primary aim was to evaluate the proportion of patients who received antibiotics on the assessment date; secondary aims were to categorize antibiotics according to indication, class and AWaRe classification. Descriptive statistics were used to derive the distribution of AWaRe Classifications and drug class.

Results

1,728 unique patients were included and 504 (29%) received ≥1 antibiotic on the assessment date. A total of 559 antibiotics were used for 504 patients and 22.0% (n=123) were for prophylaxis. Of those receiving antibiotics for treatment (N=436), 385 (88.3%) patients had a documented infection source. The most common indications for antibiotic use were pneumonia (24.2% n=93), urinary tract infection (19.7% n=76), and intraabdominal (17.9% n=69). Overall, 43.1% (n=241) of the antibiotics were categorized Access and 54.4% (n=304) Watch [Figure 1]. Cephalosporins were the most common antibiotic class (56% n=313), followed by β-lactam inhibitors (18% n=106) and narrow penicillins (8.2% n=46) [Figure 2].

Conclusion

29% of inpatients in these 5 Okinawan hospitals were prescribed an antibiotic on the survey date. A majority of antibiotics used fall under the WHO AWaRe Watch classification which are antibiotics that may be more likely to cause resistance. Understanding appropriateness of antibiotics used in this population could inform antibiotic stewardship strategies and reduce antibiotic resistance.

Figure 1. Antibiotic Distribution According to World Health Organization (WHO) Access, Watch and Reserve (AWaRe) Classification

Figure 2. Antibiotic Distribution by Class in Okinawan Hospitals

Disclosures

All Authors: No reported disclosures
173. Antimicrobial Stewardship Education Changes Prescribing Behavior and Reduces Treatment of Asymptomatic Bacteriuria
Authors: Arab Niki , Gupta Bali , Kim Brian , Jeng Arthur
Published: December 2021

Background

Treatment of asymptomatic bacteriuria (ASB) outside of pregnancy and urological procedures increases the risk of antibiotic resistance without improving outcomes. At Olive View-UCLA Medical Center (Sylmar, CA), the CDC U.S. Antibiotic Awareness Week (AAW) was utilized as a platform to promote antimicrobial stewardship (AS) for ASB. We evaluated the incidence of antibiotic treatment of ASB pre-AAW vs post-AAW, and the impact of AS education on future prescribing practices for ASB.

Methods

In this single-center retrospective observational study, AS education defining ASB vs urinary tract infection (UTI) was provided via visual aids distributed throughout the hospital during AAW from 11/18/2020 to 11/24/2020 (Figure 1). All positive urine cultures (Ucx) for adult inpatients were reviewed prior to AAW from 9/2020 to 11/2020 and after AAW from 12/2020 to 1/2021. Patients were excluded if they were unable to report UTI symptoms, pregnant, or undergoing urological procedure. The incidence of ASB treatment pre- and post-AAW was compared. A survey was sent to providers to compare the impact on antibiotic prescribing behavior for ASB pre- and post-AAW. Fisher’s exact and Chi-squared tests were used for statistical analysis.

Figure 1. Antimicrobial Stewardship Education and Poster Distribution

Results

A total of 260 cases met study eligibility. In the pre-AAW group, 56 of 131 cases presented with ASB, of which 16 were treated with antibiotics (28.6%). In the post-AAW group, 55 of 129 cases presented with ASB, and 5 were treated with antibiotics (9.1%). Antibiotics were prescribed more often for patients with ASB in the pre-AAW group compared to those in the post-AAW group (p=0.014). Forty providers completed the survey, of which 97.5% had seen the visual aids, 70% had found the education "very” or “extremely" useful, and 43.6% reported they “always or sometimes” treated ASB pre-AAW vs 15% post-AAW (p< 0.01).

Conclusion

AS posters and education defining ASB significantly decreased the treatment of ASB. AAW education on ASB antimicrobial stewardship demonstrated a high value and shifted prescribing behavior to avoid antibiotic treatment of ASB. A similar approach to deliver provider education could serve as a valuable model to change provider AS practices for ASB.

Disclosures

All Authors: No reported disclosures
175. Assessment of Institutional Uptake of Vancomycin AUC Monitoring One-Year Post Guideline Publication in Hospitals Across the United States
Authors: Bradley Nicole , Lee Yuman , Francis Ariel E , Iregbulem Duchess
Published: December 2021

Background

A new therapeutic monitoring of vancomycin for serious methicillin resistant Staphylococcus aureus infections guideline was published in March 2020. The guideline recommends a change in monitoring from trough to AUC/MIC based to improve patient outcomes. The purpose of this study was to determine institutional uptake of vancomycin AUC monitoring 1-year post guideline publication in hospitals across the U.S.

Methods

An electronic survey was created to assess vancomycin AUC monitoring practices and distributed to the American College of Clinical Pharmacy Infections Diseases Practice and Research Network (ACCP IDprn) and American Society of Health System Pharmacists (ASHP). Initial survey distribution (phase 1) occurred May-June 2020 and aimed to serve as baseline data. The survey was re-distributed (phase 2) to the ACCP IDprn and ASHP one year later, May-June 2021. Prior to re-distribution the survey was updated to assess the impact of COVID-19 on uptake. Results were analyzed and reported using descriptive statistics. Chi-Square tests were used to compare categorical data.

Results

A total of 202 responses to phase 1 and 138 responses to phase 2 were recorded. Significantly more respondents implemented AUC monitoring 1-year post guideline than at baseline (42.8% vs 29.8%, p= 0.013). In both phases, 57% of those who had not implemented AUC monitoring had plans to do so over the next year. Additionally, 46.2% phase 2 respondents reported COVID-19 impacted their ability to transition to AUC monitoring citing issues such as lack of time and inadequate resources. The most common AUC monitoring programs utilized at baseline and 1-year post guideline were purchased Bayesian software (38.3% vs. 35.6%) and homemade software (26.1% vs 23.7%). Perceived challenges to implementing AUC monitoring included cost, difficult use and integration.

Conclusion

Increased uptake of vancomycin AUC monitoring occurred from baseline to 1-year post guideline publication. However, less than half of hospitals implemented this recommendation. Although COVID-19 impacted a large portion respondents’ ability to implement AUC monitoring, majority plan to transition to vancomycin AUC monitoring over the next year. AUC monitoring should be adapted by all hospitals to optimize vancomycin efficacy and safety.

Disclosures

All Authors: No reported disclosures
176. Topical Antibiotic and Antiseptic Use in the Operating Room: An Opportunity for Antimicrobial Stewardship?
Authors: Nissan Josef Hadib , Murphy Nina Naeger , Patel Nilam , Borovicka Mary , Hecker Michelle , Gothard David
Published: December 2021

Background

Data suggest that topical antibiotic and antiseptic use in the operating room is common but not commonly monitored by antimicrobial stewardship programs. Although some data suggest a benefit in certain surgical procedures, the CDC and WHO advise against the routine use of topical antibiotics in surgery due to uncertainty and heterogeneity in the overall data.

Methods

We conducted a retrospective 28-day period prevalence study of topical antibiotic and antiseptic use during surgical procedures performed in the operating room by 6 surgical specialties at a tertiary care medical center. For the subset of patients undergoing orthopedic surgeries, we evaluated the types of topical antibiotics received and the rates of surgical site infections (SSI) and adverse drug events within 28 days of the procedure.

Results

Of 744 surgical procedures reviewed, topical antibiotics were used in 127 (17.1%), topical antiseptics in 71 (9.5%), and both in 18 (2.4%) (Table 1). Antiseptic use was higher in orthopedics relative to all other surgical specialties while topical antibiotic use was higher in neurosurgery. Hand, vascular and plastics had distinguishably lower use. In the orthopedic subgroup, after exclusions, 218 procedures were evaluated. Topical antibiotics were used in 42 (19.2%). Topical antibiotic therapy was more likely to be administered if prosthetic material was implanted, the procedure was emergent, or if a Staphylococcus aureus infection was present. Vancomycin was the most commonly used topical antibiotic and powder was the most commonly used type of application. As shown in table 2, SSI occurred more often when both topical antibiotics and antiseptics were applied; however, SSI events were relatively uncommon, and these were more likely to have infection present at the time of surgery. Adverse events were rare.

Conclusion

In our institution we noted significant variability in use of topical antibiotic and antiseptic therapy among surgical specialties as well as within the orthopedic surgical specialty. Although opportunities to standardize use/nonuse of these therapies exist, this may be challenging due to the uncertainty and heterogeneity of currently available data.

Disclosures

All Authors: No reported disclosures
178. Comparing the Incidence of Multidrug Resistant Bacteremia, Fungemia and Hospital-acquired Clostridioides difficile Infection in COVID-19 Versus Non-COVID-19 Patients: a Single Hospital, One-year Observational Study in New York City
Authors: Chiu Chia-Yu , Sarwal Amara , Widjaja Michael , Feinstein Addi
Published: December 2021

This abstract has been withdrawn.
179. Follow-up Blood Cultures for Gram-negative Bacilli Bacteremia Were Associated with Prolonged Length of Hospital Stay and Duration of Antibiotic Treatment: A Propensity Score-matched Cohort Study
Authors: Mitaka Hayato , Kuno Toshiki , Fujitani Shigeki
Published: December 2021

Background

It remains unclear if follow-up blood cultures (FUBCs) for Gram-negative bacilli (GNB) bacteremia should be performed routinely to document clearance of bacteremia due to lack of evidence on the value of FUBCs for GNB bacteremia.

Methods

We conducted a retrospective, multicenter observational study at 4 acute care hospitals to examine if FUBCs are associated with length of hospital stay, duration of antibiotic treatment, and mortality of hospitalized patients with GNB bacteremia. Participants included adult patients who were hospitalized between January 2017 and December 2018 with GNB bacteremia. Patients with and without FUBCs were propensity score-matched with a 1:1. The primary outcomes were in-hospital mortality, length of hospital stay, and duration of antibiotic treatment during the hospital stay.

Results

Of the 442 hospitalized adult patients with GNB bacteremia, 381 were included in the study. Of those, FUBCs were performed in 276 patients (72%). After propensity score matching, we included 87 patients with FUBCs and 87 patients without FUBCs for comparing outcomes. The median length of stay was longer in patients with FUBCs (9 days [interquartile range, 6.0–14.0]) compared with patients without FUBCs (7 days [interquartile range, 4.5–10.5]; P=0.017). The median duration of antibiotic treatment was also longer in patients with FUBCs (8 days [interquartile range 5.5–13.0]) compared with patients without FUBCs (6 days [interquartile range, 4.0–10.0]; P=0.007). No statistically significant difference was observed in in-hospital mortality between patients with and without FUBCs (adjusted odds ratio = 0.37; 95% confidence interval, 0.081–1.36).

Conclusion

Performing FUBCs for GNB bacteremia were associated with prolonged length of hospital stay and duration of antibiotic treatment but not with mortality.

Disclosures

All Authors: No reported disclosures
180. Duration of Therapy and Clinical Outcomes in Adult Oncology Patients with Uncomplicated Coagulase Negative Staphylococcal Bacteremia
Authors: Fairbanks Amanda , Li Jessica , Sweet Ania , Tverdek Frank , Liu Catherine
Published: December 2021

Background

Although they are often considered contaminants, coagulase negative staphylococci (CoNS) can be pathogens especially in immunocompromised patients. National and local guidelines recommend treatment durations of 7 to 14 days, depending on specific clinical scenarios. The objective was to characterize the duration of treatment for CoNS bacteremia and clinical outcomes at our cancer center.

Methods

We conducted a retrospective chart review of adult patients ≥18 years old with ≥1 blood culture with growth of CoNS between 1/1/17 and 12/31/19 at our cancer center. Patients with complicated CoNS bacteremia and polymicrobial infections were excluded.

Results

Among 128 patients identified during the study period, 98 met inclusion criteria (Figure 1). Most patients (N= 92; 94%) had a hematologic malignancy as the underlying oncologic diagnosis, and 68 (69%) were hematopoietic stem cell transplant recipients. The median total antibiotic duration was 13 days, and median duration from the date of 1st negative blood culture was 12 days; 29 (30%) patients were treated for a total duration of >14 days (Figure 2). The catheter was retained in 67 (68%) and exchanged in 4 (4%) of the cases. Three (3%) patients had recurrence of bacteremia within 30 days of treatment completion, and 8 (8%) patients were transferred to the ICU within 7 days of the index blood culture. The 30-day crude mortality rate was 10%. The most commonly used antibiotic for treatment was vancomycin (N= 95; 97%), and 32 (34%) patients on vancomycin had an increase in serum creatinine of ≥ 50% from baseline. Five (5%) patients discontinued vancomycin due to nephrotoxicity, and 4 (4%) patients required hemodialysis.

Figure 1. Results Overview

Among 128 patients identified during the study period, 98 met inclusion criteria. Of those included, 36 had one set of blood cultures that were positive for CoNS and 62 patients had at least two sets of blood cultures that were positive for CoNS.

Figure 2. Duration of Antibiotic Treatment

We evaluated duration of treatment based on total antibiotic duration and duration from date of 1st negative blood culture. The number of patients is noted above each bar.

Conclusion

Although the majority of patients were treated for ≤14 days for uncomplicated CoNS bacteremia, nearly 1/3 of patients were treated for > 14 days. Recurrent bacteremia was uncommon despite catheter retention in most patients. Relatively high rates of vancomycin associated nephrotoxicity highlight opportunities for antimicrobial stewardship to limit duration of vancomycin therapy among cancer patients with uncomplicated CoNS bacteremia.

Disclosures

All Authors: No reported disclosures
182. Clinical Presentation of Patients with Staphylococcus lugdunensis Positive Blood Cultures After the Implementation of Rapid Molecular Blood Culture Diagnostics
Authors: Constance Kristin , Hunt Alauna , Karimaghaei Sam , Masayuki Nigo
Published: December 2021

Background

Since the implementation of improved laboratory techniques, coagulase negative Staphylococcus (CoNS) have been routinely speciated to screen for S. lugdunensis (SL), which has led to increased identification. The objective of this study is to describe the characteristics of patients with SL positive blood cultures after the introduction of Verigene® Gram-Positive Blood Culture Nucleic Acid Test (BC-GP) in two large medical systems.

Methods

Retrospective review of all blood culture isolates positive for SL from Memorial Hermann Hospital System (14 hospitals) and HarrisHealth System (two acute care hospitals) since implementation of BC-GP.

Results

Between 2017 – 2021, 157 patients had SL positive blood cultures. 18 were eliminated as cultures were positive for bacteria other than CoNS, and 7 eliminated as patients were discharged prior to culture results. Of the remaining 132 patients, 39 (29.5%) were labelled contaminants by the treating physician and 93 were considered true bacteremia. Patients with hardware/implanted materials were more likely considered to have true bacteremia, while patients with other CoNS species in blood cultures were more likely considered contaminants. Only one death was attributed to SL bloodstream infection in the true bacteremia group. None of the deaths in the contaminated group were attributed to SL infection. Of the 93 patients labelled true bacteremia, the source was most frequently listed as central line associated bloodstream infection (17.2%), followed by skin/soft tissue infection (11.8%), and infective endocarditis (IE) (10.8%).

Table 1. Characteristics of Patients with S. lugdunensis Positive Blood Cultures

Conclusion

In our study, 29% of patients with positive blood culture for SL were deemed contaminants. Patients without hardwares or positive concomitant other CoNS species from the same blood culture were often considered as contaminated cases. The incidence of IE remains as high as 10.8% in those patients identified to have true bacteremia (7.6% overall in our cohort), although lower than previously reported cases. Careful evaluation is warranted in patients with positive SL blood culture to rule out severe infections and avoid unnecessary courses of antibiotic therapy. This study suggests that increased identification of SL may impact our understanding of its significance and pathogenicity over time.

Disclosures

All Authors: No reported disclosures