bluuebunny/crossref_metadata_2025 huggingface dataset:
1650. Clinical Features and Risk Factors of Active Tuberculosis in Patients with Behçet’s Disease
Authors: Liu Yaxu , Zhang Lifan , Zhou Ziyue , Sun Luxi , Zhou Baotong , Liu Xiaoqing , Zheng Wenjie
Published: January 2021

Background

Understanding the clinical characteristics and risk factors of active tuberculosis (ATB) in Behçet’s disease (BD) is of great significance to improve the treatment efficacy and guide the preventive treatment. However, the relevant studies are very limited.

Methods

We retrospectively reviewed medical records of BD patients admitted to our institute from 2010 to 2019. BD patients with ATB were enrolled as the case group, and the control group was selected by random number sampling from the remaining BD patients. Multivariate logistic regression analysis was performed to explore the potential risk factors of ATB in BD patients.

Figure 1. Flowchart of the study

Results

Twenty-one ATB cases were identified from 386 BD patients, including four (19.0%) microbiologically confirmed and 17 (81.0%) clinically diagnosed. ATB patients can present with systemic symptoms (fever, night sweating, unexplained weight loss) and/or symptoms related to the infection site. Logistic regression analysis revealed that ESR>60mm/h (OR=13.710, 95%CI (1.101, 170.702)), increased IgG (OR=1.226, 95%CI (1.001, 1.502)), and positive T-SPOT.TB (OR=7.793, 95%CI (1.312, 48.464), for 24-200 SFC/106PBMC; OR=17.705 (2.503, 125.260), for >200 SFC/106PBMC) were potential risk factors for ATB in BD patients.

Table 1. Past medical history and medication of BD patients with and without ATB

Table 2. Clinical presentation and laboratory results of BD patients with and without ATB

Table 3. Potential risk factors for ATB in BD patients

Conclusion

When BD patients have fever, night sweating, unexplained weight loss, or manifestations rarely occurred in BD, the diagnosis of ATB should be considered. Significantly elevated T-SPOT.TB indicates a high risk of ATB in BD patients.

Disclosures

All Authors: No reported disclosures
1651. Describing the Tuberculosis Infection Cascade of Care Based on Electronic Health Record Data
Authors: Vonnahme Laura A , Todd Jonathan , Puro Jon , Oakley Jee , Jones Matthew , Rivera Pedro , Langer Adam J , Ayers Tracy
Published: January 2021

Background

Appropriate screening of individuals to detect latent tuberculosis infection (LTBI) is a critical step for achieving tuberculosis (TB) elimination in the US; >80% of TB cases are attributed to LTBI reactivation. TB infection testing and treatment must engage community health clinics where populations at risk seek care. However, there are significant data knowledge gaps in the current LTBI cascade of care (CoC) in this setting. We used an electronic health record (EHR) database from OCHIN, Inc., to characterize the LTBI CoC and identify potential future interventions.

Methods

We extracted a cohort of patients from 2012–2016 EHR data; we stratified by whether patients were at risk for TB based on meeting at least one of the following criteria: non-US born or non-English language preference, homelessness, encounter at correctional facility, history of close contact with a TB case, or being immunocompromised. Along each step of the LTBI CoC, we determined the proportions with a test for TB infection, with available test results, with a positive test, with an LTBI diagnosis, and with LTBI treatment prescribed. We used Χ 2 tests to compare the LTBI CoCs among patients at risk with those classified as not at risk.

Results

Of nearly 2.2 million patient records, 701,467 (32.0%) met criteria for being at risk for TB; 84,422 at risk (12.0%) were tested; 65,562 (77.7%) had available results, of whom 9,624 (14.7%) were positive. Among those with positive results, 6,958 (72.3%) had an LTBI diagnosis, of whom 1,732 (24.9%) were prescribed treatment. Among those classified as not at risk, fewer were tested (66,773 [4.5%], p< 0.001) and had positive results (2,500 [3.7%], p< 0.0001). Among those with positive results, 1,998 (80.0%) had an LTBI diagnosis, of whom 395 (19.8%) initiated treatment.

Conclusion

This study highlights gaps in the LTBI CoC, and where interventions are most needed. The largest gaps were in testing patients at risk, as 88% were not tested, and treatment, as 75% diagnosed with LTBI were not treated. Just under half (44%) of all TB tests appeared to be performed in persons with little risk for TB; this is a substantial amount of testing given very few begin treatment. Resources could be redirected to increase screening and treatment among populations at risk.

Disclosures

All Authors: No reported disclosures
1655. Extrapulmonary Tuberculosis in a Large Healthcare System
Authors: Denmeade Travis , Smith William , Kooken Banks , Leonard Michael
Published: January 2021

Background

The US has seen a rise in the proportion of patients with extrapulmonary tuberculosis (TB) even though the yearly incidence of new TB cases has been in decline. The purpose of this study was to analyze incidence of extrapulmonary TB at Atrium Health, a large non-profit health system in the Southeastern US.

Methods

Retrospective chart review of 94 adult patients with culture confirmed extrapulmonary TB between 2008-2019. Individuals younger than 18 years were excluded from analysis. The primary objective was to examine incidence of extrapulmonary TB and compare it to that reported in the literature. Secondary objectives included determination of sites of extrapulmonary disease and associated patient characteristics including HIV status, race, ethnicity, and birthplace.

Results

237 patients were identified as having confirmed TB infection from 2008-2019 in a retrospective analysis within the Atrium Health System. 94 (40%) were found to have extrapulmonary disease; 42 (45%) with concomitant pulmonary disease. The patients were 55% male, 40% African American, 21% Hispanic or Latino, and 51% US-born. Median age was 44 years (range 20-62). The most common sites of extrapulmonary TB were lymphatic (35%), pleural (24%), GI/Peritoneal (12%), CNS (10%), and Bone/Joint (10%). Lymphatic involvement was 40% cervical, 19% intrathoracic, and 16% axillary. 66% of skeletal disease was vertebral. Other sites included GU, pericardial, skin, and disseminated disease (5%). 37% were HIV positive, 18% with unknown HIV status as they were never tested. Information regarding patient’s race, ethnicity, and birthplace were unknown for 2 patients. The percentage of extrapulmonary cases were 29% in 2008, 39% in 2012, 38% in 2016, and 49% in 2019.

Conclusion

Lymphatic and pleural involvement were the most common extrapulmonary sites. Of those tested, 37% were HIV positive but there was a significant portion never tested showing a need for increased testing. The proportion of extrapulmonary TB cases since 2008 is higher at 40% compared to the 31% reported in the United States. There has been a rise in the proportion of extrapulmonary TB within our healthcare system and deserves further analysis.

Disclosures

All Authors: No reported disclosures
1656. Factors associated with low TB preventative therapy prescription rates among healthcare workers in rural South Africa
Authors: Ahmed Amiya A , Grammatico Megan A , Malinga Sipho , Makhunga Philile , Moll Anthony , Ladines-Lim Joseph B , Jones Justin , Choi Koeun , Shenoi Sheela
Published: January 2021

Background

Despite South Africa’s initial successful rollout of tuberculosis preventative therapy (TPT) to reduce tuberculosis (TB) incidence among HIV-infected patients, recent data suggest prescription rates have decreased. This study aimed to identify associations with low prescription rates among healthcare workers (HCWs) in rural South Africa.

Methods

A cross-sectional survey was administered Nov-Dec 2019 to HCWs at a 350 bed rural district hospital and 14 primary care clinics (PCCs) in the Msinga sub-district, South Africa to obtain self-reported data on prescription rates as well as knowledge, attitudes, practices, and beliefs regarding isoniazid preventive therapy, the current TPT regimen. HCWs included professional nurses, staff nurses, counselors, and medical officers. Survey questions were consolidated into scores using exploratory factor analysis. Univariate and multivariate associations with low prescription rates, defined as < 50% of eligible patients, were determined for prescribers.

Results

Among 160 participants, the median (+ IQR) age was 39 (+13) years, 76% were women, 78% worked at a PCC, and 35% were prescribers, including professional nurses (82%) and medical officers (19%). The median (+ IQR) years as a HCW and managing patients living with HIV (PLH) among prescribers was 14 (+ 15.5) and 10 (+ 11.5) years, respectively. Compared to prescribers, non-prescribers reported more stigma (71% v. 54%; p=0.04) and placed less priority on prevention compared to treatment (32% v. 58%; p< 0.01). Among prescribers (n=54), univariate analysis identified that patient nondisclosure (OR 4.17 95% CI 1.23-14.14; p=0.02) was associated with low TPT prescription rates. Poor self-reported knowledge also trended towards significance (OR 5.23 95% CI 0.85-32.08; p=0.07). After multivariate analysis, only perceived patient nondisclosure was significantly associated with low prescription TPT rates (aOR 4.17 95% CI 1.23-14.14; p=0.02).

Conclusion

HCWs who believed their patients had not disclosed that they were taking TPT were significantly less likely to prescribe it to their patients. Strengthening HCW training about indications for and mortality benefit of TPT as well as stigma reduction is critical to enhancing TPT implementation.

Disclosures

All Authors: No reported disclosures
1660. Prevalence and Predictors of Anxiety and Depression among Leprosy Patients using the Hospital Anxiety and Depression Scale-Pilipino Score in a Tertiary Hospital
Authors: Clarito Eunice Lovelle R , Valiente Melchy V , Zabat Gelza Mae A
Published: January 2021

Background

This study was prompted by significant reports of anxiety and depression among people with skin disorders in clinical settings and primarily focuses on leprosy patients.

Methods

This is a cross-sectional descriptive study conducted at Dr Jose N. Rodriguez Memorial Hospital located at Tala, Caloocan City, Philippines. All patients admitted at the Custodial ward and seen at the outpatient during the study period will be included using convenience sampling. The prevalence of anxiety and depression was determined by a score of 8 points or higher on the HADS-P. Logistic regression analysis was utilized to determine the relationship between the socio demographic data and clinical variables with anxiety and depression. Odds ratio were calculated and P-value < 0.05 were considered as statistically significant.

Results

Among the 150 Leprosy patients included in the study with a HADS-P score of 8 and above per category showed that 86 (57.33%) of the respondents have anxiety and 37 (24.67%) have depression. Running a logistic model that predicts a person having an anxiety, having hypertension as well as having a minor disability were proven to be significant with p-value 0.02 and 0.09 respectively. An odds ratio of 3.01 denotes that a person with hypertension is twice (2.01) as likely to have anxiety than a person with no comorbidities. Running a logistic model that predicts a person having a depression, educational attainment was shown to be significant at p-value equal to .04. Having a high school degree in particular is significant at .05 alpha. An odds ratio of 3.01 denotes that a person with hypertension is twice (2.01) as likely to have anxiety than a person with no comorbidities.

Table 1. HADS-P Scores of Participants

Table 2. Predictors of Anxiety

Table 3. Predictors of Depression

Conclusion

In this study, the prevalence of anxiety is 57.33% and depression is 24.67%. Factors predictive of depression is lower educational attainment and factors predictive of anxiety is presence of comorbidity specifically Hypertension and minor physical disability. This psychiatric comorbidity will have impact on the overall well being of patients. Therefore, the need for psychiatric evaluation among patients with leprosy cannot be overemphasized, as this will provide a holistic approach in the management of these patients.

Disclosures

All Authors: No reported disclosures
1661. The association of spirometric impairment and history of TB: a population based study in Uganda
Authors: Robertson Nicole M , Porterfield J Zachary , Kayongo Alex , Kirenga Bruce , Kalyesubula Robert , Checkley William , Thornton Alice , Siddharthan Trishul
Published: January 2021

Background

Pulmonary tuberculosis (TB) is the leading infectious cause of death globally with an estimated 1.7 billion people currently infected with Mycobacterium tuberculosis and at risk of developing TB. While the treatment of drug-susceptible pulmonary TB is highly effective, up to 50% of TB survivors have varying degrees of residual pathological and functional conditions potentially leading to chronic sequelae. Post-TB patients have reported respiratory symptoms, reduced quality of life, and increased risk of mortality. The objectives of this study are to describe the prevalence and lung function in individuals with post-TB exposure status in Uganda.

Methods

We performed a secondary data analysis of the Lung Function in Nakaseke and Kampala (LiNK) study, which is a population-based cohort in urban and rural settings in Uganda. Trained fieldworkers randomly selected homes and administered standard questionnaires to adults 35 years or older that were full-time residents of each setting. Prior TB diagnosis and treatment was self-reported by participants.

Results

Among the study population (N = 1559), 50 participants (3.2%) self-reported successfully treated TB. Among this subset of participants 21 (42.0%) were HIV positive, 9 (18.0%) were ever smokers, 6 (12.0%) were current smokers, and no participants had a prior COPD diagnosis. Mean (SD) age and body-mass index (BMI) at enrollment was 48.5 (SD 10.7) years and 22.2 (SD 3.9) kg/m2 respectively. The mean ± SD pre-bronchodilator FEV1/FVC was 72.9% (12.1%) for patients with successfully treated TB and 79.6% (0.08%) (p< 0.0001) for those without prior TB. Within these groups, 30% of patients with successfully treated TB and 9% of patients without prior TB had an FEV1/FVC suggestive of possible COPD.

Comparison of FEV1/FVC

Conclusion

We found a high burden of residual effects of pulmonary TB on lung function and development of COPD, potentially increasing the global burden of COPD. Screening for chronic respiratory diseases following successful TB treatment is needed to improve lung function. Further research is needed to study lung function and quality of life in TB survivors in LMICs, where the burden of pulmonary TB is highest.

Disclosures

All Authors: No reported disclosures
139. Impact of Pharmacist Driven Outpatient Fluoroquinolone Stewardship Initiative in Community Based Setting
Authors: Norman Sarah , Jones Sara , Acklin Cara , Cheatham Christian
Published: January 2021

Background

Antimicrobial stewardship initiatives and efforts have historically had a greater emphasis in the inpatient hospital setting. There is a need for outpatient stewardship, and additionally, accreditation standards are starting to require antimicrobial stewardship efforts in the ambulatory care setting. Fluoroquinolones are a target for antimicrobial stewardship based on their broad-spectrum activity, pharmacokinetics/pharmacodynamics, safety profile, downstream resistance, and risk of super infections. The objective of this study was to compare outpatient fluoroquinolone prescribing rates before and after pharmacist led initiative.

Methods

This was a prospective, quality improvement initiative between October 1, 2019 to June 1, 2020 at a community-based physician network across Indiana. The pharmacist initiative incorporated a live, educational presentation with intervention 1 and an informational letter to healthcare providers across the outpatient physician network with intervention 2. Data was collected from a computer-generated, prescription report. The primary outcome was fluoroquinolone prescribing rates at Central Indiana (CI) sites before and after pharmacist led interventions. Rate of fluoroquinolone prescribing was defined as total number of fluoroquinolone prescriptions per month. The secondary outcome included percentage of fluoroquinolone use at CI sites. Percentage of fluoroquinolone use was defined as monthly number of fluoroquinolones prescriptions compared to monthly number of all oral antibiotic prescriptions.

Results

There was a 29.8% decrease (382 vs 268 prescriptions) in outpatient fluoroquinolone prescriptions at CI sites after intervention 1 compared to same month of previous year. There was a 43.7% decrease (428 vs 241 prescriptions) in outpatient fluoroquinolone prescriptions at CI sites after intervention 2. There was an overall 2.4% decrease (4.9% vs 2.5%) in percentage of fluoroquinolone use compared to all oral antibiotics at CI sites after intervention 2 compared to same month of previous year.

Conclusion

These findings suggest the pharmacist led outpatient antimicrobial stewardship initiative successfully decreased fluoroquinolone prescribing rates across the network.

Disclosures

Christian Cheatham, PharmD, BCIDP, Antimicrobial Resistance Solutions (Shareholder)
1664. The Utilization of Hospital Inpatient Care due to Tuberculosis, Republic of Ireland, 2015-2018
Authors: O’Connell James A , de barra Eoghan , McConkey Samuel
Published: January 2021

Background

The Republic of Ireland (ROI) is a low incidence TB country. The last reform of TB services in the ROI in 2003 recommended that most TB management should be delivered on an outpatient basis with 3 hospitals being designated as TB centres. Our aim was to describe the utilization of hospital inpatient care by patients with TB in the Republic of Ireland.

Methods

Hospital coding data were searched to identify TB hospital discharges between 01/01/2015-31/12/18. The projected cost of TB episodes of care was calculated using payment rules for public hospitals in Ireland.

Results

1185 admissions with TB as the principal diagnosis were identified. 801/1185 (68%) episodes of care were emergencies and 384/1185 (32%) were elective We estimate that 65.1% (818/1257) patients with TB notified in the Republic of Ireland from 2015-2018 had an episode of care in a public hospital and (50.8%) 639/818 had an emergency episode of care. We estimate that mean annual cost of TB inpatient care per year in the ROI from 2015-2018 was €2,638,828 - 2,955,047, with emergency episodes of care costing an average of €2,250,926 - 2,557,397 per year.

Conclusion

The burden of TB on hospital inpatient care in the Republic of Ireland is significant.

The national TB policy should change in recognition of this.

Disclosures

All Authors: No reported disclosures
1669. Antimicrobial Resistance Patterns of Uropathogenic Escherichia coli: Comparison of Infection Setting and Community Classification
Authors: Muradyan Adriana , Miller Alexandra S , Ahiawodzi Peter D , Thompson Dorothea K
Published: January 2021

Background

This study describes antibiotic resistance rates for Escherichia coli (E. coli) urinary tract infections (UTIs) and assesses differences in resistance patterns based on setting and community classification.

Methods

A cross-sectional study design was used to analyze antibiotic resistance patterns of E. coli isolates from 12,600 urine cultures processed at a large hospital system in North Carolina from 2016 to 2018. Overall 3-year and annual resistance rates of uropathogenic E. coli to routinely tested first-line antibiotics were determined. Antibiotic resistance rates per 1000 patients were compared based on setting of infection acquisition (hospital vs. community) and community classification (urban vs. rural). T-test and chi-square tests were used to compare extended spectrum beta-lactamases (ESBLs) by demographic factors and setting. Analyses were performed using SAS Version 9.3 (SAS Institute, Cary, NC) at alpha=0.05.

Results

Three-year resistance rates were highest to ampicillin (42.2%), ampicillin-sulbactam (24.7%), ciprofloxacin (21.8%), trimethoprim-sulfamethoxazole (21.6%), and levoflaxacin (21.4%). Resistance was lowest for amikacin (0.06%), meropenem (0.08%), piperacillin-tazobactam (1.3%), nitrofurantoin (1.4%), and tobramycin (1.8%). Overall resistance rates were significantly higher in hospital- compared to community-acquired UTIs (p< 0.05) with the exception of amikacin, gentamicin, and meropenem. Significant differences in E. coli resistance rates were observed for patients from rural compared to urban counties for these antibiotics: levoflaxacin (233.6 vs. 208.3, p=0.003), ciprofloxacin (239.3 vs. 211.8, p=0.002), and nitrofurantoin (19.6 vs. 12.2, p=0.003). Prevalence of ESBL-producing E. coli was significantly higher among the elderly (p< 0.001), males (p< 0.001), inpatients (p< 0.001), and catheterized patients (p< 0.001).

Conclusion

Resistance to first-line fluoroquinolones and nitrofurantoin was more prevalent in patients from rural compared to urban areas. Resistance rates and ESBL prevalence were significantly higher for hospital-acquired UTIs. Our findings have important implications for the empirical treatment of UTIs based on geographical area and setting.

Disclosures

All Authors: No reported disclosures
1670. Clinical Characteristics and Demographics of Patients with Complicated Urinary Tract Infections (cUTI) and Antibiotic Resistance or Treatment Failure: A Retrospective Database Analysis
Authors: Sulham Katherine , Reese Jennifer
Published: January 2021

Background

The incidence of complicated urinary tract infection (cUTI) in the United States estimated to be approximately 1%; however, the majority of published literature focuses on characterizing hospitalized cUTI patients. Limited data exists detailing the clinical characteristics and demographics of cUTI patients more generally; in particular, those experiencing antibiotic resistance and/or treatment failure, many of whom currently lack effective oral treatment options in the outpatient setting, yet may not have severe enough disease to warrant hospitalization. Here, we examine the clinical and demographic characteristics of this patient group.

Methods

A retrospective study was performed in partnership with Komodo Health, Inc., using aggregate data from the Komodo Healthcare Map™ for cUTI-related events. Inclusion criteria: (1) 2+ UTI-related encounters within 35 days, beginning in 2017-2018, (2) clinical/coding features indicative of recurrence, treatment failure or antibiotic resistance, or treatment with carbapenem or piperacillin/tazobactam. Clinical and demographic characteristics were examined.

Results

3,334,497 cUTI patients were identified; 1,889,216 patients with evidence of treatment failure and/or antibiotic resistance were eligible for analysis. 76.7% were female, and 40.2% were >65 years of age. 61.8% of patients had hypertension, 42.5% had hyperlipidemia, and 32.3% had uncomplicated type 2 diabetes. 38.7% had concomitant gastroesophageal reflux disease; 17.0% had mild renal impairment and 29.5% had moderate/severe renal impairment. Most common treatments were nitrofurantoin (21.8%), trimethoprim-sulfamethoxazole (19.2%), and cephalexin (14.4%). Approximately half (48.9%) of patients had an inpatient hospital stay during the study period.

Conclusion

cUTI patients with antibiotic resistance and/or treatment failure are predominantly female and present with a variety of common comorbidities, the most common being hypertension. Approximately half of patients in this cohort were treated successfully in outpatient settings and did not require hospitalization during the study period.

Disclosures

Katherine Sulham, MPH, Spero Therapeutics (Independent Contractor) Jennifer Reese, PharmD, Spero Therapeutics (Employee)
140. Impact of Pharmacist-led Audit & Feedback on Outpatient Antibiotic Prescribing for UTIs and SSTIs
Authors: Choi Patricia , Benzer Jessica , Coon Joel , Egwuatu Nnaemeka , Dumkow Lisa E
Published: January 2021

Background

An estimated 30% of all outpatient antibiotic prescriptions in the U.S. are unnecessary. Effective January 2020, The Joint Commission has implemented new core elements of performance requiring antimicrobial stewardship programs (ASP) to expand to outpatient practice settings. The purpose of this study was to determine whether pharmacist-led audit-and-feedback would improve antibiotic prescribing for urinary tract infections (UTI) and skin and soft tissue infection (SSTI) at two primary care practices.

Methods

This retrospective, quasi-experimental study was conducted evaluating patients treated for UTI and SSTI at two outpatient primary care offices, one Family Medicine and the other Internal Medicine. The primary objective was to compare rates of total appropriateness of antibiotic prescribing before (Pre-ASP) versus after (Post-ASP) implementing a pharmacist-led audit-and-feedback process reviewing antibiotics prescribed for UTIs and SSTIs. Total appropriateness was defined by appropriate antibiotic selection, dose, duration, and therapy indication in accordance with institutional outpatient empiric therapy antimicrobial guidelines. Secondary objectives included comparing patient outcomes, including infection-related re-visits and Clostridioides difficile infections between groups.

Results

A total of 400 patients were included in this study (Pre-ASP n=200, Post-ASP n=200) Total antibiotic appropriateness improved significantly from 27.5% to 50.5% after implementation of the audit-and-feedback process (p< 0.0001). Significant improvement was also seen for individual prescribing components including appropriate drug selection (94% vs. 98%, p=0.041), duration (57.5% vs.83.5%, p< 0.0001), and therapy indication (94% vs. 98%, p=0.041). There were no differences in patient outcomes between groups including adverse drug events, treatment failure, C.difficile infections, and infection-related re-visits or hospitalizations within 30 days.

Conclusion

A pharmacist-led audit-and-feedback outpatient stewardship strategy demonstrated significant improvement in outpatient antibiotic prescribing for UTI and SSTI.

Disclosures

All Authors: No reported disclosures
1672. Eligibility and Outcomes of Conversion to Oral (PO) Therapy in Patients Hospitalized with Enterobacteriaceae (ENT) Urinary Tract Infection (UTI) in the United States (US): A Multicenter Analysis
Authors: Melnick David , Jain Akash , Gupta Vikas , Sulham Katherine
Published: January 2021

Background

Rising rates of fluoroquinolone resistance (FQ-R) and third-generation cephalosporin resistance/extended-spectrum beta-lactamases (ESBL+) have left patients with urinary tract infections (UTI) few oral options. Here, we evaluate the eligibility of hospitalized UTI patients to take PO medications and estimate the potential impact on hospital cost and length of stay (LOS).

Methods

We analyzed the first positive enterobacteriaceae (ENT) urine culture ≤ 3 days from hospital admission in patients with a primary or secondary UTI ICD10 discharge diagnosis from 68 US hospitals admitted October 1, 2015-2017. Eligibility for PO was classified as: (1) received at least 24 hours intravenous (IV) antimicrobial, (2) ability to tolerate PO drug as evidenced by a pharmacy order for non-antibiotic PO medication, (3) stable/normal white blood count (WBC). Fisher’s exact test was used to test for significance; results were examined by severity quartile, PO conversion and resistance status (FQ-R and ESBL+)

Results

5,842 patients were eligible for PO conversion and analysis; 1,890 (32.5%) actually converted to PO during their hospital stay; 2,199 (37.6%) were either FQ-R, ESBL+, or both. Baseline demographics were similar between groups. Highly resistant patients (FQ-R and ESBL+) were less likely to transition to PO compared to those with neither FQ-R nor ESBL infections (16.7% vs. 37.0%). Among patients who did convert to PO, post-PO-eligible LOS was shorter across all severity strata compared to patients who did not convert (p< 0.0001). For those who did not convert, post PO-eligible LOS was 2.6, 2.9, 3.3, and 4.0 days by severity quartile, respectively. Among patients who did convert to PO, the total cost was $1,043 less (p=0.024) for patients in the 3rd quartile of severity and $1,512 less (p=0.004) for patients in the 4th quartile of severity, compared to the patients who did not convert.

Conclusion

Only ~1/3 of patents eligible for PO therapy are converted during hospitalization. Reduced LOS and substantial cost savings could be recognized by efficient PO conversion and hospital discharge. Lack of PO therapies with activity against resistant pathogens has made this challenging; new PO options may help reduce hospital costs and resources required to treat these UTI patients.

Disclosures

David Melnick, MD, Spero Therapeutics (Employee)Spero Therapeutics (Employee) Akash Jain, PhD, Spero Therapeutics (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Katherine Sulham, MPH, Spero Therapeutics (Independent Contractor)
1673. Epidemiology of Complicated Urinary Tract Infections (cUTIs) Presenting in Emergency Departments Across the United States (US)
Authors: Lodise Thomas , Chopra Teena , Nathanson Brian , Sulham Katherine
Published: January 2021

Background

Complicated urinary tract infection (cUTI) is a common emergency department (ED) diagnosis. Results of urine culture and antimicrobial susceptibility testing are usually not available for up to 48 hours after an ED visit; therefore, diagnosis and treatment decisions are empiric and based on symptoms, physical findings, and underlying risk of resistance. We sought to understand the epidemiology and incidence of resistance to commonly used oral antibiotics among patients presenting to US EDs with cUTI.

Methods

A retrospective multi-center study using data from the Premier Healthcare Database (2013-18) was performed. Inclusion criteria: (1) age ≥ 18 years, (2) primary cUTI ED/inpatient discharge diagnosis, (3) positive blood or urine culture between index ED service days -5 to +2. Transfers from acute care facilities were excluded. We examined rates of resistance to the following drugs/classes: 3rd generation cephalosporins, fluoroquinolones, trimethoprim-sulfamethoxazole, fosfomycin, and nitrofurantoin in patients presenting to the ED, stratified by those who were ultimately admitted as inpatients vs. not. Regional variation by US Census Division was examined.

Results

187,789 patients met inclusion criteria; 119,668 (63.7%) were admitted to the hospital. 4.6% had positive cultures only with gram-positive bacteria; the remainder had at least one gram-negative pathogen. E. coli was the most common infecting pathogen, present in 72.1% of ED-only infections and 51.4% of those admitted. 44.7% and 58.4% of ED-only and admitted patients, respectively, were resistant to at least 1 of the 5 drugs/classes examined (see table). We saw substantial regional variation; resistance to at least 3 of 5 drugs/classes across all patients ranged from 5.0% in West North Central region to 11.1% in East South Central region (national average: 9.1%).

Resistance Rates by Drug/Drug Class and Hospital Admission Status

Conclusion

Patients with cUTI infections presenting to EDs in the US are frequently resistant to many commonly used oral antibiotics, even in patients not admitted to the hospital. Local epidemiology and resistance should be considered when making empiric treatment decisions in the ED. New oral options for cUTI patients are needed to address the growing challenge of resistance.

Disclosures

Thomas Lodise, PharmD, PhD, Paratek Pharmaceuticals, Inc. (Consultant) Teena Chopra, MD, MPH, Spero Therapeutics (Consultant, Advisor or Review Panel member) Brian Nathanson, PhD, Spero Therapeutics (Independent Contractor) Katherine Sulham, MPH, Spero Therapeutics (Independent Contractor)
1677. Evaluation of Optimal Treatment for Urinary Tract Infections in Outpatient Clinics at an Academic Medical Center
Authors: Walters Jennifer , Kim Jihye , Stevens Michael
Published: January 2021

Background

Inappropriate prescribing of antibiotics is an important modifiable risk factor for antibiotic resistance. The Joint Commission has identified the need for outpatient antimicrobial stewardship efforts. The purpose of this study was to assess the incidence of optimal empiric antibiotic therapy for urinary tract infections (UTIs) in outpatient clinics at VCU Health.

Methods

This was a retrospective study of patients seen in internal medicine (IM) and urology clinics between July 1, 2018 and June 30, 2019. Patients were included if they were ≥ 18 years old, had a diagnosis of UTI per ICD-10 code, and received a prescription to treat a UTI at the visit. Patients were excluded if they had a concurrent infection, currently prescribed antibiotics, or pregnant. The primary outcome was to evaluate the incidence of optimal empiric treatment for UTIs. Appropriateness of antibiotic therapy was assessed based on prior culture data along with our institutional UTI treatment guideline.

Results

Two hundred and twenty-six patients were included: 136 in IM clinics and 90 in urology clinics. Patients in the IM clinics were significantly older (mean age 64.8 vs. 60.5, p= 0.033) and more were female (88% vs. 38%, p< 0.001). More patients in the urology clinics had a history of a UTI within 24 months (72% vs. 57%, p= 0.016), history of fluoroquinolone-resistant Gram-Negative UTIs (35% vs. 13%, p= 0.007), and history of genitourinary cancer (28% vs. 1%, p< 0.001). Overall, 61% of patients were treated with optimal empiric antibiotics. Incidence of optimal prescribing in the IM clinics was significantly higher compared to urology clinics (69% vs 49%, p= 0.002). See table 1 for additional results.

Table 1. Optimal UTI Treatment in Internal Medicine Clinics vs Urology Clinics

Conclusion

IM clinics more frequently prescribed optimal empiric antibiotics for UTIs compared to urology clinics. Resident prescribers were more likely to prescribe optimal empiric therapy. Presence of a beta-lactam allergy was not predictive of optimal prescribing. These data highlight opportunities for antibiotic therapy optimization for UTIs at our health system.

Disclosures

All Authors: No reported disclosures
1684. Hospital Costs and Reimbursement in Patients with Resistant Enterobacteriaceae (ENT) Urinary Tract Infection (UTI) in the United States (US): A Multicenter Analysis
Authors: Melnick David , Jain Akash , Gupta Vikas , Sulham Katherine
Published: January 2021

Background

Rates of fluoroquinolone resistance (FQ-R) and third-generation cephalosporin resistance/extended-spectrum beta-lactamases (ESBL+) are rising. These pathogens generally retain susceptibility to intravenous (IV) carbapenems; however, the loss of susceptibility to commonly used oral (PO) antibiotics limits the opportunity to transition these patients home, leading to increased length of stay (LOS) and higher costs. Here, we evaluate the hospital LOS, costs and reimbursement for UTI hospitalizations.

Methods

We analyzed the first positive enterobacteriaceae (ENT) urine culture ≤ 3 days from hospital admission in patients with a primary or secondary UTI ICD10 discharge diagnosis from 68 US hospitals admitted October 1, 2015-2017. Patient characteristics and outcomes were categorized by ESBL+ and FQ-R status. IV to PO was identified as PO therapy after 24 hours of IV. Outcomes were stratified by resistance and PO conversion status.

Results

16,022 patients were eligible for analysis; 5,017 (31.3%) were FQ-R, 1,763 (11.0%) were ESBL+, and 1,433 (8.9%) were both FQ-R and ESBL+; 2,367 (14.8%) were converted to PO antibiotics during their hospitalization. Overall, mean LOS, costs, and reimbursement were 5.2 days, $9,303 and $8,501 (mean difference between cost and reimbursement: -$878). Mean LOS was shorter and mean difference between cost and reimbursement was lower overall for patients converted to PO therapy vs. those who did not (4.7 vs. 5.3 days, -$532 vs. -$938). Drug resistance was associated with higher LOS and a larger difference between cost and reimbursement; patients who were FQ-R and ESBL+ and did not convert to PO had a mean LOS of 6.0 days, costs of $11,482, and reimbursement of $9,243 (difference: -$2,446). Mean LOS, costs, and reimbursement for patients who were neither FQ-R nor ESBL+ and who did convert to PO therapy were 4.6 days, $7,904, and $7,496 (difference: -$527), respectively.

Conclusion

Reduced LOS and substantial cost savings could be recognized by efficiently converting patients receiving IV antimicrobials to PO and discharging them from the hospital. Lack of PO therapies with activity against resistant pathogens has made this challenging; new PO options may help reduce hospital costs and resources required to treat these UTI patients.

Disclosures

David Melnick, MD, Spero Therapeutics (Employee)Spero Therapeutics (Employee) Akash Jain, PhD, Spero Therapeutics (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Katherine Sulham, MPH, Spero Therapeutics (Independent Contractor)
1689. Oral Beta-lactam Step Down in Bacteremic E. coli Urinary Tract Infections
Authors: Saad Stephan , Mina Neil , Lee Colin , Afra Kevin
Published: January 2021

Background

Literature is scarce regarding oral step down to beta-lactams in bacteremic urinary tract infections. Oral fluoroquinolones are an accepted and common step down for bacteremic urinary tract infections; however, their use is associated with mounting safety concerns. We compared clinical cure in patients with E. coli bacteremic urinary tract infections who were stepped down to oral beta-lactams compared to oral fluoroquinolones.

Methods

This multicentre retrospective cohort study included patients with first positive concurrent urine and blood cultures from January 2016 to December 2016. Patients were included if they received empiric intravenous beta-lactam therapy with step down to either oral beta-lactam or fluoroquinolone for treatment completion. The primary outcome was clinical cure. Secondary outcomes were length of hospitalization, all-cause mortality and C. difficile infection. Multivariate analysis and propensity score were used to control for confounding.

Results

A total of 207 patients were identified with bacteremic E.coli urinary tract infections. Clinical cure was achieved in 72/77 (94%) in the oral beta-lactam group versus 127/130 (98%) in the oral fluoroquinolone group (absolute difference -4.2%, 95% confidence interval [CI] -10.3% to 1.9%, p=0.13). The adjusted odds ratio (OR) for clinical cure with oral beta-lactams was 0.31 (95% CI 0.05 – 1.90, p=0.21); propensity score adjusted analysis showed a similar result. There was no statistically significant difference in secondary outcomes.

Table 2

Table 3

Table 4

Conclusion

Oral beta-lactams appear to be a safe and effective step down option in bacteremic E. coli urinary tract infections compared to oral fluoroquinolones.

Disclosures

All Authors: No reported disclosures
1691. Pre- and Post-Hospitalization Resource Utilization and Costs Associated with Urinary Tract Infection (UTI) in both Commercial and Medicare Populations
Authors: Melnick David , Baljian Nayiri , Jain Akash , Sulham Katherine
Published: January 2021

Background

In the United States, urinary tract infections (UTIs) result in an estimated 7 million office visits, 1 million emergency department visits, and over 500,000 hospitalizations with an associated annual cost of $1.6 billion. Little is known regarding pre- and post-hospitalization resource use. Here, we quantify resource utilization and costs associated with both commercially insured and Medicare patients hospitalized for UTI.

Methods

A retrospective multi-center study using data from the MarketScan® Commercial and Medicare Supplemental Databases was performed. Inclusion criteria: (1) inpatient hospital admission with a primary ICD-10 diagnosis for UTI between October 1, 2015 and December 31, 2017 (index hospitalization), (2) at least 6 months of continuous enrollment and pharmacy benefits prior to the index date, (3) at least 12 months of continuous enrollment and pharmacy benefits after the index date, (4) patient age < 64 (Commercial) or ≥65 (Medicare) on the index date. Demographics, hospitalization characteristics, antibiotic use, and resource utilization/costs in the pre- and post-index periods were examined.

Results

5,248 Commercial and 7,791 Medicare patients were eligible for analysis. 29.7% and 24.1% of Medicare and Commercial patients, respectively, were male. 5.9% of Medicare patients had a claim for skilled nursing facilities (SNF) in the 14 days pre-index admission (1.0% Commercial), 9.1% had emergency department claims (13.1% Commercial), and 39.8% had office visit claims (49.9% Commercial). Post-hospitalization, 20.3% (1.3% Commercial) were discharged to SNF and 15.4% (4.7%) were discharged to home health services. Mean insurer UTI-related costs were $8,677 (Commercial) and $5,358 (Medicare) in the 6 months pre-index hospitalization. Similarly, costs were $21,135 (Commercial) and $22,342 (Medicare) in the 12 months post hospitalization ($3,944 and $2,988 in the first 30 days post-discharge, respectively).

Conclusion

UTI is associated with substantial costs and resource utilization to insurers in both pre- and post-hospitalization settings. Understanding total costs of care and location of service may aid in cost-reduction strategies for treating UTI.

Disclosures

David Melnick, MD, Spero Therapeutics (Employee)Spero Therapeutics (Employee) Nayiri Baljian, n/a, Spero Therapeutics (Employee) Akash Jain, PhD, Spero Therapeutics (Employee) Katherine Sulham, MPH, Spero Therapeutics (Independent Contractor)
1692. Retrospective Review on the Safety and Efficacy of Nitrofurantoin for the Treatment of Cystitis in the Veteran Population With or Without Renal Insufficiency
Authors: Welch Elwyn W , Sheth Shaila , Ashong Chester , Pham Caroline
Published: January 2021

Background

Nitrofurantoin has been used to treat cystitis in women; however, data supporting its use in men is lacking. In addition, recent retrospective studies have challenged the manufacturer’s recommendation to avoid nitrofurantoin with creatinine clearances (CrCl) less than 60 mL/min. The purpose of this study is to compare the efficacy and safety of nitrofurantoin for the treatment of acute cystitis in male and female veterans with variable degrees of renal dysfunction.

Methods

A retrospective chart review was conducted in adult patients who received nitrofurantoin for acute cystitis in the outpatient setting between May 1, 2018 and May 1, 2019. The primary outcomes were rates of clinical cure as compared between males and females, and across various renal function groups (CrCl greater than 60 mL/min, 30 to 60 mL/min, and less than 30 mL/min) following treatment with nitrofurantoin. The secondary outcome was adverse event rates.

Results

A total of 446 patients were included with 278 females and 168 males. Overall clinical cure rate was 86.5% (n=386). Clinical cure rate did not vary between genders (p=0.0851) or CrCl ranges (p=1.0) as shown in the tables. Benign prostatic hyperplasia (BPH) was associated with decreased odds of clinical cure (OR 0.50 [95% CI 0.26-0.97], p=0.0404) in addition to cirrhosis (OR 0.22 [95% CI 0.06-0.91], p=0.0357). Adverse events occurred in 2% of patients and did not vary based on gender or renal function.

RATES OF CLINICAL CURE

Conclusion

There was no statistically significant difference in clinical cure with nitrofurantoin between genders and various renal impairments. However, history of BPH and cirrhosis were associated with decreased efficacy. Subgroup analysis also revealed lower efficacy in males with CrCl greater than 60 mL/min versus females with similar renal function. This study adds to the growing body of literature suggesting that renal dysfunction with CrCl of 30 to 60 mL/min may not carry the risk of treatment failure and adverse effects previously associated with nitrofurantoin, but large randomized trials are needed to confirm these results.

Disclosures

All Authors: No reported disclosures
1700. What Is Specific With Bacterial Escherichia Coli Urinary Tract Infection
Authors: Hammami Fatma , Koubaa Makram , Chakroun Amal , Rekik Khaoula , Smaoui Fatma , Elleuch Emna , Marrakchi Chakib , Jemaa Mounir Ben
Published: January 2021

Background

Bacterial urinary tract infections continue to be a major health problem, responsible for a significant morbidity and mortality. Its prognosis is more severe than non-bacterial forms. The aim of this work was to study the clinical and evolutionary features of bacterial urinary tract infections caused by Escherichia coli (E.coli).

Methods

We conducted a retrospective study including all patients hospitalized in infectious diseases department for urinary tract infection (UTI) caused by E.coli between 2010 and 2017.

Results

During the study period, we enrolled 613 cases of UTI caused by E.coli, among whom 75 cases (12.2%) were bacterial. There were 47 females (62.7%). The mean age was 59 ±17 years. Thirty-three patients were aged ≥ 65 years (44%). Diabetes was noted in 38 cases (50.7%) and renal lithiasis in 14 cases (18.7%). A history of UTI was reported in 13 cases (17.3%). The most common clinical presentation was acute pyelonephritis (59 cases; 78.7%) and followed by prostatitis (8 cases; 10.6%). Renal abscess was noted in 5 cases (6.7%) and prostatic abscess in 3 cases (4%). There were 36 cases of multidrug-resistant bacteria (48%). Community-acquired UTI were noted in 70 cases (93.3%). The mean duration of treatment was 18 ± 6 days. Surgery and radiological drainage were indicated in 4 (5.3%) and 2 cases (2.7%), respectively. The outcome was favourable in 58 cases (77.3%). Complications were noted in 10 cases (13.3%) represented mainly by acute renal failure in 4 cases (5.3%). Relapse was noted in 9 cases (12%) and reinfection in 6 cases (8%). Two patients died (2.7%).

Conclusion

Bacterial urinary tract infections were associated to complications such as renal and prostatic abscess, requiring surgery and long duration of treatment.

Disclosures

All Authors: No reported disclosures