bluuebunny/crossref_metadata_2025 huggingface dataset:
76. Uncomplicated Urinary Tract Infections in the Multi-resistance Era: Is It Time of Microbiologic Diagnosis? An Observational Study in Buenos Aires City
Authors: Otreras Alvaro , Sabato Sofia , D′Alessandro Daniela , Errea Sylvia , Bottaro Edgardo , Ormazabal Cecilia , Alfonso Claudia , Scapellato Pablo
Published: December 2021

Background

Uncomplicated urinary tract infection (uUTI) is one of the main causes of antibiotics prescription in outpatient setting. Current recommendations, based on studies from pre-antimicrobial resistance era, suggest that diagnosis of uUTI can be made based on clinical symptoms and that urine analysis leads only to a minimal increase in diagnostic accuracy. We analyzed urine cultures (UC) from patients with clinical diagnosis.

Methods

Prospective and observational study carried out in an Emergency Department during August 2016 to August 2017. Women older than 15 years with 2 or more classic symptoms of uUTI and the absence of vaginal discharge and irritation were included. Those with complicated and recurrent urinary tract infection (UTI) were excluded. Urine cytology and UC were performed in all episodes. A bivariate and multivariate analysis was performed considering the probability of having a positive urine culture according to the different symptomatology variables.

Results

We enrolled 208 patients, with a median age of 25 (14-68 years). Previous UTI 6 (2.9%), previous antibiotic (last 3 months) 20 (9.6%). Inflammatory cytology 173 (83.2%), positive UC 109 (52.4%), cystitis 155 (74.5%). Symptoms: dysuria 154 (74%), frequency 111 (53.4%), tenesmus 97 (46.6%), fever 78 (37.5%), hematuria 43 (20, 7%), hypogastric pain 128 (61.5%), back pain 84 (40.4%). Combinations of 3 or more classic symptoms occurred in 52 (25%) episodes. The most frequent association was dysuria, frequency and tenesmus. No statistically significant association was found either in the bivariate or multivariate analysis in relation to presenting positive UC (Tables 1 and 2).

Conclusion

The results show that almost 50% of the patients with a clinical diagnosis of UTI had a negative urine culture. We consider it necessary to rethink the prescription of antibiotics without microbiological confirmation in the first episode of uUTI as a strategy to reduce inappropriate use of antibiotics.

Disclosures

All Authors: No reported disclosures
77. Opportunity for Improved Use of a Commercially Available Meningitis/Encephalitis Panel in Pediatric Patients
Authors: Valentine Marilyn E , Olson Jared , Thorell Emily A , Bonkowsky Anne , Lake Jason
Published: December 2021

Background

The BioFire® FilmArray Meningitis/Encephalitis (ME) panel delivers timely CSF analysis when meningitis or encephalitis is suspected and has the potential for earlier optimization of patient care. It is unclear if the M/E panel provides incremental benefit over standard microbiologic methods such as culture and cell counts, especially in the absence of significant pleocytosis. We evaluated the clinical utility of the ME panel with respect to CSF white blood cell count per high power field (WBC/hpf) and patient age.

Methods

We identified paired CSF ME panels and CSF cultures collected throughout a large healthcare system from 2016–May 2021 in children < 18 years of age. CSF results from the same calendar day were included in the dataset. We reviewed standalone HSV and Enterovirus (EV) CSF studies to determine frequency of duplicative testing. Results were stratified by CSF WBC/hpf and patient age (< 14 days, 14–60 days, > 60 days and < 5 years, and > 5 years).

Results

1045 paired cultures and ME panels were identified. Of those, 921 (88%) ME panels were negative, but 5 of those cultures grew bacteria. Of 124 (12%) positive ME panel results, 66% were viral: 46 (37%) EV, 22 (18%) HHV-6 and 6 (5%) parechovirus. In 498 cases, ME panels were sent when CSF had < 10 WBC/hpf, resulting in only 2 (0.4%) PCRs positive for bacteria, one which was gram stain positive and the other was considered a false positive (Table 1). In addition to a ME panel, standalone PCRs for enterovirus and HSV were sent in 134 (13%) and 213 (20%) of cases, respectively, with < 2% discordance. Pathogen distribution by ME panel did not vary with age (Table 2).

Meningitis and encephalitis panel, standalone PCR and culture results overall and by age group.

Conclusion

In our cohort, the ME panels were overwhelmingly negative. Only 12% of ME panels were positive, mostly with self-limited viral pathogens (e.g., EV, parechovirus). Performance was worse when samples had < 10 WBC/hpf. Duplicative testing was common and had no benefit. Performance was similar across age groups. More targeted use of the ME panel could improve the utility and efficacy of this test.

Disclosures

Anne Bonkowsky, MD/PhD, BioFire Diagnostics (Consultant, Grant/Research Support, Other Financial or Material Support, I have intellectual property through the University of Utah in BioFire Diagnostics and the FilmArray and receive royalties through the University of Utah.)Merck (Advisor or Review Panel member)
78. Impact of Methicillin-Resistant Staphylococcus aureus (MRSA) Nares Screen on Vancomycin Utilization for Respiratory Tract Infections
Authors: Debnath Ashita , King Esther , Patel Dimple , Giordano Pamela
Published: December 2021

Background

S. aureus, including MRSA, is a common colonizer of the nares. Recent data have shown that a negative MRSA nares screen by PCR has a negative predictive value of 98%. This implies that the absence of colonization can significantly reduce empiric vancomycin utilization. This study aimed to determine the utilization of MRSA nares screening on patients receiving vancomycin for respiratory tract infections (RTI) following the addition of the screen to the institutional RTI management guidelines.

Methods

This was a retrospective chart review of adult inpatients presenting to two community-teaching hospitals who were prescribed vancomycin for the treatment of RTIs. Patients were divided into pre-guideline (Jan-Feb 2019), post-guideline 1 (Jan-Feb 2020), and post-guideline 2 (Jan-Feb 2021) groups. The primary endpoint was the difference in percent of vancomycin orders discontinued within 24 hours of a negative screen. Secondary endpoints included the percent of screens ordered, re-initiation of vancomycin within seven days for RTI, and total vancomycin days of therapy (DOT) per 1000 patient days (PD).

Results

Of 493 vancomycin orders screened, 100 orders in each arm were analyzed. There was an absolute increase of 20.6% in vancomycin orders discontinued within 24 hours of a negative screen between the pre-guideline and post-guideline 2 groups (59.1% vs. 79.7%, p = 0.0177). When compared to the pre-guideline group, utilization of the screen increased by 15% in the post-guideline 1 group (48% vs. 63%, p = 0.0328) and 26% in the post-guideline 2 group (48% vs. 74%, p = 0.000164). There was no difference in re-initiation of vancomycin. A statistically significant reduction in total vancomycin DOT/1000PD from the pre-guideline to the post-guideline 1 and 2 groups (66 to 63 to 60, respectively) was also observed.

Conclusion

The addition of the MRSA nares screen to the institutional RTI guidelines increased utilization of the test and demonstrated a reduction in vancomycin utilization. With an increase in education, prospective audit and feedback, and prescriber comfort with the use of the MRSA nares screen in the post-guideline 2 group, there was significant improvement in MRSA nares screen utilization, vancomycin discontinuation after a negative screen, and vancomycin utilization.

Disclosures

All Authors: No reported disclosures
79. Clinical Utility of Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal PCR Assays Beyond Respiratory Infections
Authors: Noeldner Haley M , Bushman Amanda , Bliek Zach , Wilkinson Melissa S , Jones Nephi , Prusa Ryan , Rosa Rossana M
Published: December 2021

Background

Empiric use of vancomycin is common in clinical practice. Currently there is strong evidence to support the use of MRSA nasal screening to predict the absence of MRSA in respiratory infections; however, minimal data exists regarding its utility as a de-escalation tool beyond pulmonary indications. Furthermore, MRSA nasal PCR has been shown to be a more efficient way to detect the presence of MRSA colonization than traditional culture methods. The purpose of this study was to evaluate the correlation between results of MRSA nasal PCR assays and blood or bone/soft tissue cultures.

Methods

This was a retrospective study of patients who presented to any of three hospitals part of an integrated health system in Des Moines, Iowa, from March 1, 2019 to February 29, 2020. Included patients were those who underwent MRSA nasal PCR screening and had a clinical culture (blood, bone, tissue, deep podiatric wound, joint aspirate, or synovial fluid) obtained within 3 days of the MRSA nasal PCR. Data on age, sex, diabetes mellitus and dialysis were collected. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for all cultures, and blood and bone/soft tissue cultures separately were estimated.

Results

A total of 1989 patients were included in the study. Of these patients, 1953 patients had a blood culture obtained and 171 patients had a bone/soft tissue culture obtained. The median age was 66 years, and 1086 (54.6%) patients were male. At baseline, 33.1% and 3.8% of patients had diabetes or were on dialysis, respectively. The overall prevalence of MRSA colonization was 12.3%. The sensitivities of the MRSA nasal PCR screening were 67.5% for all clinical cultures, 81.8% for blood cultures, and 55% for bone/soft tissue cultures. Specificities were 88.8%, 88.5%, and 92.7% for all cultures, blood cultures, and bone/soft tissue cultures, respectively. The PPVs were 11%, 7.5%, and 50% for all cultures, blood cultures, and bone/soft tissue cultures, respectively, and the NPVs were 99.3%, 99.8%, and 92.7%, respectively.

Conclusion

MRSA nasal PCR screening showed high NPV across blood and bone/soft tissue cultures. These results indicate the clinical utility of MRSA nasal PCR assays beyond respiratory infections and can further support antimicrobial stewardship activities.

Disclosures

All Authors: No reported disclosures
81. Reducing Unnecessary Blood Cultures Through Diagnostic Stewardship
Authors: Govindan Sujeet , Strnad Luke
Published: December 2021

Background

At our institution, we learned the frequency of blood cultures was sometimes being changed from “Once” to “Daily” without a defined number of days. We hypothesized this led to unnecessary blood cultures being performed.

Methods

Over a 3 month period from 12/6/2019-3/6/2020, we retrospectively evaluated the charts of patients who had a blood culture frequency changed to “Daily”. We evaluated if there was an initial positive blood culture within 48 hours of the “Daily” order being placed and the number of positive, negative, or “contaminant” sets of cultures drawn with the order. Contaminant blood cultures were defined as a contaminant species, present only once in the repeat cultures, and not present in initial positive cultures.

Results

95 unique orders were placed with 406 sets of cultures drawn from 89 adults. ~20% of the time (17 orders) the order was placed without an initial positive blood culture. This led to 62 sets of cultures being drawn, only 1 of which came back positive. 78/95 orders had an initial positive blood culture. The most common initial organisms were Staphylococcus aureus (SA) (38), Candida sp (10), Enterobacterales sp (10), and coagulase negative staphylococci (7). 43/78 (55%) orders with an initial positive set had positive repeat cultures. SA (26) and Candida sp (8) were most common to have positive repeats. Central line associated bloodstream infections (CLABSI) were found in 5 of the orders and contaminant species were found in 4 of the orders. 54% of the patients who had a “Daily” order placed did not have positive repeat cultures. The majority of the cultures were drawn from Surgical (40 orders) and Medical (35 orders) services. Assuming that SA and Candida sp require 48 hours of negative blood cultures to document clearance and other species require 24 hours, it was estimated that 51% of the cultures drawn using the "Daily" frequency were unnecessary. Cost savings over a year of removing the "Daily" frequency would be ~&14,000.

Data from "Daily" blood culture orders drawn at Oregon Health & Science University from 12/6/2019-3/6/2020

Conclusion

Unnecessary blood cultures are drawn when the frequency of blood cultures is changed to "Daily". Repeat blood cultures had the greatest utility in bloodstream infections due to SA or Candida sp, and with CLABSI where the line is still in place. These results led to a stewardship intervention to change blood culture ordering at our institution.

Disclosures

All Authors: No reported disclosures
82. Assessment of Clinical Outcomes and Antibiotic Prescribing Patterns Following Implementation of the GenMark ePlex® Blood Culture Identification Panel for Gram-positive Bloodstream Infections
Authors: Wein Megan , Binkley Shawn , Athans Vasilios , Saw Stephen , Lee Tiffany , Patel Sonal , Hamilton Keith W , Binkley Amanda , Degnan Kathleen , Glaser Laurel , Dutcher Lauren , Talati Naasha J , Richard-Greenblatt Melissa
Published: December 2021

Background

Rapid diagnostic testing (RDT) of bloodstream pathogens provides key information sooner than conventional identification and susceptibility testing. The GenMark ePlex® blood culture identification gram-positive (BCID-GP) panel is a molecular-based multiplex platform, with 20 Gram-positive target pathogens and 4 bacterial resistance genes that can be detected within 1.5 hours of blood culture positivity. Published studies have evaluated the accuracy of the ePlex® BCID-GP panel compared to traditional identification methods; however, studies evaluating the impact of this panel on clinical outcomes and prescribing patterns are lacking.

Methods

This multi-center, quasi-experimental study evaluated clinical outcomes and prescribing patterns before (December 2018 – June 2019) and after (August 2019 – January 2020) implementation of the ePlex® BCID-GP panel in June 2019. Hospitalized, adult patients with growth of Enterococcus faecalis, Enterococcus faecium, or Staphylococcus aureus from blood cultures were included. The primary endpoint was time to targeted antibiotic therapy, defined as time from positive Gram-stain to antibiotic adjustment for the infecting pathogen.

Results

A total of 200 patients, 100 in each group, were included. Time to targeted therapy was 47.9 hours in the pre-group versus 24.8 hours in the post-group (p< 0.0001). Time from Gram-stain to organism identification was 23.03 hours (pre) versus 2.56 hours (post), p< 0.0001. There was no statistically significant difference in time from Gram-stain to susceptibility results, hospital length of stay (LOS), or all-cause 30-day mortality.

Conclusion

Implementation of the GenMark ePlex® BCID-GP panel reduced time to targeted antibiotic therapy by nearly 24 hours. Clinical outcomes including hospital LOS and all-cause 30-day mortality did not show a statistical difference, although analysis of a larger sample size is necessary to appropriately assess these outcomes. This study represents the effect of RDT implementation alone, in the absence of stewardship intervention, on antibiotic prescribing patterns. These findings will inform the design of a dedicated RDT antimicrobial stewardship intervention at our institution, while also being generalizable to other institutions with RDT capabilities.

Disclosures

All Authors: No reported disclosures
83. Impact of a Urine Culture Best Practice Advisory on Collection of Urine Cultures and Subsequent Antibiotic Therapy
Authors: White Logan , Dooley-Wood Andrea , Nguyen Hien , Bandali Aiman
Published: December 2021

Background

In the acute care setting, urinary tract infections (UTIs) may be over diagnosed in up to 40% of cases. In most scenarios, asymptomatic bacteriuria (ASB) is not an indication for antibiotic therapy; inappropriate therapy is associated with a higher incidence of antibiotic-resistant bacteria and adverse drug reactions. Limiting inappropriate collection of urine cultures may decrease unnecessary treatment of ASB. The objective of this study is to assess the impact of a urine culture best practice advisory (BPA) on collection of unnecessary urine cultures.

Methods

This retrospective, observational, single-center study included adult inpatients with an order for urinalysis/urine culture. Those who were pregnant, had a concomitant infection other than UTI and/or were taking antimicrobials for a non-UTI indication, and were undergoing urological procedures were excluded. Duplicate urine culture collections and/or admissions were excluded. Incorporation of a BPA into computerized provider order entry, allowing providers to assess need and document indication for urine culture collection, was implemented on July 2019. The following clinical outcomes were assessed: number of unnecessary urine cultures collected, number of antibiotic treatments, and antibiotic-associated adverse reactions.

Results

Two hundred met criteria for inclusion; 96 in the pre-BPA group (Aug – Oct 2018) and 104 in the post-BPA group (Aug – Oct 2019). Seventy-four (37%) were male and the mean age was 64 and 70 years (p=0.249), respectively. The Charlson Comorbidity Index (CCI) was similar between groups (4 vs. 5, p=0.162) and majority were admitted to a general medical ward (94.5%). Seventy patients (72.9%) in the pre-BPA group and 47 (51.6%) in the post-BPA group had inappropriately ordered urinalysis/urine cultures (OR 0.40; 95% CI 0.22-0.73; p=0.003). Of these patients, 15 (21.4%) and 9 (19.1%) from the pre- and post-BPA groups, respectively, were treated (p=0.077). Among those treated, only two adverse drug reactions were reported.

Conclusion

Implementation of a BPA significantly reduced the number of inappropriate urinalysis/urine culture orders. There was a trend towards decreased antibiotic use for ASB. Future studies are warranted to assess sustainability of these results.

Disclosures

All Authors: No reported disclosures
85. Evaluation of Urinalysis and Urine Culture Use at a Community Health-system
Authors: Brenneman Martin , Bohn Brian C , Moore Sarah E , Wilde Ashley , Wilde Ashley , Song Matthew
Published: December 2021

Background

The Infectious Diseases Society of America asymptomatic bacteriuria (ASB) guidelines recommend against screening for or treating ASB in most patients without symptoms of a urinary tract infection (UTI). The purpose of this study was to characterize current urine testing practices and their potential impact on identification and treatment of asymptomatic bacteriuria on hospitalized adults.

Methods

This retrospective, point prevalence study conducted at a 4 hospital community health-system that included all inpatients ≥ 18 years old present on November 13th, 2019. Patients were excluded if they were admitted or transferred to either a labor & delivery or mother-baby unit. A chart review was performed for a sub-group of patients with abnormal urine testing, with a target sample size of 200 (n=50 from each hospital). The primary outcome was the prevalence of patients with a urinalysis, urine culture, or both performed during their admission. Secondary outcomes included abnormal urine testing in the overall cohort and symptomatology and antibiotic use in the sub-group (Figure 1).

Results

947 patients met inclusion criteria. Of those patients, 516 (54%) had urine testing performed during their admission. 322 (34%) patients had abnormal urine testing results (Table 1). In the sub-group, 192 patients with abnormal urine tests were included. Antibiotics with a documented indication of UTI were administered to 66 (34%) patients. Of those given antibiotics with a UTI indication, 49/66 (74%) did not have documented signs or symptoms of a UTI (Figure 2).

Conclusion

Urine testing was performed on the majority of admitted adult patients. Unnecessary testing likely contributes to guideline discordant screening and treatment of ASB. Future studies are needed to identify effective diagnostic stewardship interventions to decrease screening and treatment of ASB.

Disclosures

Ashley Wilde, PharmD, BCPS-AQ ID, Nothing to disclose
88. Effect of an MDR Enterobacterales Screening Tool on Antibiotic Prescribing for Abdominal Infections Caused by Mixed Bacteria
Authors: Panichsillapakit Theppharit , Alby Kevin , Marx Ashley H , Mavrogiorgos Nikolaos
Published: December 2021

Background

Background: Choosing antibiotics for infections caused by mixed Enterobacterales is challenging. Our microbiology lab implemented a multi-drug resistance (MDR) screen for cultures with mixed gram-negative to direct clinicians to use 3rd generation cephalosporins for screen neg. pathogens, and to use broader beta-lactams for screen-pos. pathogens. Here we report the effect of MDR screen on final antibiotic choice.

Methods

Methods: We retrospectively reviewed cases with abdominal infections caused by mixed bacteria at UNC Medical Center between August and November 2020. Cultures with non-Enterobacteraeles gram negatives were excluded. MDR screen was done by plating mixed Enterobacterales on HardyCHROM™ ESBL agar. Screen-pos. cases were updated “MDR Enterobacterales present” and pathogens were identified with full susceptibilities. Screen-neg. cases were labeled “MDR Enterobacterales not present”. Definitely covering antibiotics were defined by the use of 3rd generation cephalosporins for screen neg. cases, or based on susceptibilities in case of screen pos. organisms or concomitant bacteremia. Possibly covering antibiotics included regimens whose susceptibility could not be predicted based on the screen (e.g., amox/clav or quinolone+metronidazole).

Results

Results: 51 cases were identified. Median age was 51 years (range 10 to 87). 54.9% were female and 45.1% male. Infections included intra-abdominal abscesses (n =35), perirectal or scrotal abscesses (10), abdominal wound infections (4), perineal necrotizing fasciitis (1), and cholecystitis (1). Sample types were abscess fluid (43), wound purulence (4) or tissue (3). MDR screen was pos. in 7.8%. Antibiotics were adjusted in 17.6% as a result of the screen report. 31.5% of final antibiotics definitely covered the isolated bacteria, 56.9% possibly covered, and 5.9% did not have an active antibiotic. Among screen pos. cases, final antibiotics definitely covered in 75% and possibly in 25%.

Conclusion

Conclusions: The MDR Enterobacterales screening tool for abdominal infections had limited impact on final antibiotic choice, but was useful when positive. Further directions include assessment of provider understanding of the MDR screen results and investigation of utility of screen in other infection types.

Disclosures

All Authors: No reported disclosures
93. Developing Urinary Tract Infection Clinical Vignettes for the Nursing Home Setting: A Mixed-Methods Approach
Authors: Taylor Lindsay N , Irvine Jessica , Jolles Sally , Bej Taissa A , Crnich Christopher J , Jump Robin L , Jump Robin L
Published: December 2021

Background

Little is known about how providers choose antibiotics for nursing home residents when concerned about urinary tract infections. To better assess this in a simulated setting, we used a mixed-methods approach to develop robust clinical vignettes.

Methods

First, we developed 7 vignettes and distributed them to resident physicians as a survey, randomizing participants’ response type to rank-order or free-text entry. Second, we shared 5 vignettes with nursing home prescribers and conducted semi-structured interviews that asked providers to explain their thinking out loud (Think Aloud structure). Interviews were continued until content saturation was achieved. Two authors (LT & RJ) determined appropriateness of decisions about antibiotic initiation and antibiotic choice; two authors (LT & JI) coded feedback on the vignettes with adjudication by a third (RJ).

Results

Of 23 residents (11 rank-choice; 12 free-response) that participated in the pilot survey, only 6 (26%) completed 7 vignettes, with a mean completion of 69.4%. Completion of all vignettes was similar between groups, however, greater attrition at the first question was observed in respondents randomized to rank-choice (4/11) compared to free-response (6/12). Of the original 7 vignettes, 5 free-response cases were chosen for further development. We conducted semi-structured interviews with 7 nursing home prescribers, 4 of whom were physicians. The prescribers had a median age 39 (range 34 to 54) and a median of 10 years of post-graduation experience. Figure 1 summarizes appropriateness of respondents’ answers regarding antibiotic initiation and antibiotic choice. The most common inappropriate choice was a fluoroquinolone. Vignettes were edited iteratively based on participant feedback on each case’s realistic characteristics, missing necessary clinical data, formatting changes, and clarity (Figure 2).

Figure 1. Appropriateness of antibiotic initiation and antibiotic choice per clinical vignette.

Figure 2. Example of vignette editing process based on Think Aloud interview responses

Conclusion

This mixed-methods approach effectively captured prescribers’ feedback about length, response method, and case characteristics for our clinical vignettes. Responses assessed differences in prescribers’ decision to initiate antibiotic treatment and antibiotic choice. The refined vignettes will be used in a national survey.

Disclosures

Robin L. Jump, MD, PhD, Pfizer (Individual(s) Involved: Self): Consultant
94. Implementation of Antibiotic Prescribing Scorecards in the Ambulatory Care Setting
Authors: Revolinski Sara , Njeri Wainaina J , Enzmann Maxx , Olexia Deanna , Sobczak Christopher
Published: December 2021

Background

Up to 56% of antibiotics prescribed in the ambulatory setting in the United States are inappropriately prescribed, with 30% of those determined to be unnecessary. In order to increase transparency and education about antibiotic prescribing in our ambulatory clinics at our institution, we implemented quarterly scorecards demonstrating antibiotic prescribing trends for primary care prescribers.

Methods

This pre-post interventional study analyzed the impact of prescriber scorecards on antibiotic prescribing, with the intervention consisting of real-time education and presentation of baseline data via scorecards. Prescribers were educated on the scorecard project via live meetings in Nov-Dec 2020. In Dec 2020, prescribers were sent individual emails describing their baseline antibiotic prescription rate (defined as number of prescriptions per 100 patient encounters), de-identified comparison data for other prescribers within their individual clinic, and average rate of the top 10% of prescribers with the lowest prescription rates. Baseline data was from prescriptions dated Jan-Mar 2020. The email also explained the project and shared that quarterly scorecards would be distributed in 2021. Baseline data was compared to prescription data from Jan-Mar 2021. Knowing the COVID-19 pandemic resulted in significantly fewer encounters for respiratory infections, data was also analyzed with respiratory diagnoses removed from the dataset.

Results

In the pre-intervention period, 11,769 antibiotics were prescribed during 92,239 encounters for a prescription rate of 12.8 (95%CI: 12.5-13.0). Of 96,449 encounters in the post-intervention period, 7,326 antibiotics were prescribed for a rate of 7.6 (95%CI: 7.4-7.8; p< 0.0001). When respiratory diagnoses were removed, prescription rates were 6.1 (95%CI: 5.9-6.2) in the pre-group, compared to 6.3 (95%CI: 6.1-6.5; p=0.0546). When analyzed by prescriber, significant decreases were seen in prescriptions by physicians (5.8 vs 5.4, p=0.0035) while increases were seen in prescriptions by advanced practice prescribers.

Conclusion

Antibiotic scorecards sent to prescribers may result in reduced antibiotic prescribing, but further research is needed to elucidate the impact of the scorecards in light of the COVID-19 pandemic.

Disclosures

All Authors: No reported disclosures
96. Impact of Hospital-Based Pharmacist Discharge Prescription Review on the Appropriateness of Antibiotic Therapy
Authors: Spigelmyer Amy , Howard Catessa , Rybakov Ilya , Burwell Sheena , Slain Douglas
Published: December 2021

Background

Inappropriate antibiotic prescribing upon hospital discharge poses an increased risk of excess costs, adverse drug reactions, readmission, and resistance. Despite high rates of antibiotic prescription errors upon discharge, there is no widely accepted antimicrobial stewardship initiative to prevent such errors. This study evaluated the impact of hospital-based clinical pharmacist discharge prescription review on the appropriateness of antibiotic prescriptions.

Methods

This was a retrospective assessment of patients with discharge antibiotic prescriptions for treatment of pneumonia, urinary tract infections, Clostridioides difficile infections, acute skin and skin structure infections (ABSSSI), or Gram-negative bacteremia between January 2019 and July 2020. The two cohorts that were studied were patients on Hospitalist services versus patients on Medicine services, in which only the Medicine services had rounding pharmacists who perform discharge prescription reviews. Outcomes included demographics, appropriateness of therapy, 30-day readmission rates, and error types in discharge prescriptions. Appropriateness of therapy was validated by evidence-based guidelines and three Infectious Diseases-trained pharmacists.

Results

Our study included 300 patients, 150 per cohort. Baseline characteristics were similar between groups, with the exception of increased age (p=0.025) and fewer cases of ABSSSI (p=0.001) in the Hospitalist cohort. A statistically significant higher rate of inappropriateness was seen in the Hospitalist group versus Medicine (pharmacist) group, [69/150 (46% versus 25/150 (17%, respectively (p< 0.00001)]. The difference in appropriateness was mainly driven by pneumonia and UTI prescriptions. Thirty day readmission rates were 17% (26/150) for the Hospitalist cohort versus 11% (16/150) in the Medicine (pharmacist) cohort (p=0.134). The most common prescription error was the duration of therapy.

Conclusion

Appropriateness of antibiotic discharge prescriptions significantly improved in the setting of pharmacist discharge prescription review. This initiative highlights the important role of clinical pharmacists in the setting of outpatient antimicrobial stewardship.

Disclosures

All Authors: No reported disclosures
97. Pharmacist Driven Antimicrobial Stewardship Interventions on the Management of Urinary Tract Infections in the Emergency Department at a Tertiary Military Treatment Facility
Authors: Ayalew Memar D , raiciulescu Sorana , Brooks Daniel , Williams Robin , Crull Paulette , Ressner Roseanne
Published: December 2021

Background

With the Joint Commission standards targeting ambulatory settings serving as a catalyst, we designed a quality improvement (QI) project was designed to evaluate the existing management and prescribing patterns for urinary tract infections (UTI) in the Walter Reed National Military Medical Center (WRNMMC) Emergency Department (ED) in order to identify targets for ASP intervention.

Methods

This was a Pharmacist-driven, prospective, QI project conducted over a 3-month period. The clinical presentations and microbiological data of uncomplicated cystitis and pyelonephritis cases managed in the ED were reviewed. Within 24-72 hours of ED discharge, recommendations were relayed to both patients and ED staff. Diagnostic criteria and management concordant with established clinical guidelines were assessed. Inclusion criteria included age ≥ 18, admission status, urine culture and antibiotics for UTI or pyelonephritis.

Results

A daily urinalysis (UA) report identified 1781 ED encounters of which 117 cases met inclusion criteria. Nitrofurantoin was most prescribed empirically at 39.3% followed by a cephalosporin (23.1%) or a fluoroquinolone (19.7%), accounting for 32% of inappropriate empiric antibiotic selection. Cases were identified with inappropriate duration of therapy (22.2%), dosage (9.4%), and drug-bug mismatch (9.4%). Nearly 38% of cases required intervention to discontinue (32.5%) or initiate new antibiotics (3.4%). Diagnostic concordance was defined as having positive urinary symptoms, clinically significant UA and positive urine culture. This was only observed in 37.6% of all cases, of which only 43.2% were treated with a guideline concordant empiric regimen, dosage and duration of therapy. Although not included in the final analysis, it was noted 916 urine culture results were ordered where 70% were not associated with genitourinary complaints or sepsis.

Conclusion

Despite guidelines for UTI management, considerable practice discordance was found in the ED. Multiple Pharmacist targeted interventions were identified. Prioritized areas for ED provider education include first-line therapy, treatment duration, and diagnostic stewardship. This QI project has potential for optimizing prescribing practices in Military Health System ambulatory settings.

Disclosures

All Authors: No reported disclosures
98. Outcomes of Clinical Decision Support for Outpatient Management of Clostridioides difficile Infection
Authors: Wu Tiffany , Davis Susan L , Davis Susan L , Church Brian , Alangaden George J , Kenney Rachel
Published: December 2021

Background

Our antimicrobial stewardship program identified high rates of suboptimal metronidazole prescribing for Clostridioides difficile infection (CDI) within ambulatory clinics. An outpatient best practice advisory (BPA) was implemented to notify prescribers “Vancomycin or fidaxomicin are preferred over metronidazole for C.difficile infection” when metronidazole was prescribed to a patient with CDI.

Methods

We conducted an IRB approved quasi-experiment before and after implementation of the BPA on June 3, 2020. Inclusion: Adult patients diagnosed with and treated for a first episode of symptomatic CDI at an ambulatory clinic between 11/1/2019 and 11/30/2020. Exclusion: fulminant CDI. Primary endpoint: guideline-concordant CDI therapy, defined as oral vancomycin or fidaxomicin. Oral metronidazole was considered guideline-concordant if prescribed due to cost barrier. Secondary endpoints: reasons for alternative CDI therapy, patient outcomes, prescriber response to the BPA. Descriptive and bivariate analyses were completed.

Results

189 patients were included in the study, 92 before and 97 after the BPA. Median age: 59 years, 31% male, 75% Caucasian, 30% with CDI-related comorbidities, 35% with healthcare exposure, 65% with antibiotic exposure, 44% with gastric acid suppression therapy within 90 days of CDI diagnosis. The BPA was accepted 23 out of 26 times and optimized the therapy of 16 patients in six months. Guideline-concordant therapy increased after implementation of the BPA (72% vs. 91%, p=0.001) (Figure 1). Vancomycin prescribing increased and metronidazole prescribing decreased after the BPA (Figure 2). Reasons for alternative CDI therapy included medication cost, lack of insurance coverage, and non-CDI infection. There was no difference in clinical response or unplanned encounter within 14 days after treatment initiation. Fewer patients after the BPA had CDI recurrence within 14-56 days of the initial episode (27% vs. 7%, p< 0.001).

Figure 1. Guideline-concordant CDI therapy

Figure 2. Specific CDI therapy

Conclusion

Clinical decision support increased prescribing of guideline-concordant CDI therapy in the outpatient setting. A targeted BPA is an effective stewardship intervention and may be especially useful in settings with limited antimicrobial stewardship resources.

Disclosures

Susan L. Davis, PharmD, Nothing to disclose Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)
100. Assessment of Emergency Department Prescribing Practices for Outpatient Treatment of Urinary Tract Infection, Community-Acquired Pneumonia, and Skin and Soft Tissue Infections
Authors: Thaller Matthew , Dempsey Casey J , Levine Alexander , Shepard Kelly
Published: December 2021

Background

Studies have found a need for improved antimicrobial stewardship in the outpatient setting. The literature is limited by the populations and disease states studied as many focus on viral infections. This study focuses on the adult emergency departments (EDs) in a large healthcare system and quantifies the proportion of antibiotic prescriptions deemed inappropriate for common outpatient infections.

Methods

A retrospective study was conducted in patients with selected common infections treated as an outpatient from the ED. Patients were reviewed for eligibility based on the inclusion and exclusion criteria in Table 1. Appropriateness was analyzed based on: need for antimicrobial therapy; agent choice, dose, duration, and directions in concordance with national guidelines and local resistance patterns; and no clinically relevant drug interactions, unnecessary dual coverage, or a better or safer alternative available. The entire prescription was marked inappropriate if any factor was deemed inappropriate.

Table 1. Inclusion and Exclusion Criteria

Based on the Epic report generated, a random sample of patients were selected for manual review. Only patients who met the following criteria were eligible for inclusion in the final analysis.

Results

Of the 318 patients reviewed, 274 were included. Treatment was deemed inappropriate 64% (174/274) of the time, significantly above the estimated 30% (p < 0.001). The agent selection, duration, and dose were the most the frequent factors deeming a prescription inappropriate. The most inappropriately used agents were fluoroquinolones and azithromycin. A positive culture required modification of therapy 31% (22/70) of the time and more so when the drug was guideline recommended. For example, when empiric antibiotic selection was per urinary tract infection guidelines, 31% (14/53) required modification compared to 19% (3/16) when the agent was not. This was most apparent when cephalexin was used.

Conclusion

The use of antibiotics at the studied EDs was not in concordance with guidelines in the study period. However, the cultures were sensitive less often to agents deemed appropriate per guidelines for empiric therapy. It is possible that the ideal treatments of bacterial infections in this community are not representative of national resistance patterns. Using ED-specific antibiograms to create order panels for common infections, as well as prospective pharmacist review at ED discharge, could increase appropriate utilization of preferred agents.

Disclosures

All Authors: No reported disclosures
102. Evaluation of the Association between the Antibiotic Spectrum Index and Antibiotic Days of Therapy: A Retrospective Study across 124 Acute-care Hospitals
Authors: Kakiuchi Satoshi , Goto Michihiko , Casado-Castillo Fernando , Perencevich Eli N , Livorsi Daniel J
Published: December 2021

Background

Antibiotic stewardship programs often measure antibiotic days of therapy (DOT), but this metric does not reflect the antibiotic spectrum. In this study, we used the previously published Antibiotic Spectrum Index (ASI), which attaches a score (1-13) to the spectrum of each antibiotic, to evaluate the content of antibiotic use across all Veterans Health Administration (VHA) hospitals. We also assessed how benchmarking hospital performance changed when ASI was used instead of DOT.

Methods

We conducted a retrospective cohort study of patients admitted to 124 acute-care VHA hospitals during 2018. We obtained data on administered antibiotics, the days of antibiotic use (DOT), and days-present (DP) from the VHA Corporate Data Warehouse and then aggregated data to the hospital-level using the National Healthcare Safety Network’s methodology. We modified the original ASI by changing 3.8% of the bug-drug scores to ensure consistency across all scores and adding 27 new antibiotics agents. For each hospital, we calculated ASI/DOT, ASI/1,000 DP, and DOT/1,000 DP and ranked hospitals on their performance. We performed a Spearman’s rank-order correlation to compare hospitals on these metrics and their associated rankings.

Results

At the hospital-level, the median ASI/DOT, ASI/1,000 DP and DOT/1,000 DP were 5.4 (interquartile range: 5.2-5.8), 2,332.7 (1,941.8-2,796.2) and 443.5 (362.5-512.2), respectively. There was a strong correlation between the ASI/1,000 DP and DOT/1,000 DP metrics [Spearman’s correlation test: r=0.97 (p< 0.01)] but only a weak and insignificant correlation between ASI/DOT and DOT/1,000 DP [r=0.17 (p=0.06), Figure 1]. Twenty (16.1%) hospitals showed a difference of 10% or more in their ranking for ASI/1,000 DP compared to their ranking for DOT/1,000 DP. The range of ranking difference was from -17.7% to 21.0% (Figure 2a and b).

Figure 1. Distribution of the Antibiotic Spectrum Index / Day of Therapy by Days of Therapy / 1000 Days Present for 124 Acute-Care VHA Hospitals during 2018. Black line: Median values of DOT/1,000 DP and ASI/DOT, respectively.

Figure 2. (a) Distribution of the rankings in DOT/1,000 DP and ASI/1,000 DP. Blue line: the position of same ranking between ASI/1,000 DP and DOT/1,000 DP. (b) Distribution of the differences in each hospital’s ranking for DOT/1,000 DP and ASI/1,000 DP

Conclusion

Our findings suggest that hospitals using fewer days of antibiotic therapy did not necessarily use narrower-spectrum antibiotics. ASI/1,000 DP, as a combined measure of antibiotic consumption quantity and average spectrum, provided a different view of hospital performance than DOT/1,000 DP alone. Future work is needed to define how this new metric relates to the quality of antibiotic use.

Disclosures

All Authors: No reported disclosures
103. Expansion of an Antimicrobial Stewardship Program Through Implementation of a Discharge Verification Queue
Authors: Rubin Ellen C , Blackman Alison L , Broadbent Eleanor K , Wang David , Plasari Ilda , Ketema Pawlose , Brade Karrine , Barlam Tamar F
Published: December 2021

Background

Antimicrobial stewardship programs (ASPs) have traditionally focused interventions on inpatient care to improve antibiotic prescribing. Support of effective interventions for ASPs targeting antibiotic prescriptions at hospital discharge is emerging. Our objective was to expand stewardship services into the outpatient setting through implementation of a process by the antimicrobial stewardship team (AST) to verify antimicrobials prescribed at discharge.

Methods

This quality improvement initiative incorporated a discharge order verification queue managed by AST pharmacists to review electronically prescribed antimicrobials Monday through Friday, from 8:00 am to 4:00 pm. The queue was piloted Sep 2020 and expanded hospital-wide Feb 2021. Patients < 18 years old and those with observation or emergency department status were excluded. The AST pharmacist reviewed discharge prescriptions for appropriateness, intervened directly with prescribers, and either rejected or verified prescriptions prior to transmission to outpatient pharmacies. Complicated cases were reviewed with the AST physician to evaluate intervention appropriateness. Interventions were categorized as either dose adjustment, duration, escalation or de-escalation, discontinuation, or safety monitoring.

Results

A total of 602 prescriptions were reviewed between Sep 2020 and Apr 2021. An AST pharmacist intervened on 28% (171/602) of prescriptions. The most common intervention types were duration (41%, 70/171), discontinuation (18%, 31/171), and dose adjustment (17%, 30/171). The most common indications in which the duration was shortened was community acquired pneumonia (26%, 18/70), skin and soft tissue infection (21%, 15/70), and urinary tract infection (17%, 12/70). The most common antibiotics recommended for discontinuation were cephalexin (32%, 10/31) and trimethoprim-sulfamethoxazole (10%, 3/31). The overall intervention acceptance rate was 78%.

Conclusion

An AST pharmacist review of antimicrobial prescriptions at discharge improved appropriate prescribing. The discharge queue serves as an effective stewardship strategy for inpatient ASPs to expand into the outpatient setting.

Disclosures

All Authors: No reported disclosures
104. Improving Efficiency of Antimicrobial Stewardship Reviews Using Artificial Intelligence Modelling
Authors: Tang Si Lin Sarah , Lee Winnie , Chong Yiling , Saigal Akshay , Zhou Peijun Yvonne , Hung Kai Chee , Tan Lun Yi , Chung Shimin Jasmine , Kwa Lay Hoon Andrea
Published: December 2021

Background

Antimicrobial stewardship programs (ASP) in hospitals improve antibiotic prescribing, slow antimicrobial resistance, reduce hospitalisation duration, mortality and readmission rates, and save costs. However, the strategy of prospective audit and feedback is laborious. In Singapore General Hospital (SGH), 10 reviews are required to identify 2 inappropriate cases. Limited manpower constraints ASP audits to only about 30% of antibiotics prescribed. This proof-of-concept study explored the feasibility of developing a predictive model to prioritise inappropriate antibiotic prescriptions for ASP review.

Methods

ASP-audited adult pneumonia patients from January 2016 to December 2018 in SGH were included. Patient data e.g., demographics, allergies, past medical history, and relevant laboratory investigations at each antibiotic use episode were extracted from electronic medical records and re-assembled through linking for analysis. Ground truth for model training was based on ASP-defined appropriateness for each encounter. The dataset was split into 80% and 20% for training and testing respectively. Three modelling techniques, XGBoost, decision tree and logistic regression, were assessed for their relative performance in terms of precision, sensitivity and specificity.

Results

There were 12471 unique patient encounters. Training was done on 10459 encounters and 39 data elements were included. When tested on 2012 encounters, the logistic regression model performed the best (86.7% sensitivity, 71.4% specificity). The model correctly classified 1377 out of 1388 (99.2%) encounters as “appropriate” (do not require ASP intervention). 624 antibiotic use encounters were classified as “inappropriate”, of which only 72 were truly inappropriate (positive predictive value for ASP intervention, PPV 11.5%). The low PPV was likely due to inadequate representation of “inappropriate” cases in the training dataset (4.1%). Applying this model would prioritise the number of immediate ASP reviews needed to identify cases for intervention by two-thirds, from 2012 to 624 (Figure 1).

Figure 1. Illustration of AI benefits in ASP

Conclusion

ASPs can leverage on machine learning capabilities to improve audit efficiency. This can increase ASP’s productivity and staff’s job satisfaction as they are freed up to perform other work.

Disclosures

All Authors: No reported disclosures