bluuebunny/crossref_metadata_2025 huggingface dataset:
207. Travel Related Risk Behaviors and Antibiotic Use among Older Travelers
Authors: Costello Varea H , Tribble David , Eickhoff Christa , Tilley Drake H , Utz Gregory , Telu Kalyani , Ganesan Anuradha , Fraser Jamie , Lalani Tahaniyat
Published: January 2021

Background

Older travelers (≥ 60 years) are a unique risk population for travel related infections and adverse events from antibiotics. We evaluated the differences in travel characteristics, exposures, illnesses and antibiotic use among older travelers and those between 18 – 59 y using a prospective, observational cohort of US Department of Defense (DoD) beneficiaries traveling outside the US for ≤ 6.5 months (TravMil).

Methods

Adult DoD beneficiaries were enrolled pre-travel. Itineraries limited to Western/Northern Europe, Canada, or New Zealand and active duty personnel on military travel were excluded. Demographics, itineraries and prescriptions were abstracted. A post-travel survey collected information on exposures and illnesses (travelers’ diarrhea (TD), influenza-like illness (ILI) or febrile illness). Categorical variables were analyzed using chi-square or Fishers exact test and the Mann-U Whitney test was used for continuous variables.

Results

Of the 1468 travelers, 755 were ≥ 60y and 719 were < 60y. Asia (35%) and South/Central America (28%) were the most common travel regions. Older travelers were more likely to be Caucasian (80% vs. 67%), male (52% vs. 39%) and travel for tourism (84% vs. 51%) (p< 0.05). Younger travelers were more likely engage in risk behaviors (e.g. consume poorly cooked meat or seafood (16% vs 9%) or street vendor food (26% vs 8.6%), wade in fresh water (24% vs. 18%), and non-compliance with malaria prophylaxis (22% vs 12%) (p< 0.05). Older travelers had a lower incidence of TD (18% vs 24%), and a higher proportion of cases with loose stool or mild TD that did not interfere with daily activities (63% vs. 51%) (p< 0.05). Inappropriate antibiotic use for loose stool or mild TD were similar among the two age groups (67% vs 59%). Non-significant trends of lower incidence and mild infections were observed for ILI and febrile illness in older travelers.

Conclusion

Older travelers were less likely to engage in risk behaviors, had a lower TD incidence and reported mild diarrheal symptoms. Inappropriate antibiotic use for loose stool or mild TD was common in both age groups. Enhancing antibiotic stewardship is important for older travelers to prevent potential side effects, drug interactions and antibiotic resistance.

Disclosures

All Authors: No reported disclosures
208. Variation in Clinical Practice and Attitudes in the Management of Fever and Neutropenia in Patients With Hematologic Malignancy: A Survey of Cancer Centers Across the United States
Authors: Aitken Samuel L , Aitken Samuel L , Barreto Jason N , Nagel Jerod , Seo Susan K , Seo Susan K , Liu Catherine
Published: January 2021

Background

Fever and neutropenia (FN) is common in cancer patients after chemotherapy, and there are national guideline recommendations for FN prevention and treatment. We conducted a survey of practices across multiple US cancer centers to determine the extent to which these guidelines have been adapted.

Methods

US cancer centers performing 20 allogeneic hematopoietic stem cell transplantations annually were identified from the National Marrow Donor Program’s “Be the Match” directory. Antimicrobial stewardship physicians and pharmacists at each institution were identified using institutional websites, residency or fellowship program directories, and personal contacts. A survey assessing institutional practices and individual attitudes on FN management in high-risk patients was distributed via email. Duplicate responses at the hospital level were removed. Complete surveys regarding individual attitudes were assessed using a 5-point Likert scale ranging from “Strongly Agree” to “Strongly Disagree.”

Results

Thirty-four (23%) responses from 148 individuals were received, representing 31 of 86 hospitals (36%). 29 (94%) hospitals reported having guidelines for the management of FN. Of these, cefepime was the most commonly recommended agent for empiric treatment (26, 90%) and 16 (55%) provide guidance based on presumed site of infection. Eighteen (62%) hospitals recommend de-escalation of Gram negative therapy in certain situations, most often after being afebrile 48 – 72 hours or after neutrophil recovery (7 each, 39%). Twenty-seven (93%) hospitals recommended antibiotic prophylaxis, most often with levofloxacin (21, 78%). Of 34 respondents, attitudes were split regarding the statement “The benefit of antibiotic prophylaxis outweighs the harms in high-risk patients” (10 strongly agree or agree, 10 strongly disagree or disagree; 29% each); most agreed with the statement “I would use antibiotic prophylaxis in high-risk patients” (25, 78%).

Conclusion

Most cancer centers across the US have guidelines for the management of FN. While most recommend antibacterial prophylaxis, there were differences in individual perceptions regarding the risk / benefit. Significant variation exists in the approach to antibiotic de-escalation.

Disclosures

All Authors: No reported disclosures
209. Antibiotic Utilization During the COVID-19 Surge in Detroit
Authors: Shallal Anita , Kenney Rachel , Suleyman Geehan
Published: January 2021

Background

Antibiotic overutilization during the COVID-19 pandemic has been reported, despite relatively infrequent bacterial co-infection. We explored antibiotic utilization before, during and after the COVID-19 surge in Michigan.

Methods

Cross-sectional study at an 877-bed hospital in Detroit, Michigan from January 2019 through May 2020. Measures: Count of COVID-19 hospital admissions by day. Monthly antibiotic utilization for formulary agents used to treat pneumonia were measured using monthly days of therapy (DOT) per 1000 patient days present and the National Health Care Safety Network Standardized Antimicrobial Administration Ratio (SAAR). Descriptive analysis was utilized.

Results

The first COVID-19 case was detected March 11, 2020 and peaked in early April (Figure 1). Antibiotic utilization is demonstrated in Figure 2. The COVID-19 peak was associated with increased use of multiple antibiotics; notably, DOT per 1000 days present for ceftriaxone, cefepime and doxycycline were 85.43, 79.42 and 71.56, respectively in April. The institutional all-antibacterial SAAR was significantly reduced in May at 0.96, p=0.0022, after the COVID-19 surge.

Figure 1

Figure 2

Conclusion

We observed increased utilization of multiple antibiotics during the COVID-19 surge, and reduction in the all-antibacterial SAAR after the surge. More robust information is needed to promote optimal antibiotic use for patients with COVID-19 infections.

Disclosures

All Authors: No reported disclosures
210. Vancomycin Infusion Frequency and Intensity: Analysis of Real-World Data Generated from Automated Infusion Devices
Authors: Yamaga Cynthia , Bostick David L , Tabak Ying P , Liu-Ferrara Ann , Morel Didier , Yu Kalvin
Published: January 2021

Background

Automated infusion devices captures actual infused medication administration data in real-time. Vancomycin use is now recommended to be driven by AUC (area under the curve) dosing. We evaluated automated infusion device data to depict vancomycin administration practices in acute care hospitals.

Figure 1. Distribution of vancomycin infusion dosing

Figure 2. Distribution of time intervals between each vancomycin infusion session (mostly around 8 or 12 hours)

Methods

We analyzed archived vancomycin infusion data from 2,417 patients captured by automated infusion systems from 3 acute care hospitals. The infusion device informatics software recorded a variety of events during infusion – starting and stopping times, alarms and alerts, vancomycin dose, and other forms of timestamped usage information. We evaluated infusion session duration and dosing, using data-driven clustering algorithms.

Results

A total of 13,339 vancomycin infusion sessions from 2,417 unique adult patients were analyzed. Approximately 26.1% of patients had just one infusion of vancomycin. For the rest of the patients, the median number of infusion sessions per patient was 4; the interquartile range was 3 and 8. The most common dose was 1.0 gram (53.7%) or 1.5 gram (24.6%) (see Figure 1). The distribution of infusion session duration (hours) was 4.2% (≤1.0 hh); 40.1% (1.01–1.5 hh); 29.1% (1.51–2.0 hh); and 26.6% (>2.0 hh). The dosing frequency was 39.5% (q8 hh), 42.9% (q12 hh), 11.1% (q24 hh), and 6.5% (>q24 hh) (Figure 2), demonstrating clinical interpretability.

Conclusion

A considerable number of patients received just one vancomycin infusion during their hospital stay, suggesting a potential overuse of empiric vancomycin. The majority of infusion doses were between 1 to 1.5 grams and most infusion sessions were administered every 8 or 12 hours. The actual infusion duration for each dose often exceeds the prescribed 1- or 2-hour infusion orders, which may be due to known instances of infusion interruptions due to patient movement, procedures or IV access compromise. The data generated by infusion devices can augment insights on actual antimicrobial administration practices and duration. As vancomycin AUC dosing becomes more prevalent, real world infusion data may aid timely data-driven antimicrobial stewardship and patient safety interventions for vancomycin and other AUC dosed drugs.

Disclosures

Cynthia Yamaga, PharmD, BD (Employee) David L. Bostick, PhD, Becton, Dickinson and Co. (Employee) Ying P. Tabak, PhD, Becton, Dickinson and Co. (Employee) Ann Liu-Ferrara, PhD, Becton, Dickinson and Co. (Employee) Didier Morel, PhD, Becton, Dickinson and Co. (Employee) Kalvin Yu, MD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding)
211. A Comprehensive Assessment of Carbapenem Use across 90 Veterans Health Administration Hospitals with Defined Stewardship Strategies for Carbapenems
Authors: Suzuki Hiroyuki , Perencevich Eli N , Goto Michihiko , Alexander Bruce , Nair Rajeshwari , Puig-Asensio Mireia , Ernst Erika , Livorsi Daniel J
Published: January 2021

Background

Carbapenems are an important target for antimicrobial stewardship (AS) efforts. In this study, we sought to compare different hospital-based strategies for improving carbapenem use.

Methods

We analyzed a cohort of all patients hospitalized at Veterans Health Administration (VHA) acute-care hospitals during 2016 and mandatory survey data that characterized each hospital’s carbapenem-specific AS strategy into one of three types: no strategy (NS), prospective audit-and feedback (PAF), or restrictive policies (RP). Sites that could not be classified were excluded. Inpatient carbapenem use was compared across strategies using risk-adjusted generalized estimating equations that accounted for clustering within hospitals. Two Infectious Disease (ID) physicians independently performed manual chart reviews in 425 randomly-selected carbapenem-treated cases (100 for PAF/NS and 225 for RP). Auditors assessed for the presence of ID consultation and carbapenem appropriateness on day 4 of therapy. Assessments were categorized as follows: appropriate (1), acceptable (2), suboptimal (3), unnecessary (4) and inappropriate (5). Assessment scores across strategies were compared with the Kruskal-Wallis test.

Results

There were 429,602 admissions in 90 sites (8 PAF, 24 NS, 58 RP). Median carbapenem use across sites was 17.4 (IQR 8.6–28.4) days of therapy/1,000 days-present. Inpatient carbapenem use was lower at PAF than NS sites [RR 0.67 (95% CI, 0.46–0.98); p=0.04] but similar between RP and NS sites [RR 0.86 (95% CI, 0.61–1.22); p=0.41].

Carbapenem use was considered appropriate or acceptable in 215 (50.6%) of the reviewed cases. Assessment scores were higher (i.e. worse) at NS than RP sites (mean 2.7 vs 2.3; p< 0.01) but did not differ significantly between NS and PAF sites (mean 2.7 vs 2.5; p=0.14).

ID consultations were more common at PAF/RP than NS sites (51% vs 29%; p< 0.01). ID consultations were associated with lower (i.e. better) assessment scores (2.3 vs. 2.6; p< 0.01).

Conclusion

In this VHA cohort, AS strategies and ID consultations were associated with either less or more appropriate carbapenem-prescribing. The use of AS and ID consultations may be complementary, and hospitals could leverage both to optimize carbapenem use.

Disclosures

Daniel J. Livorsi, MD, MSc, Merck and Company, Inc (Research Grant or Support)
212. Acute Kidney Injury with Piperacillin-tazobactam versus Cefepime in Combination with Vancomycin
Authors: Nguyen Phuong Khanh , Tran Thuong , Jetsupphasuk Kristy , Wang Nina , Chun Patricia , Tan Susanna , Graber Christopher J
Published: January 2021

Background

Drug-induced nephrotoxicity in the form of acute kidney injury (AKI) is a potential adverse effect of vancomycin, which is commonly prescribed empirically with an antipseudomonal agent. It is unclear if combinations with certain antipseudomonal agents (e.g., piperacillin-tazobactam) are associated with more AKI relative to others.

Methods

This retrospective cohort study conducted at two Veterans Affairs (VA) Medical Centers with differing preferred empiric vancomycin-antipseudomonal regimens aimed to assess the incidence of AKI in patients receiving vancomycin and piperacillin-tazobactam (VPT) at VA Greater Los Angeles Healthcare System (HCS) versus vancomycin and cefepime (VC) at VA Long Beach HCS. Patients who received VPT or VC for at least 48 hours in 2016–2018 were included. AKI definitions were derived from 2012 Kidney Disease Improving Global Outcomes guidelines. Secondary assessments included hospital length of stay, 90-day mortality, and incidence of Clostridioides difficile infection (CDI) within 90 days. Patients who developed AKI were further assessed for time-to-onset of AKI, development of chronic kidney disease (CKD) within 90 days, and hemodialysis (HD) dependence within 1 year. Statistical analysis was performed using Fisher’s exact and Mann-Whitney U tests where appropriate. Propensity score matching using logistic regression with nearest-neighbor matching was performed to control for potential confounding baseline characteristics.

Results

21/120 patients receiving VPT developed AKI vs. 4/120 receiving VC (17.5% vs. 3.3%, p=0.0005). After propensity score matching, AKI incidence remained significantly higher for VPT patients (15.2% vs. 4.0%, p=0.01). Median length of stay was significantly longer for VPT patients (10 days vs. 8 days, p=0.03). There was no significant difference in time-to-onset of AKI, 90-day mortality, or CDI. No significant difference was found in the development of CKD within 90 days nor the requirement of HD within 1 year.

Conclusion

VPT combination therapy was associated with increased incidence of AKI compared to VC, though 90-day mortality and other outcomes were similar. Advising prescribers about potentially increased risk of AKI with VPT is a viable stewardship intervention.

Disclosures

All Authors: No reported disclosures
215. Appropriateness and Accuracy of Antimicrobial Prescriptions at Pediatric Emergency Department Discharge
Authors: lau Jackelyn , Islam Shamim , Polischuk Emily
Published: January 2021

Background

Up to 20% of pediatric emergency department visits result in an antimicrobial prescription. The objective of this study was to evaluate the appropriateness and dosing accuracy of antimicrobial prescriptions given at discharge from an ED of a freestanding children’s hospital.

Methods

Electronic medical records of patients seen in the ED at Oishei Children’s Hospital from 12 dates (3 in each of 4 seasons) were screened. All patients discharged from the ED with a prescription for an antimicrobial were included. Diagnosis, provider type, antibiotic dose per weight, duration and frequency were recorded. Appropriateness of antibiotic choice and dosing accuracy were assessed using major medical society guidelines, pharmacy references and hospital antibiograms. Antibiotic doses were considered inaccurate if >10% outside of recommended weight-based dose ranges.

Results

Of a total of 1733 screened patients, 12% (207) were discharged with a systemic antimicrobial prescription. The percentage of visits resulting in an antimicrobial prescription varied by season, and was highest during the winter at 19%. Amoxicillin (33% of all) and oseltamivir (15%) were most frequently prescribed. Overall, 98% of patients were prescribed the appropriate antimicrobial, but only 65% of systemic antimicrobial prescriptions had accurate dosing. Amoxicillin was dosed incorrectly in 32% of prescriptions, Figure 1, specifically being below the high-dose recommended range in 28% of otitis media (OM) and 29% of pneumonia cases. Despite being the most common diagnosis, OM was treated with accurate dosing only 57% of the time, Figure 2. Also, more than 40% of patients with UTI or pneumonia had inaccurate drug dosing. Nurse practitioners (NP) prescribed the most antibiotics. Appropriate prescribing did not vary by provider, but accuracy of dosing did; for example, NP dosing accuracy was 58%, vs. 73% for residents (p < 0.04), Figure 3.

Dosing Accuracy of Antimicrobials

Dosing Accuracy by Diagnosis

Appropriateness and Accuracy by Prescriber Group

Conclusion

An eighth of pediatric ED visits resulted in an antimicrobial prescription. Inaccurate dosing occurred regularly for common infections; most notably underdosing of amoxicillin for OM and pneumonia. Education and audit related to specific drugs and providers promises to be of high stewardship impact in pediatric EDs.

Disclosures

All Authors: No reported disclosures
216. Are Automatic Antimicrobial Stop Orders an Effective Stewardship Tool for Urinary Tract and Intra-Abdominal Infections?
Authors: Maguire Christina , Rose Dusten T , Jaso Theresa
Published: January 2021

Background

Automatic antimicrobial stop orders (ASOs) are a stewardship initiative used to decrease days of therapy, prevent resistance, and reduce drug costs. Limited evidence outside of the perioperative setting exists on the effects of ASOs on broad spectrum antimicrobial use, discharge prescription duration, and effects of missed doses. This study aims to evaluate the impact of an ASO policy across a health system of adult academic and community hospitals for treatment of intra-abdominal (IAI) and urinary tract infections (UTI).

ASO Outcome Definitions

ASO Outcomes

Methods

This multicenter retrospective cohort study compared patients with IAI and UTI treated before and after implementation of an ASO. Patients over the age of 18 with a diagnosis of UTI or IAI and 48 hours of intravenous (IV) antimicrobial administration were included. Patients unable to achieve IAI source control within 48 hours or those with a concomitant infection were excluded. The primary outcome was the difference in sum length of antimicrobial therapy (LOT). Secondary endpoints include length and days of antimicrobial therapy (DOT) at multiple timepoints, all cause in hospital mortality and readmission, and adverse events such as rates of Clostridioides difficile infection. Outcomes were also evaluated by type of infection, hospital site, and presence of infectious diseases (ID) pharmacist on site.

Results

This study included 119 patients in the pre-ASO group and 121 patients in the post-ASO group. ASO shortened sum length of therapy (LOT) (12 days vs 11 days respectively; p=0.0364) and sum DOT (15 days vs 12 days respectively; p=0.022). This finding appears to be driven by a decrease in outpatient LOT (p=0.0017) and outpatient DOT (p=0.0034). Conversely, ASO extended empiric IV LOT (p=0.005). All other secondary outcomes were not significant. Ten patients missed doses of antimicrobials due to ASO. Subgroup analyses suggested that one hospital may have influenced outcomes and reduction in LOT was observed primarily in sites without an ID pharmacist on site (p=0.018).

Conclusion

While implementation of ASO decreases sum length of inpatient and outpatient therapy, it may not influence inpatient length of therapy alone. Moreover, ASOs prolong use of empiric intravenous therapy. Hospitals without an ID pharmacist may benefit most from ASO protocols.

Disclosures

All Authors: No reported disclosures
217. Broad Spectrum Antibiotic use in Outpatient Parenteral Antibiotic Therapy (OPAT): Opportunities for Antibiotic Stewardship
Authors: Brenon Jessa R , Shulder Stephanie , Munsiff Sonal , Burgoyne Colleen , Nagel Angela , Pillinger Kelly E
Published: January 2021

Background

Broad-spectrum antibiotics are often chosen for OPAT due to the convenience of once daily dosing. Current literature suggests that at least 20–30% of these regimens could be narrowed, but this has not been well-defined.

Methods

This was a multicenter, retrospective cohort study of adult inpatients evaluated by the infectious diseases (ID) team with culture positive infections with susceptibilities (C&S) on select intravenous (IV) antibiotics (ampicillin, ampicillin-sulbactam, cefazolin, ceftriaxone, daptomycin, ertapenem, meropenem, nafcillin, penicillin, piperacillin-tazobactam, and vancomycin) enrolled in OPAT and discharged from January 1 - June 30, 2019. Susceptibilities were not required for Actinomyces, Streptococcus spp., Haemophilus spp., anaerobes, Corynebacterium spp., or coagulase-negative Staphylococcus spp. when considered a contaminant by ID. Patients were excluded if the regimen included oral antibiotics (not including rifampin or metronidazole). Primary outcome was the percent of broad-spectrum regimens that could’ve been narrowed based on C&S (alternative available therapy or AAT group). Secondary outcomes included comparison of baseline characteristics and 30-day readmission rates between patients on narrow-spectrum IV antibiotics (NSA) vs AAT group, and the documented reason(s) for broad-spectrum antibiotic selection.

Results

113 patients met study criteria; majority were male (56%), and median age was 60 years. Sixty-four patients were discharged on a broad-spectrum regimen, and 32 (50%) met our AAT definition. Ceftriaxone was used in 75% of these cases (24/32), and mono-microbial Streptococcus spp. infection was the primary indication (54%). AAT group patients were more likely to have Enterobacterales (24.1% vs 1.9% p=< 0.001) or polymicrobial infections (28.1% vs 8.2% p=0.019) compared to NSA group. Reasons for broad-spectrum antibiotic selection were largely undocumented (71%). No significant differences were seen in 30-day readmission rates.

Conclusion

At our institution, 50% of select IV broad-spectrum OPAT regimens had the potential to be narrowed based on C&S data. This rate is higher than previously reported. It warrants further investigation into the barriers to narrower-spectrum antibiotic prescribing in OPAT.

Disclosures

Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker)
223. Difference in Carbapenem Use by ASP Intervention in Japanese Healthcare Facilities
Authors: Endo Mio , Tsuzuki Shinya , Asai Yusuke , Tajima Taichi , Matsunaga Nobuaki , Hayakawa Kayoko , Ohmagari Norio
Published: January 2021

Background

Antimicrobial stewardship program (ASP) interventions have been reported to reduce unnecessary antimicrobial use (AMU). In this study, we investigated the difference in the use of carbapenems by ASP intervention in Japanese healthcare facilities.

Methods

Data on two components of AMU and ASP registered in Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) from January to December 2019, were used. Facilities with an infection control team in addition to an antimicrobial stewardship team responsible for the proper use of antimicrobial agents were included in the study. AMU data (such as DOT [Days of Therapy / 100 patient days]) are entered semi-automatically from medical fee statement (receipt) file at each facility. ASP intervention is divided into four categories 1) pre-authorization, 2) prospective audit and feedback (PAF), 3) PAF and required notification (RN), 4) RN. The Kruskal-Wallis test is performed to see overall difference and the Dunn test with the Bonferroni correction is done for each pair of categories.

Results

A total of 114 hospitals were included in the analysis. The median number of beds at participating facilities were 430 [IQR: 281–602], the median average hospital stay was 13.0 days [IQR: 11.4–15.2] and total number of inpatients per month was 10087 [6247–14536]. PAF and RN were the most common ASP interventions for carbapenems (62.5%), followed by RN (33.6%). The median DOT [IQR] of participating facilities were 2.1 [1.2–3.1] and 1) 0.7 [0.2–1.1], 2) 2.7 [2.1–3.4], 3) 2.1 [1.4–3.1] and 4) 2.0 [1.2–3.5] by ASP categories. There are significant differences between 1) and 2), 1) and 3), and 1) and 4) (p=0.014, p< 0.01 and p< 0.01, respectively) while the differences between 2) and 3), 2) and 4), and 3) and 4) are not significant (p=1.00).

Table 1. Summary statistics of healthcare facilities by ASP Interventions

Figure 1. DOT by ASP Interventions

Conclusion

Only 3.5% of ASP interventions belong to 1) pre-authorization category and this might be due to the complexity of registration process. This category was found to have the lowest DOT among all ASP interventions in Japanese healthcare facilities. The variances of DOT were especially large in categories 3) and 4), and more detailed analyses would be necessary to evaluate their efficacies accurately.

Disclosures

All Authors: No reported disclosures
224. Effect of Easing Overnight Restrictions on Antimicrobial Starts
Authors: Yarrington Michael E , Wrenn Rebekah , Spivey Justin , Shoff Christopher , Spires Steven S , Turner Nicholas A , Smith Michael J , Diez Anthony , Anderson Deverick J , Moehring Rebekah W
Published: January 2021

Background

Some institutions allow administration of restricted antibiotics overnight until evaluation the following day (i.e. first dose free) to adapt to limitations in personnel resources. Whether this method results in higher number of overnight requests compared to strict 24/7 preauthorization has not been fully described.

Methods

In October 2019, Duke University Hospital (DUH) changed from strict preauthorization to allow initiation of two restricted agents (meropenem and micafungin) between the hours of 11pm to 7am. We performed an interrupted time series (ITS) analysis to evaluate the phase shift and change in trend in the number of new meropenem and micafungin orders per week before (Jan 2019-Oct 2019) and after (Oct 2019- Mar 2020) the process change. First antimicrobial orders for meropenem and micafungin were counted for unique patient encounters. We fit a Gaussian distribution function to the number of orders per hour of day to estimate the percent of orders initiated overnight (11p-7a) and during day/evening hours (7a-11p) before and after the process change.

Results

Hospital data included 1728 new meropenem and micafungin orders over a 61-week period (~28 per week). The total number of meropenem and micafungin orders was constant between Jan 2019 and October 2019 (+0.07 orders/week, 95% CI -0.13 to 0.27, Figure 1) and the phase shift during the first week of October was non-significant (-4.38 orders, 95% CI -12.34 to 3.58). The number of orders increased after October 2019 (+0.70 orders/week, 95% CI 0.13 to 1.25), however a sensitivity analysis removing the largest outlier eliminates significance. The percent of total orders between 11am to 7pm increased from 13.3% to 17.2% after the intervention (Figure 2). Overall antibiotic use remained similar through the study period.

Figure 1. Estimated Approvals per Week

Figure 2. Approvals by Hour of Day

Conclusion

There was no significant immediate change in overnight prescribing of meropenem and micafungin, however a trend towards increased number of orders appeared after removing overnight restriction requirements. Instead of “stealth dosing”, where providers wait to enter restricted antibiotic orders until evening hours, we observed a small increase in starts in early morning hours (1am-6am). Preauthorization approaches must adapt to personnel resources and quality of life for antimicrobial stewards.

Disclosures

Michael J. Smith, MD, MSC.E, Kentucky Medicaid (Grant/Research Support)Merck (Grant/Research Support) Rebekah W. Moehring, MD, MPH, Agency for Healthcare Quality and Research (Grant/Research Support)Centers for Disease Control and Prevention (Grant/Research Support)
226. Evaluating the Unnecessary Use of Intravenous Broad-Spectrum Antibiotics in Patients Based on Systemic Inflammatory Response Syndrome Criteria in the Emergency Department (ED)
Authors: Bae Esther Y , Monogue Marguerite , Smith Tiffeny T
Published: January 2021

Background

Recognition of sepsis frequently occurs in the ED. To demonstrate the need to optimize antibiotic use for suspected sepsis and evaluate the reliability of systemic inflammatory response syndrome (SIRS) criteria in predicting bacterial infection, we quantified the rate of unnecessary intravenous (IV) broad-spectrum antibiotic use for suspected sepsis in the ED at an academic medical center.

Methods

Adult patients who were admitted to the ED between January 2018 and June 2018 with suspected sepsis (≥ 2 SIRS) and received ≥ 1 dose of IV broad-spectrum antibiotic were included in this retrospective study. The presence of bacterial infection was determined using Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) definitions, microbiologic, radiographic, and laboratory findings. Suspected infections lacked microbiologic data. The primary outcome was the percentage of confirmed and suspected infections. Secondary outcomes included 90-day Clostridioides difficile infection (CDI) and 90-day drug-resistant organism (DRO) infections.

Results

A total of 218 patients were included. The percentages of confirmed/suspected and absence of bacterial infections were 63.8% and 36.2%, respectively. Elevated SIRS (≥ 2) and Quick Sequential Organ Failure Assessment (qSOFA; ≥ 2) scores were not associated with the presence of bacterial infections. 82% of patients were discharged from the ED. Antibiotic exposure in days of therapy in the ED and/or hospital admission did not significantly vary between patients with confirmed/suspected bacterial infection and those with absence of bacterial infections. Among patients who lacked evidence of bacterial infections, 44% were prescribed outpatient antibiotics after being discharged from the ED. 90-day CDI and DRO infections were identified in 7 and 6 patients, respectively, regardless of the presence of bacterial infections.

Table 1. Baseline demographics of patients admitted to the ED with suspected sepsis

Conclusion

A third of the patients with suspected sepsis received IV broad-spectrum antibiotics in the ED but ultimately lacked bacterial infection. Our findings suggest that identification of bacterial infection and patients with sepsis using SIRS or qSOFA lack specificity and can lead to the overuse of unnecessary antibiotics in the ED.

Disclosures

All Authors: No reported disclosures
227. Evaluation of Empiric Vancomycin Utilization at 72 Hours Post Admission: is De-escalation of Vancomycin Appropriate?
Authors: Naderi Mandana , Welker Kimberly , Pourshams-Manzouri Tina , Huang Vanthida , Buros Amy
Published: January 2021

Background

At both of our institutions in 2018, the average vancomycin days of therapy per 1,000 patient days was 112. The purpose of this study was to examine a 72-hour time-out as an effective de-escalation tool by evaluating the indication and clinical appropriateness of the continuation of empiric vancomycin therapy.

Methods

A retrospective chart review was performed from January 2018 to October 2018 at two community hospitals. Patients > 18 years who received at least 3 days of empiric vancomycin therapy were included. Patients were excluded if immunocompromised, pregnant, on hemodialysis, received vancomycin for surgical prophylaxis, or expired within 72 hours of vancomycin initiation. Criteria for appropriate continuation of vancomycin at 3 days: positive culture for methicillin-resistant Staphylococcus aureus (MRSA), presence of infection with or without defined sources with systemic signs of infection (i.e. white blood cells >12,000 cells/L or < 5,000 cells/L and/or elevated temperature ≥ 37.5°C), or pending wound/sputum cultures after vancomycin initiation.

Results

A total of 160 adult patients initiated on vancomycin were analyzed; 118 of 160 (74%) met appropriate criteria. The most common indications for vancomycin were: skin and soft tissue infections (SSTI) 82 patients (51%); pneumonia 37 patients (23%); and positive blood culture 20 patients (13%). Risk factors for MRSA were similar between both groups. Forty-four (28%) patients had cultures pending and 23 patients (14%) had a known non-MRSA pathogen at time of assessment. American Indian race (OR 3.01 (1.21, 7.53) p-value= 0.0174) and SSTI indication (OR 2.87 (1.24, 6.80) p-value= 0.0147) were associated with not meeting appropriate criteria.

Conclusion

Approximately 25% of patients receiving empiric vancomycin therapy did not meet clinical criteria for continuation beyond 72 hours. The indication most commonly associated with continued vancomycin utilization was SSTI. These results identified indications in which empiric vancomycin prescribing can be optimized, and a 72-hour antibiotic time-out may be warranted as a stewardship intervention. Timely culture obtainment and intervention when another pathogen is identified are possible strategies to ensure success of 72-hour time-out.

Disclosures

All Authors: No reported disclosures
232. Impact of Weekend Initiation of Vancomycin or Piperacillin/Tazobactam on Days of Therapy Received upon Hospital Admission
Authors: McGregor Jessina C , McCracken Caitlin M , Hohmann Samuel F , Pakyz Amy L
Published: January 2021

Background

Antibiotic therapy for inpatients with suspected infections is typically empirically initiated and therapy narrowed or altered when additional diagnostic evidence becomes available. For patients whose therapy is initiated on a weekend, differences in hospital staffing may impact the timing of therapy changes. We aimed to compare the duration of therapy of vancomycin and piperacillin-tazobactam between those who had therapy initiated on a weekday versus a weekend day.

Methods

We performed a cross-sectional study among U.S. hospitals that contributed pharmacy data for inpatients to the Vizient clinical database in 2016. We identified vancomycin and piperacillin-tazobactam courses initiated within the first 48 hours of admission; courses were categorized as weekend initiation (Friday, Saturday, Sunday) versus weekday initiation. The median days of therapy were compared between weekend and weekday initiation using the Wilcoxon rank-sum test.

Results

Among the 145 hospitals representing approximately 3.7 million patient encounters there were 401,101 encounters with vancomycin and 221,751 with piperacillin/tazobactam initiated within the first 48 hours of admission. Of these courses, 33% of vancomycin and 40% of piperacillin/tazobactam were initiated on a weekend day. The median (IQR) days of therapy for vancomycin initiated on a weekend was 2 days (1–4 days) compared to 2 days (1–3 days) when initiated on a weekday (p< .01). The median (IQR) days of therapy for piperacillin/tazobactam was 3 days (2–5 days) for courses initiated on either a weekend or weekday (p< .01).

Conclusion

We observed a statistically significant difference in the days of therapy received by patient encounters with vancomycin or piperacillin/tazobactam initiated on weekdays versus weekends. However, because of the large sample size in this study, we had power to identify small differences as statistically significant. Still, for vancomycin the 75th percentile received at least one additional day of therapy when initiated on a weekend versus a weekday. Further exploration is needed to identify if weekend initiation is associated with extended durations of therapy in specific sub-populations of patients.

Disclosures

All Authors: No reported disclosures
233. Improved Penicillin Susceptibility of Streptococcus pneumoniae and Increased Penicillin Consumption in Japan, 2013–18
Authors: Tsuzuki Shinya , Akiyama Takayuki , Matsunaga Nobuaki , Yahara Koji , Shibayama Keigo , Sugai Motoyuki , Ohmagari Norio
Published: January 2021

Background

Penicillin is often recommended as the first choice for Streptococcus pneumoniae infection due to its effectiveness and narrow spectrum. However, it is not clear whether increased penicillin consumption at the population level induces penicillin resistance in S. pneumoniae. The main objective of this study was to examine the association between penicillin susceptibility of S. pneumoniae and penicillin consumption in Japan.

Methods

We used Japan Nosocomial Infection Surveillance data, which comprehensively collected all routine microbiological test results from approximately 2,000 out of 8,000 hospitals across Japan that voluntarily participated in the surveillance. on susceptibility of S. pneumoniae, and sales data obtained from IQVIA Services Japan on national penicillin and cephalosporin consumption from January 2013 to December 2018. Clinical and Laboratory Standards Institute minimum inhibitory concentration breakpoints for meningitis were used as indicators of susceptibility. We analysed both sets of data by decomposing them into seasonality components and chronological trend components. The cross-correlation function was checked using Spearman’s rank correlation coefficient to examine for correlation between susceptibility and consumption.

Results

After adjusting for the influence of seasonality, the susceptibility of S. pneumoniae to penicillin gradually improved from 0.53 in January 2013 to 0.61 in December 2018 and penicillin consumption increased in the same period from 0.67 defined daily doses per 1,000 inhabitants per day (DID) in January 2013 to 1.23 DID in December 2018, thus showing positive cross-correlation (coefficient = 0.801, p < 0.001). Conversely, cephalosporin consumption decreased from 3.80 DID in January 2013 to 3.33 DID in December 2018, showing negative cross-correlation with penicillin susceptibility of S. pneumoniae (coefficient = -0.981, p < 0.001).

Figure 1. Trend of penicillin-susceptibility of Streptococcus pneumoniae in Japan, 2013–2018 (based on non-meningitis MICs)

Figure 2. Sales amount of penicillins in Japan, 2013–2018

Figure 3. Sales amount of cephalosporins in Japan, 2013–2018

Conclusion

The rate of penicillin-resistant S. pneumoniae isolate was not positively correlated with penicillin consumption at the population level. Increased penicillin consumption might not induce penicillin resistance of S. pneumoniae.

Disclosures

All Authors: No reported disclosures
234. Improving Antibiotic Prophylaxis Selection for Patients Undergoing Urology Procedures
Authors: Mattappallil Arun , Magan Alyssa M , Kim Eun Hyun , Sackey Joachim D , Chew Debra
Published: January 2021

Background

Evidence evaluating prescribing patterns in antibiotic (ABC) prophylaxis (PPX) for urology (UGY) procedures is limited. Although national guidelines give direction on the ABC PPX for specific procedures, ABC PPX should also be based on local ABC resistance patterns, individual host factors and procedure type factors. Our institution’s urine culture antibiogram illustrates increasing resistance to Cefazolin, a national guideline preferred ABC. The purpose of this study is to assess the impact of a quality improvement intervention on prescribing practices for ABC PPX in patients undergoing UGY procedures.

Methods

This is a retrospective study evaluating all patients receiving perioperative ABC PPX for UGY procedures from 01/01/2019 to 07/31/2019. The intervention (focusing on UGY provider education for ABC PPX based on local ABC resistance patterns, host factors and UGY procedure type) occurred on multiple in-person sessions during 04/2019. Emphasis occurred with replacing Cefazolin with Ceftriaxone, given local resistance patterns. We compared patient characteristics, appropriate ABC PPX use (deemed by local ABC Stewardship Team) and postoperative infections between the “pre” (01/01/2019 – 03/31/2019) and “post” (05/01/2019 – 07/31/2019) groups.

Results

The “pre” group had 85 patients and the “post” group had 80 patients. 62% had a same day UGY procedure with the most common procedures designated as “clean-contaminated” (81.8%) and ASA physical status classification as “ASA II” (53.9%). After the intervention, appropriate ABC PPX choice improved (14.5% to 76%, P < 0.001) based on local ABC resistance patterns. No significant difference is noted in urine culture collection before procedure (36.4% to 43.7%, P = 0.3), ABC PPX choice based on prior patient-specific culture results including multi-drug resistant pathogens (75% to 82.3%, P = 0.6), use of ABC PPX post-procedure (40% to 35%, P = 0.5) and postoperative infections (7% to 11.2%, P = 0.4).

Conclusion

Utilization of education sessions as a quality improvement intervention resulted in significant improvement in ABC PPX choice for UGY procedures based on local ABC resistance patterns. Further interventions are necessary to optimize additional areas related to ABC PPX use for UGY procedures.

Disclosures

All Authors: No reported disclosures
239. Outcomes Associated with Empiric Aztreonam Use Compared to Anti-Pseudomonal β-lactams in Patients with Sepsis: An Opportunity for Allergy Stewardship
Authors: Jaffa Rupal K , Pillinger Kelly E , Medaris Leigh A , Anderson William E , Heffner Alan C , Hammer John M
Published: January 2021

Background

Aztreonam is often given to patients with a documented β-lactam allergy in lieu of a first-line anti-pseudomonal β-lactam (APBL). However, aztreonam offers no gram positive coverage and data suggest that gram negative organisms have lower susceptibility rates to this antibiotic than to APBLs. Septic patients are especially vulnerable to poor outcomes since inappropriate initial antimicrobial therapy has been shown to be an independent predictor of increased mortality. The purpose of this study was to determine whether septic patients treated with aztreonam experience inferior outcomes compared to those treated with an APBL.

Methods

This was a retrospective, multicenter, cohort study of all adult patients in metro Charlotte Atrium Health facilities treated for sepsis or septic shock from January 2014 to October 2017. Patients receiving either aztreonam or an APBL were identified using the system-wide sepsis database and enrolled in a 1:2 ratio. Patients were excluded if there was no infection-related discharge ICD-9 or ICD-10 code, if they received both aztreonam and an APBL in the first 8 hours, or if they received fewer than 2 doses of the study antibiotic. The primary endpoint was in-hospital mortality.

Results

A total of 194 patients received aztreonam and 388 patients received an APBL. β-lactam allergies were more common in patients who received aztreonam compared to APBL (97% vs. 14.2%, p < 0.01). In-hospital mortality rates were greater in the patients who received aztreonam vs. APBL (22.7% vs. 12.9%, p = 0.0025). After adjusting for APACHE II score, initial aztreonam exposure remained independently associated with hospital mortality (OR = 1.74, 95% CI: 1.0 – 2.8, p = 0.02). Additionally, we identified an increase in combination therapy with the use of aminoglycosides (28.9% vs. 12.4%, p < 0.0001) and fluoroquinolones (50.5% vs. 25.8%, p < 0.0001) in patients receiving aztreonam. No difference was found in overall length of stay or ICU length of stay.

Conclusion

In septic patients, the use of aztreonam as the backbone of antimicrobial therapy may result in increased mortality. This highlights the importance of stewardship interventions that obtain an accurate allergy history and encourage the use of APBL antibiotics whenever feasible.

Disclosures

Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker)
240. Reduction of antibiotic use in children admitted with viral respiratory tract infections
Authors: Dutta Ankhi , Lo Huay-Ying , Singh Amrita , Mobeen Samrah , Kulik Kelli , James Megan
Published: January 2021

Background

Viral respiratory tract infections (VRTI) accounts for a significant proportion of hospitalized children and contributes to a substantial use of health care resources and costs. American Academy of Pediatrics (AAP) recommends against using antibiotics in uncomplicated viral respiratory infections in children. Overuse of antibiotics ranges between 29–80%. The goal of an Antibiotic stewardship programs (ASP) is to decrease antibiotic misuse, lower costs, and prevent emergence of antibiotic resistance in the community.

Proportion of children with Viral respiratory tract infections on antibiotics

Methods

Our smart aim was to reduce antibiotic use by 25% in admitted children with VRTI between October 2019-March 2020. Our outcome measure was to reduce inappropriate antibiotic use during the 2019–20 season by 25%. Process measures included percentage of antibiotic used in viral RTI, antibiotic days of therapy and appropriate audit-feedback from the ASP team to facilitate discontinuation or de-escalation of antibiotics based on culture data. Our balance measure included readmission rates in patients in whom antibiotics were discontinued or de-escalated. Several PDSA cycles implemented with predominant emphasis on communication between ASP team and primary providers.

Results

No differences were noted in patient demographics including sex, age, ethnicity between the viral season in 2018–19 and 2019–2020. In our previous study in 2018–2019 RSV season, there was 40.7% antibiotic use in patients admitted with RSV bronchiolitis. In 2019–2020 season we included all patients admitted with viral RTI. Of the 213 patients evaluated between October 2019 through Dec 2020, 40% of the patients received antibiotics. 100% of the antibiotics were justified, based on independent review of antibiotic data by the team. Most common cause of antibiotics were community acquired pneumonia, rule out sepsis and otitis media. Antibiotic discontinuation and de-escalation were achieved in over 90% of the justified antibiotics.

Conclusion

Though antibiotic usage was still at 40% at our institution, 100% of antibiotic use was deemed appropriate and significant proportion were discontinued or deescalated by the ASP team.

The ASP team played a crucial role in communicating with the primary providers to advocate for appropriate antibiotic use in the children.

Disclosures

All Authors: No reported disclosures