bluuebunny/crossref_metadata_2025 huggingface dataset:
51. Sustained Impact of an Antimicrobial Stewardship (AS) Initiative Targeting Asymptomatic Bacteriuria and Pyuria in the Emergency Department (ED)
Authors: Cash Mary Catherine , Hile Garrett , Johnson James , Stone Tyler , Luther Vera , Luther Vera , Ohl Chris , Beardsley James
Published: December 2021

Background

The sustainability of unique AS initiatives are largely unstudied. A multi-faceted initiative to reduce inappropriate treatment of asymptomatic pyuria (ASP) and asymptomatic bacteriuria (ASB) in the ED was implemented at our institution in 2016. A pre-post intervention analysis demonstrated reduction in the inappropriate treatment (tx) of ASP/ASB from 100% to 32% (p< 0.001) following the intervention. The purpose of this present study was to determine the sustained impact of the initiative and determine if re-education provided in Oct 2020 could further reduce inappropriate tx.

Methods

This was a retrospective, interrupted time series study conducted at an 885 bed academic medical center. Patients (pts) discharged from the ED in Nov 2019 – Feb 2020 (group 1) and Nov 2020 – Feb 2021 (group 2) were retrospectively screened in chronologic order until 50 pts in each group met study criteria. Similar to the 2016 study, pts were included if they were ≥ 18 years old and had a positive urine culture or pyuria. Pts were excluded if they had symptoms of a urinary tract infection (UTI), another infection requiring antibiotics (ABX), indwelling catheter, ureteral stent, or nephrostomy tube, or if pregnant or immunocompromised. The primary outcome was the proportion of pts prescribed ABX within 72 hrs of ED discharge. The secondary outcome was the number of pts returning to the ED with symptomatic UTI within 30 days of discharge. Group 1 was compared to the 2016 study’s post group to determine the sustained impact of the initial initiative; group 2 was compared to group 1 to determine the impact of re-education, which involved a presentation to ED providers and a posted algorithm and fact sheet.

Results

Results from all time periods are summarized in Table 1. Improvement in inappropriate tx was still noted 3 years after the intervention (28% vs 32%; p = NS). Re-education did not further improve inappropriate prescribing, with 28% of group 2 pts still receiving tx.

Table 1.

Conclusion

The decrease in inappropriate use of ABX for ASP/ASB was still noted 3 years after implementation of a multi-faceted AS initiative. Re-education did not result in further improvement.

Disclosures

James Johnson, PharmD, FLGT (Shareholder) Vera Luther, MD, Nothing to disclose
52. Direct Communication Improves Response Time to Acceptance of Antimicrobial Stewardship Interventions
Authors: Shafi Humaira , Donoghue Stephen G , Seah Jonathan , Yong Pu En Ow , Lee Wee Boon
Published: December 2021

Background

Hospital antimicrobial stewardship program (ASP) reviews broad-spectrum antibiotics and recommends interventions to optimise antimicrobial use. However, about 30% of interventions are not accepted. This project aims to improve the response rate and time for acceptance of ASP interventions by direct communication with providers (via call or text messaging) once an intervention was made.

Methods

Pre-direct communication (PC) phase lasted from 1st Jan - 31st Dec 2017. A typed intervention was placed into the patient’s medical records for the team to review. Thereafter, a direct communication (DC) phase ran from 1st Jan 2018 - 31st Jan 2019. Teams were immediately notified of any ASP interventions made via a call or text message, in addition to the document placed in the medical records. Specialty, acceptance rates, type of intervention and time to acceptance was recorded. Overall acceptance was counted if team followed the ASP recommendations within 48 hours.

Results

A total of 621 interventions were made over the 25-month period (PC n=334, DC n=287). We found that direct communications did not improve the overall acceptance rates (PC 66% vs. DC 65%, p=0.791), but significantly improved same day acceptance rates (PC 15% [49/334] vs. DC 33% [96/287], p< 0.001). This trend for higher same-day acceptance was also noted regardless of specialty. It increased from 15% to 45% (p< 0.001) for medicine & 15% to 25% (p=0.025) for surgery. Furthermore, overall acceptance for medical discipline was significantly higher in the DC phase (68% to 80%, p=0.024); no significant difference noted for the surgical disciplines. Same-day acceptance also improved when we compared the most common types of interventions (culture based de-escalation, discontinue antibiotic, narrow empirical coverage). In addition, DC helped narrow empiric antibiotic choices, with improvements in both same-day and overall acceptance of interventions (increased from 8% to 43%, p< 0.001 and 57% to 78%, p=0.12, respectively).

Conclusion

Direct communication with clinicians boosted same-day acceptance for ASP interventions. In addition, it increased overall acceptance for medical disciplines, and to narrow empiric antibiotic use. Future efforts will focus on in-person strategy with surgical teams for fruitful results.

Disclosures

All Authors: No reported disclosures
53. Optimizing Transitions of Care Antimicrobial Prescribing at a Community Teaching Hospital
Authors: Naik Kushal , Frens Jeremy J , Smith Jordan R
Published: December 2021

Background

Antimicrobial stewardship integral to patient care. Institutions with stewardship decrease antibiotic use, cost, and antibiotic-associated infections. However, few efforts have been formally made to address discharge antimicrobial prescribing, even though many patients started on antibiotic therapy in the hospital are prescribed oral antibiotics to complete their regimens.

Methods

This was an IRB approved, quasi-experimental, pre-post study. Patients were included if they were >18 years and were discharged from the hospital with an oral antibiotic prescription. Patients discharged against medical advice, prescribed indefinite prophylactic antimicrobial therapy for legitimate reasons, or discharged to a skilled nursing facility were excluded. The retrospective group evaluated a random sample of patients discharged in 2/2020. The prospective group included patients discharged between 1/2021 – 6/2021. In the prospective group, a clinical pharmacist assessed the indication for antibiotics and pended discharge antibiotic prescriptions for physician review. Antibiotic choice and duration of therapy were based on local and national guidelines.

Patient Screening for Inclusion and Exclusion

Breakdown of patients screened, included, and excluded for study

Results

86 (53.1%) of 162 retrospective patients from 2/2020 prior to implementation of the program demonstrated were discharged on inappropriate antimicrobial therapy with excessive duration being the principal driver for inappropriateness. In the prospective group of 64 patients, the rate of patients discharged on inappropriate antibiotics decreased to 28.1% (p=0.001). The duration of inappropriate therapy decreased from a mean of 4.6 days to 2.7 days (p=0.001). 45 (70.3%) of 64 prospective pharmacist’s interventions were accepted by providers.

Study Outcomes

Outcomes including overall appropriate prescribing, appropriate duration, spectrum, frequency, and dose, as well as days of inappropriate therapy

Conclusion

Literature demonstrates that prospective evaluation of discharge antibiotics by a clinical pharmacist is effective in improving appropriateness of discharge antibiotic prescriptions, optimizing duration of outpatient antibiotics as well as reducing unnecessarily broad-spectrum therapy. The prospective results from this study demonstrate that this innovative approach can improve outpatient oral antibiotic prescribing and provide a framework for other institutions to implement similar programs.

Disclosures

All Authors: No reported disclosures
54. The Effect of Targeting High-Risk Patients for Antimicrobial Stewardship Intervention on Hospital-Onset Clostridioides Difficile Infection Rates
Authors: Yang Albert , Donnelley Monica
Published: December 2021

Background

Clostridioides difficile infection contributes to significant burden on patients and the healthcare system, costing billions in excess costs every year for hospital care. Continued use of antibiotics after C. difficile infection diagnosis is a risk factor for recurrent infection. Also, individuals who have had a recurrence of C. difficile infection are at a higher risk of subsequent episodes.

Methods

This prospective, observational, pre-post study evaluated the effect of implementing a targeted antimicrobial stewardship initiative towards a high-risk target population on the rate of in-hospital C. difficile infection rates. High-risk targets were identified through an electronic health system report of admitted patients at a large academic medical center who were toxin assay positive or had a documented history of C. difficile infection. Subjects who met the criteria were assessed for interventions by the pharmacy-driven antimicrobial stewardship service. The primary outcome compared the hospital-onset C. difficile rates and standardized infection ratio (SIR) before and after implementation of the initiative. The SIR is reported to the National Healthcare Safety Network (NHSN) and is calculated as a ratio between the number of observed and predicted infections, which is adjusted for facility-specific factors that contribute C. difficile risk. Negative binomial regression was used to calculate the predicted C. difficile infections in the SIR. Poisson regression was used to generate a 95% prediction interval for the predicted C. difficile infection rate.

Results

The mean age of subjects was 63 years old and 85% had no history of prior C. difficile infection. The most common intervention was de-escalation of antibiotics (46%). The post-implementation SIR was 0.55 and hospital-onset C. difficile rate was 13, both of which were significantly lower than predicted.

Conclusion

Targeting patients who have a history of or are newly diagnosed with C. difficile infection may decrease hospital-onset C. difficile rates.

Disclosures

All Authors: No reported disclosures
55. Impact of Testing Methodology and Reporting on Time to Preferred Antibiotic Therapy in Extended Spectrum Beta-Lactamase producing Enterobacteriaceae (ESBL-E) Bloodstream Infections
Authors: Bui Hanh , Tverdek Frank , Carnes Stephanie , Chan Jeannie D , Bryan Andrew , Bourassa Lori , Jain Rupali , Matsuda-Fong Brendon
Published: December 2021

Background

Harborview Medical Center (HMC) identifies organisms and an ESBL genotype (CTX-M) via Verigene® Gram-Negative Blood Culture Nucleic Acid Test (BC-GN). University of Washington-Montlake (UWML) uses matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) for organism identification directly from positive blood cultures and ceftriaxone results by Kirby Bauer disk diffusion (KB) are reported 18 hours later. No ESBL comment is reported at UWML. We aimed to determine whether the methodology in identification and reporting of ESBL-E from blood cultures between two hospitals has an impact on time to preferred therapy with a carbapenem antibiotic.

Methods

Retrospective observational study conducted at UWML and HMC in Seattle, WA between 1/10/2015 and 9/15/2020. Adult patients were eligible if they had ≥1 positive blood culture with an Enterobacteriaceae isolate resistant to ceftriaxone and were on antibiotic treatment. The primary outcome was the difference in time to preferred definitive therapy with a carbapenem antibiotic in patients an ESBL-E bloodstream infection (BSI) identified by Verigene® vs. MALDI-TOF MS/KB.

Results

A total of 199 patients were screened; 67 were included for UWML and 68 at HMC. The average time to initiation of a carbapenem antibiotic was 42 ±26.5 hours at UWML and 28 ±19.7 hours at HMC. A t-test detected a difference in time to preferred therapy between a Verigene® vs. MALDI-TOF MS/KB tested ESBL-E BSI [95% confidence interval (CI), 5.3-22.9]. The hazard ratio to carbapenem initiation for HMC is 1.73643 [95% CI, 1.1405-2.644].

Conclusion

A statistically significant difference in time to preferred definitive therapy among patients with an ESBL-E BSI processed by Verigene® was found compared to MALDI-TOF MS. The results suggest standardization in protocols between the UWML and HMC hospitals is warranted.

Disclosures

Andrew Bryan, MD, PhD, Shionogi Inc. (Grant/Research Support)
57. Financial Impact of a Regional Antimicrobial Stewardship Cost Saving Initiative in a Large Integrated Healthcare System
Authors: Nguyen Van , Taylor Colton , Christensen Alyssa , Footer Brent
Published: December 2021

Background

A regional antibiotic stewardship program (ASP) within a large integrated healthcare system covering two, non-academic, tertiary care medical centers and an additional six community hospitals implemented multiple interventions to optimize antimicrobial therapy and reduce unnecessary hospital costs, such as transition to extended-infusion (EI) piperacillin/tazobactam (TZP), formulary restriction of antimicrobials, and antimicrobial stewardship clinical review. The purpose of this study was to evaluate the cost savings associated with these regional ASP initiatives.

Methods

This was a multicenter, retrospective, observational review of regional stewardship interventions across eight inpatient medical centers in Oregon. Data was collected from January 2019 to December of 2020. Cost savings associated with reduced TZP administrations was based on the duration of therapy for each encounter in adults who received TZP for >24 hours in 2020. The regional antimicrobial restriction policy was implemented in February 2020. Cost savings attributed to antimicrobial formulary restrictions and reduction in overall days of therapy/1000 patient days (DOT) were based on EPIC costs.

Results

The reduction in number of administrations with implementation of EI TZP resulted in &226,420 saved in 2020. &182,837 was saved due to decreased usage of restricted antimicrobial agents. An additional &433,341 was saved for overall antimicrobial costs due to 19,775 days reduction in overall DOT/1000 patient days.

Conclusion

A community-based regional ASP has resulted in substantial financial impact and identified areas for future cost savings within the region.

Disclosures

All Authors: No reported disclosures
58. Impact of Order-set Modifications and Provider Education on Broad-Spectrum Antibiotic Use in Patients Admitted with Community Acquired Pneumonia
Authors: Colmerauer Jessica L , Linder Kristin , Dempsey Casey J , Kuti Joseph L , Nicolau David P , Bilinskaya Anastasia
Published: December 2021

Background

Following updates to IDSA guidelines in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education.

Methods

This was a multi-center, quasi-experimental, retrospective study of patients with CAP from 9/1/19 to 10/31/19 (pre-intervention) and 9/1/20 to 10/31/20 (post-intervention). Patients were identified using ICD-10 codes indicating lower respiratory tract infection and excluded if had a positive SARS-COV-2 PCR during admission. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS).

Results

A total of 331 and 352 patients were included in the pre- and post-intervention groups, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period (p< 0.001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs. [190/312] 60.9%; p = 0.003). There were no differences in order set usage (10% vs. 11.3%, p = 0.642) between the pre- and post-intervention groups, respectively. Hospital LOS was lower in the post-intervention cohort (4.8 days [2.9-7.2 days] vs. 5.3 days [IQR 3.5-8.5 days], p = .002).

Conclusion

Despite low utilization of the order-set, education surrounding order-set changes appeared to improve antibiotic prescribing and hospital LOS in our population. Further opportunities to improve order-set use and thus further increase guideline-concordant therapy are still available.

Disclosures

Joseph L. Kuti, PharmD, Allergan (Speaker’s Bureau)BioMérieux (Consultant, Research Grant or Support, Speaker’s Bureau)Contrafect (Scientific Research Study Investigator)GSK (Consultant)Merck (Research Grant or Support)Paratek (Speaker’s Bureau)Roche Diagnostics (Research Grant or Support)Shionogi (Research Grant or Support)Summit (Scientific Research Study Investigator) David P. Nicolau, PharmD, Abbvie, Cepheid, Merck, Paratek, Pfizer, Wockhardt, Shionogi, Tetraphase (Other Financial or Material Support, I have been a consultant, speakers bureau member, or have received research funding from the above listed companies.)
60. Penicillin Allergy Delabeling Program in the Post-acute Care Setting
Authors: Galipean Joseph , Jacob Jerry
Published: December 2021

Background

A significant proportion of inpatients labeled with penicillin allergies do not have a true IgE-mediated hypersensitivity, which may unnecessarily limit options for treatment of infection and lead to suboptimal antibiotic selection. Post-acute care settings may provide a unique opportunity to capture patients at risk for adverse outcomes related to penicillin allergy labels. The objective of the study was to assess the feasibility and impact of a penicillin delabeling program in an inpatient rehab setting.

Methods

We conducted a prospective observational study. Inpatients with penicillin allergies were identified weekly by manual review of electronic medical records. A clinical pharmacist reviewed each patient’s chart and identified patients for inclusion. Patients were excluded if they had a history of IgE-mediated hypersensitivity to penicillin within last 5 years, a history of a non-IgE mediated hypersensitivity, were severely immunocompromised, or were prescribed a contraindicated medication.

Results

A total of 72 charts were reviewed over nine months, and 37 (51.4%) had their penicillin allergy updated to reflect prior beta-lactam tolerance. Of the 72 patient that were evaluated, 28 (38.9%) were eligible for potential penicillin allergy delabeling, and 44 (61.1%) were ineligible. 59 (81.9%) of the patients had a moderate-high risk allergy, 12 (16.6%) had a low risk allergy, and 1 (1.4%) had an intolerance. Of the 28 eligible patients, 11 (39.3%) had their allergy removed, 13 (46.4%) deferred testing, and 4 (14.2%) could not be tested due to staffing. Of the 28 patients that had their allergy delabeled, 7 (21.4%) had their allergy removed by MAR review, 2 (7.2%) had a skin test with a negative result, and 2 (7.2%) had a direct oral challenge with a negative result.

Conclusion

A penicillin allergy delabeling program using a collaborative physician-pharmacist team model efficiently removed reported allergies in post-acute care patients. The post-acute care setting is an opportune environment to conduct a penicillin allergy delabeling program for patients not currently needing acute medical treatment.

Disclosures

All Authors: No reported disclosures
61. A Multidisciplinary Quality Improvement Initiative to Promote Penicillin Allergy Delabeling
Authors: Monday Lea , Michniak Jaclyn , Zoratti Edward , Weinmann Allison J
Published: December 2021

Background

Penicillin (PCN) allergies are reported in up to 10% patients and are associated with adverse clinical and antimicrobial stewardship outcomes. Here we describe a multidisciplinary quality improvement (QI) initiative to facilitate PCN delabeling at a large urban hospital.

Methods

Starting in August 2020, the departments of Allergy and Infectious Diseases (ID) began a joint QI effort to employ a part time allergist nurse practitioner (ANP) for PCN allergy assessment and delabeling. The ANP used a daily system generated list to identify and assess adult patients with PCN allergy and contact teams to request a consult. An ID fellow also assisted with identifying patients and contacting care teams. The ANP then offered skin/oral PCN challenge or direct label removal based on history after discussion with an allergist physician. Baseline, clinical, and allergy characteristics were compared between patients delabeled and not delabeled using Chi-square and Mann-Whitney U test. Primary endpoints were antibiotic utilization outcomes from index admission post ANP assessment to 30-days post discharge. Secondary endpoints included readmission, length of stay (LOS), mortality, and sustained removal of the PCN allergy at 30-days.

Results

Between 30 August 2020 and 6 May 2021 (250 days), 139 PCN allergic patients were assessed (81 delabeled versus 58 not delabeled) (Figure 2). Some patients (37%) were delabeled via history alone, while 63% had further skin/oral testing. Baseline characteristics were similar between groups (Table 1). In the delabeled group, we observed increased narrow-spectrum PCN use (p< 0.001), and decreased vancomycin (p< 0.001), fluoroquinolone (p=0.013), carbapenem (p< 0.011), and overall restricted antimicrobial use (Table 2). Rates of 30-day readmission, LOS, and mortality were comparable. Four (5%) of delabeled patients had had PCN allergy re-entered in the chart at 30-days.

Patients were similar between groups on all baseline clinical and allergy characteristics except for more patients with infection classified as “other” in the non-delabeled group.

In the delabeled patients, we observed increased narrow-spectrum PCN use and decreased vancomycin, fluoroquinolone, carbapenem, and overall restricted antimicrobial use. Use of first and second generation cephalosporines was comparable between groups. Rates of 30-day readmission, LOS, and mortality were comparable.

Conclusion

This QI effort between the departments of Allergy and ID to employ an ANP increased narrow spectrum antibiotic use and reduced use of restricted antimicrobials. Challenges included the part time position of the ANP unable to see every patient, reemergence of allergy in the chart, and clinical or other exclusions for delabeling (Fig 3).

Disclosures

All Authors: No reported disclosures
62. Secondary Prophylaxis in Clostridioides difficile Infections: a Closer Look at Outcomes
Authors: Rodriguez Rubi , Mulugeta Surafel , Faison Darius , Kenney Rachel , Davis Susan L , Davis Susan L
Published: December 2021

Background

Clostridioides difficile infection (CDI) is an urgent public threat and carries a 25% chance of recurrence (rCDI). Data on safety and efficacy of oral vancomycin prophylaxis (OVP) in reducing rCDI is limited. We implemented a best practice advisory (BPA) to alert the prescriber and antibiotic stewardship (ASP) team for patients with CDI in the previous 60 days being initiated on systemic antimicrobials. The alert states “Don’t use antibiotics in patients with recent CDI without convincing evidence of need. Antibiotics pose a high risk of recurrence”. ASP team would recommended OVP if antibiotics are continued. This study evaluated the impact of the BPA alert on OVP prescribing and patient outcomes.

Methods

IRB approved, retrospective, observational cohort study comparing patients who received OVP to no OVP. Inclusion: adults with history of laboratory confirmed CDI, ≥ 14 days post-CDI treatment completion, BPA from 3/7/19 – 3/31/20, receiving non-CDI systemic antimicrobials, and without history of bezlotoxumab infusion. Data were reported using descriptive statistics and bivariate analysis. Primary endpoint: rCDI within 2-8 weeks post-OVP completion. Secondary endpoints: vancomycin-resistant Enterococcus spp (VRE) in clinical culture post-OVP and 1-year mortality.

Results

70 patients included: 32 (46%) no-OVP and 38 (54%) OVP. Baseline characteristics, previous CDI treatment, and outcomes were similar (Table 1). Index CDI was severe in the OVP group (18, 47% vs. 9, 28%). Median Charlson comorbidity index: 7 (3 – 9) no-OVP and 7 (5 – 9) OVP. OVP regimens, 125 mg by mouth: once daily 4 (10%), twice daily 22 (58%), and every 6 hours 12 (32%). Median prophylaxis duration: 10 days (6 – 13). rCDI occurred in 3 (9%) no-OVP and 2 (5%) OVP (P = 0.654). Mortality: 10 (31%) no-OVP and 16 (42%) OVP (P = 0.458).

Table 1. Patient Characteristics and Endpoints

Conclusion

OVP was utilized in approximately half of patients who required non-CDI antibiotics. Efficacy interpretation is limited by inconsistent dosing regimens and significant comorbid illness in the cohort. Future work will focus on further optimizing the BPA and standardizing the OVP regimen.

Disclosures

Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder) Susan L. Davis, PharmD, Nothing to disclose
63. Impact of Infectious Disease Fellow-Driven Antimicrobial Stewardship Interventions on Inpatient Fluoroquinolone Use
Authors: Nunez Carlos M , Mattappallil Arun , McCrink Katie A , Rybak Debbie , Taha Basil , Chew Debra
Published: December 2021

Background

Fluoroquinolone (FQ) antibiotics are frequently used in hospitalized patients to treat a wide range of infections but are often misused and implicated in antibiotic-associated adverse events. The purpose of this study is to evaluate the impact of Infectious Disease fellow (IDF)-driven antimicrobial stewardship program (ASP) interventions on inpatient FQ use.

Methods

This is a retrospective study of all admitted patients who received a FQ for greater than 48 hours from 01/01/2019 -12/31/2020 in an urban academic center. “Phase 1” (pre-intervention phase) covered 01/1/2019- 03/31/2019. “Phase 2” (intervention phase) covered 03/03/2020- 12/23/2020. In “Phase 2”, our ASP reviewed FQ use 2-3 days per week and an IDF provided feedback interventions that averaged 30-60 minutes of IDF time spent per day. We categorized FQ use as either: “appropriate”, “appropriate but not preferred”, or “inappropriate”, as determined by local clinical guidelines and ASP team opinion. We compared FQ use in both phases, indications for FQ use, and new Clostridioides difficile infections (CDI).

Results

A total of 386 patients are included (76 in “Phase 1”and 310 in “Phase 2”). Patient characteristics are similar (Table 1). Overall, 63 % of FQ use was empiric, and 50% FQ use was deemed “appropriate”, 28% “appropriate but not preferred”, and 22% “inappropriate”. In “Phase 2”, 126 interventions were conducted, with 86% of these accepted. Appropriate FQ use increased significantly in “Phase 2” vs. “Phase 1” (53.5% vs 35.5%, p = 0.008), with decrease in mean days of FQ use (4.38 days vs 5.87 days, p =.021). Table 2 shows “appropriate” FQ use by clinical indication. New CDIs occurred more in “Phase 1” vs. “Phase 2” (6.6% vs 0.6%, p=.001).

Conclusion

An IDF-driven ASP intervention has a positive impact on appropriate inpatient use of FQs in our hospital. This highlights a promising ASP model which not only improves appropriate use of FQ, but also offers an opportunity for IDF mentorship and use of available resources to promote ASPs.

Disclosures

Katie A. McCrink, PharmD, ViiV Healthcare (Employee)
64. Absolute Monocyte Count (AMC) as Early and Safe Marker for Discharge in Low-risk Pediatric Febrile Neutropenia with Cancer
Authors: Alali Muayad , Bartlett Allison , Danziger-Isakov Lara , Danziger-Isakov Lara
Published: December 2021

Background

Fever with neutropenia (FN) is common and the timing of antibiotic cessation in patients without an identified fever source is uncertain. Absolute neutrophile count (ANC) recovery has been used clinically to represent bone marrow recovery (BMR) but other options should be considered. We hypothesized that absolute monocyte count (AMC), and absolute phagocyte count (APC) are more sensitive, and an earlier safe marker of antibiotic cessation (AC) compared with ANC

Methods

A retrospective review was performed for FN episodes (FNEs) at UCM Comer Children’s Hospital between 2009 and 2016 in pediatric oncology patients. Eligible FNEs who were a febrile for 24 hours, had no bacterial source identified at time of AC, and did not receive chemotherapy 10 days following AC. Ten-day post-AC outcomes, length of stay and cost were assessed and compared among different BMR parameters (ANC vs AMC).

Results

A total of 928 FN episodes (FNEs) were identified. 391 eligible FNEs occurred in 235 patients. Three groups were compared based on ANC (cells/μL) at the time of AC : < 200 in 102 (26%), 200-500 in 111 (28%), and >500 /uL in 178 (46%) (Figure1) with an overall ten-day recurrent fever rate 7.4% (29/391) and readmission rate of 5.6% (22/391). No significant differences in recurrent fever rates were identified among 3 ANC groups (11.7%, 6.3% and 5.6% respectively, P=0.08) and readmission (10%,4.5%, 4%, respectively; P=0.07)(Table 1).In subset analysis of AMC for each ANC group, patients with AMC >100 at AC have favorable outcomes, regardless ANC threshold (P< 0.01) (Table 1). Median of length of stay of FN was 3 days shorter using AMC >100/uL for BMR compared with any threshold of ANC (P< 0.01) and decrease overall FN cost stay (P< 0.01) (Table 2). Similar analysis show APC >300/uL at time of AC has favourable outcomes and decrease LOS regardless ANC threshold (data not shown here).

Conclusion

Our results suggest that a AMC > 100 /uL regardless of ANC/uL, is a safe threshold value for empiric AC and discharge. This approach may shorten length of stay, reduce burden of cost of febrile neutropenia cost and potential long term antibiotics side effects.

Disclosures

Lara Danziger-Isakov, MD, MPH, Ansun (Individual(s) Involved: Self): Scientific Research Study Investigator; Astellas (Individual(s) Involved: Self): Scientific Research Study Investigator; Merck (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Pfizer (Individual(s) Involved: Self): Scientific Research Study Investigator; Shire (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Viracor: Grant/Research Support
65. Impact of an Antibiotic Side-Chain-Based Cross-Reactivity Chart on Antibiotic Use in Patients With β-lactam Allergies and Pneumonia
Authors: Collins Curtis D , West Nina , Shankar Tara , Leo Harvey L , Bookal Renee
Published: December 2021

Background

β-lactam antibiotics with dissimilar R-group side chains are associated with low cross-reactivity. Despite this, patients with β-lactam allergies are too often treated with alternative antibiotic therapy. An institutional β-lactam side-chain-based cross-reactivity chart was developed and implemented to guide in antibiotic selection for β-lactam allergies patients.

Methods

This single center, retrospective, cohort study analyzed the impact of the implementation of the cross-reactivity chart for patients with documented β-lactam allergies with pneumonia. Study time periods were defined as January 2013 to October 2014 prior to implementation of the chart (historical cohort) and January 2017 to October 2018 (intervention cohort) following institutional implementation and adoption. The primary outcome was the incidence of β-lactam utilization between time periods. Propensity-weighted scoring and interrupted time-series analyses compared outcomes across time periods.

Results

A total of 341 and 623 patient encounters were included in the historical and intervention cohorts, respectively. There was a significant increase in the use of β-lactams for treatment of pneumonia (70.4% vs 89.3%; p < 0.001) and the use of any alternative therapy decreased between cohorts (58.1% vs. 36%; p < 0.001) (Figure 1). β-lactam use per patient significantly improved between cohorts in patients with mild, Type 1 IgE-mediated hypersensitivity reactions (HSRs) and in patients with unknown reactions. There was no difference in overall HSRs between cohorts (2.4% vs. 1.45; p = 0.628), or in patients who received β-lactam antibiotics (1.3% historical group vs 1.1% intervention group; p = 0.467). Median alternative antibiotic days of therapy (3 vs. 2; p = 0.027) and duration of therapy per patient (3 days vs. 2 days; p = 0.023) decreased between cohorts. There was a significant increase in mortality while healthcare facility-onset Clostridioides difficile infections decreased between cohorts.

β-Lactam vs. Alternative Therapy Use per Patients by Calendar Quarter

Conclusion

Implementation of a β-lactam side-chain-based cross-reactivity chart significantly increased the utilization of β-lactams in patients with pneumonia without increasing HSRs.

Disclosures

All Authors: No reported disclosures
66. Improving Antimicrobial Stewardship through Allergy Testing Referrals
Authors: Smith Clarissa , Poplin Victoria , Barry Brogan , Mason Mathew J , Gregory Eric , Clough Lisa A , Gierer Selina , Newman Adelyn R
Published: December 2021

Background

Penicillins and cephalosporins (PCN/CEPH) are considered first-line antibiotics for numerous infections for their efficacy, tolerability, and cost effectiveness. Unfortunately, their use may be precluded in approximately 10% of the general adult population who self-report ‘allergy’. As a result, suboptimal antimicrobials are substituted which may increase toxicities, length of hospitalizations, and antimicrobial resistance with subsequent expense and morbidity. Multiple organizations endorse beta-lactam allergy skin testing (BLAST) as an essential component of antimicrobial stewardship programs..In an attempt to better describe this patient population as well as to protocolize and improve rates of referral to allergy/immunology clinic, a quality initiative was undertaken at our institution.

Methods

Adult inpatients for whom an infectious disease consult was placed over a 6-month period were chart-reviewed for PCN/CEPH allergy. Inappropriately charted allergies were reconciled and patients were recommended referral to allergy/immunology for formal evaluation with BLAST when appropriate. Referrals were placed for agreeable patients who were then evaluated for appropriateness through history and then scheduled for BLAST. Patients who tolerated oral exposures without adverse effects had the allergy removed from their chart and were educated.

Results

322 patients met inclusion criteria for allergy referral. Of those, 103 agreed to further evaluation, and referrals were placed for 100%. Unfortunately, 7 patients died before referrals could be completed, and 88 referred patients did not complete BLAST for other reasons. In total 8 patients completed BLAST, and allergy was de-labeled in 75% (N= 6) of those cases.

Conclusion

Our data indicated similar prevalence of reported PCN/CEPH allergy between our institution and the general population. We achieved our aim of improving allergy referral rates among this population, however there was a high rate of attrition in the transitions of care. Qualitative review of selected patients highlights common thematic barriers including the COVID-19 pandemic, fiscal concerns, and acuity of condition. Future directions should include BLAST at the point of care or making referrals from the primary care setting.

Disclosures

Lisa A. Clough, MD, Merck (Scientific Research Study Investigator)Merck (Research Grant or Support)ViiV (Scientific Research Study Investigator)
67. Transitioning from Permissive to Restrictive Urine Reflex Criteria: Compiling the Data
Authors: Nix Chad D , Villamagna Angela H
Published: December 2021

Background

Reflex urine cultures (UCx) are a diagnostic stewardship practice that limit the progression of UCx to specimens that meet pre-defined urinalysis criteria, but there is no widely recommended threshold for culture. At our institution, urinalyses (UAs) are reflexed to UCx for positive nitrites, leukocyte esterase, presence of bacteria, or ≥5 white blood cells per high powered field (WBC/hpf). Our aim is to assess if a more restrictive criteria of >10 WBC/hpf would result in missed UTI diagnoses.

Methods

We performed a retrospective chart review of a systematic sampling of urine specimens collected from July 2018 to June 2019 in the emergency department and adult inpatient units. Inclusion criteria were UA with a WBC/hpf of 5-10 – samples that would not reflex to culture under our proposed criteria – and a UCx. We recorded signs, symptoms and antibiotic use via chart review. Positive UCxs were defined as ≥10e5 CFU/mL of bacterial growth (BG) and these cases were assessed using standardized CDC UTI definitions.

Results

486 urine specimens with < 10e5 CFU/mL BG and 96 with ≥10e5 CFU/mL BG met inclusion criteria. Chart review was performed on 99 cases. 81 (82%) specimens had negative UCxs and 18 (18%) were positive. 45% had documented localizing UTI symptoms. 26% of all urine studies were sent for an indication of fever, 15% for altered mental status (AMS), and 8% for malaise. Among the 18 patients with positive UCxs, 11 (61%) met UTI criteria. Among the 81 patients with negative UCxs, 33/81 (41%) had a local symptom compatible with UTI. 7/81 (9%) patients had positive tests from other body sites; all 7 of these UCxs were sent for a new or worsening fever.

Conclusion

Of the 99 UCxs reviewed, less than half had a urinary symptom consistent with UTI, and almost half of studies were sent for non-specific indications such as fever, which suggests reflex UCxs are overutilized at our institution. However, our data demonstrate that a more restrictive UCx criteria may not be the solution, as at least 11 clinically significant UTIs would have been missed under the new criteria. We recommend improved clinical decision support tools and more data to validate restrictive reflex UCx criteria before their implementation.

Disclosures

All Authors: No reported disclosures
69. Implementation of a Pharmacist-Driven Blood Culture Communication Process in a Non-Profit Community Hospital
Authors: Thumann Alexis , Williams Jennifer , Bernabe Megan , Hankewich Jillien
Published: December 2021

Background

Rapid diagnostic testing allows for faster identification of culture results and quicker time to targeted antimicrobial therapy. For this to be effective, however, the clinician needs to understand its capabilities and limitations. Pharmacists are well-positioned to assist providers in interpreting rapid diagnostic test results and in the selection of optimal antimicrobial therapy. This study aims to determine if implementing a process in which pharmacists communicate positive blood culture and rapid diagnostic test results improves time to optimal antimicrobial therapy in a community-based hospital.

Methods

In November 2020, Mercy Medical Center implemented a new process in which positive blood culture and rapid diagnostic test results are communicated to a pharmacist instead of a nurse on the patient care unit. The pharmacist is responsible for interpreting the results, assessing patient information, and providing the culture results along with drug therapy recommendations to the appropriate licensed independent practitioner. This study was a single-center, pre-post, quasi-experimental study (Pre: November 2019-March 2020; Post: November 2020-March 2021). The electronic medical record was used to identify admitted patients 18 years and older with positive blood cultures in which treatment was provided. Time from culture positivity to optimal antimicrobial therapy was collected and compared pre-post intervention. Secondary outcomes included hospital length of stay and mortality.

Results

A total of 480 patients were identified during the study period, of which 247 met inclusion criteria (n = 125 in 2019-2020; n = 122 in 2020-2021) with comparable baseline characteristics. There was no statistical difference in time to appropriate therapy between the groups (p = 0.796). Time to optimal therapy was 6.12 hours shorter in the post-intervention cohort (p = 0.0492). No difference was found for both secondary outcomes of hospital length of stay and inpatient mortality (p = 0.2958, p = 0.096, respectively).

Conclusion

A pharmacist-led blood culture communication process improved the care of hospitalized patients in a non-academic, community-based hospital by shortening time to optimal antimicrobial therapy.

Disclosures

All Authors: No reported disclosures
71. Diagnostic Stewardship of Clostridioides difficile Testing
Authors: Qamar Zahra , Spacek Lisa A , Coppock Dagan , Patel Kaya , L’Etoile Nathan , Huang Jingwen , Arya Akanksha , Flomenberg Phyllis
Published: December 2021

Background

C. difficile (CD) testing is frequently ordered inappropriately. Highly sensitive polymerase chain reaction (PCR) tests can detect CD colonization leading to misdiagnosis. Providers often overlook other causes of diarrhea, notably laxatives. To improve diagnostic stewardship, our hospital introduced an electronic medical record (EMR)-based order set (OS).

Methods

In a 926-bed, teaching hospital, we conducted a 3-step intervention to improve CD diagnostic stewardship. (1) A retrospective analysis of CD orders before and after OS implementation was done to assess its impact on inappropriate orders. The OS included two questions: (a) Did patient have ≥ 3 loose bowel movements in past 24 hours? and (b) No laxatives in past 24 hours? An appropriate order was defined if “yes” to both questions. It was still appropriate if “no” to either question but ≥ 2 unexplained following features: fever > 100.4 F, abdominal pain, megacolon, ileus or leukocytosis > 11,000 cells/mm3 in prior day. (2) After implementation of OS, house staff compliance with OS was surveyed via email. (3) Rationale for inappropriate orders was discussed with providers.

Results

Of 238 patients in retrospective analysis, 44% were ≥ 65 years and 37% had other potential causes of diarrhea. Common clinical features were leukocytosis (40%) and fever (31%). There was no significant difference in inappropriate testing: pre-OS 27/99 (27%) vs post-OS 44/139 (32%) (p=0.47). Of 43 house officers who participated in the survey, 75% indicated they over rode the OS. When asked to provide rationale of inappropriate CD testing, providers acknowledged inappropriate ordering but did not want to miss a CD diagnosis and frequently overlooked other causes of diarrhea.

Conclusion

Appropriate CD testing relies on providers’ appreciation of a clinical picture consistent with CD infection, confirmation of clinically significant diarrhea, and consideration of other causes of diarrhea. Providers order inappropriate tests, not due to lack of knowledge, but likely fear of missing diagnosis and overlooking other causes of diarrhea.

Disclosures

All Authors: No reported disclosures
74. Evaluation of the Differences in Appropriateness of BioFire® FilmArray® Gastrointestinal Panel Testing between Emergency Department and Inpatient Services
Authors: Weichman Brittani , Bushman Amanda , Rosa Rossana M
Published: December 2021

Background

Use of rapid molecular diagnostic panels in the evaluation of diarrhea provides increased sensitivity for organism identification and decreased time to results. However, their inappropriate use can lead to unnecessary expenditures and antimicrobial exposures. We aimed to characterize the appropriateness of testing using the BioFire® FilmArray® Gastrointestinal Panel (SFA) in different clinical settings and to describe the impact of SFA results on patient care.

Methods

Retrospective study of adult patients presenting to hospitals part of an integrated health system in Des Moines, Iowa, between July 30 and September 30, 2019, and who had a SFA ordered and collected in the Emergency Department (ED) or an inpatient service. The appropriateness of SFA testing was determined according to adherence to a local algorithm available through the hospital’s intranet (Figure 1). Reason for testing, appropriateness of SFA test, molecular targets identified, and antibiotic exposures were collected.

Results

We identified 257 patients, 111 (43.2%) who had SFA done in the ED and 146 (56.8%) as inpatients. Testing was deemed inappropriate in 46 (41.4%) of ED patients compared to 100 (68.5%) of inpatients (p< 0.0001). Documented indications for SFA are presented in Table 1. Among ED patients testing was most frequently considered inappropriate due to absence of diarrhea on the day of test collection (41.3%), and among inpatients due to the use of SFA for assessment of hospital-onset diarrhea (47.0%) (Table 2). Overall, there were 94 (36.6%) positive SFA (Figure 2). Among ED patients, the percentage of positive SFA samples was 30.4% and 50.8% for inappropriate and appropriate testing respectively (p=0.03), while for inpatients it was 33.0% for inappropriate orders and 30.4% for appropriate orders (p=0.76). Antibiotics were prescribed to 28.2% and 28.1% of patients tested in the ED and inpatient service respectively.

Conclusion

High proportions of inappropriate SFA testing were identified both in the ED and inpatient services, with distinct issues in each site. Characterization of the reasons underlying inappropriate use of SFA can aid in the design of diagnostic stewardship interventions tailored to each clinical setting.

Disclosures

All Authors: No reported disclosures
75. Utility of Fungal Blood Cultures in Portland, Oregon
Authors: Govindan Sujeet , Strnad Luke
Published: December 2021

Background

Fungal blood cultures (fungal isolators) should be used, if at all, primarily for identification of mold infections. At our institution we noted patients having fungal blood cultures drawn in many other situations, including when the primary team was concerned for candida bloodstream infection. We sought to describe the utility of this practice and of fungal blood cultures in general.

Methods

We retrospectively reviewed the results of fungal blood cultures for 2 years, from 3/1/2019-3/1/2021. We evaluated the number of episodes, culture results, whether there was a had prior bloodstream infection, and risk factors for fungal infection including renal replacement (RRT), ECMO, and immunosuppression (IS). Immunosuppression was defined as chronic systemic steroid use, recent receipt of high dose steroids within 2 weeks, history of organ transplantation, history of stem cell transplantation, hematologic malignancies, or receipt of a biologic agent.

Results

187 fungal blood cultures were drawn in 143 patients - 80 cultures in 70 patients from 3/2019-3/2020 and 107 cultures in 73 patients from 3/2020-3/2021. Only 3 patients had positive fungal blood cultures:1 (Candida krusei) from 3/2019-3/2020 and 2 (Candida albicans and Cyrptococcus neoformans) from 3/2020-3/2021; in all 3 cases the organism also grew from standard blood culture isolators. From 3/2019-3/2020, 1/80 cultures were drawn from an individual on ECMO while 15/80 were drawn from individuals on RRT, and 32/80 were in a IS individuals. From 3/2020-3/2021, 45/107 cultures were drawn from an individual on ECMO, 24/107 were drawn in an individual on RRT, and 73/107 were drawn in a IS individuals. The majority of individuals in whom a fungal blood culture was drawn during 3/2020-3/2021 were individuals with COVID-19. Upon chart review most of the cultures were drawn due to concern for candidemia.

Results of fungal blood cultures drawn from 3/2019-3/2021 at OHSU

Conclusion

Fungal blood cultures have an extremely low yield at our institution, with a 1.6% positivity rate over a 2 year period, and all of those cultures were detected by standard blood culture isolators. Most of these cultures were drawn in situations where this test has no utility. Furthermore, the test has limited utility to detect dimorphic and mold bloodstream infections. Restriction of this test may limit inappropriate use.

Disclosures

All Authors: No reported disclosures