bluuebunny/crossref_metadata_2025 huggingface dataset:
1721. In Vitro Activity of Cefiderocol against IMP-Producing Enterobacterales Isolated in Japan
Authors: Yamashiro Hidenori , Nakai Ryuichiro , Takemura Miki , Yamano Yoshinori
Published: December 2022

Background

Beta-lactam resistance is a major worldwide concern. Metallo-β-lactamases (MBLs) are a group of enzymes that can inactivate most commonly used β-lactam antibiotics including carbapenems and are not affected by new β-lactamase inhibitors. Therefore, treating infections caused by MBL producing strains is difficult. Imipenemase (IMP) type MBL is a rare family of acquired carbapenemases detected from Enterobacterales globally, however, it has been detected and become a major therapeutic concern in clinical settings mainly in East Asia including Japan [1]. Cefiderocol (CFDC) is a novel injectable siderophore cephalosporin antibiotic with potent activity against a wide variety of carbapenem resistant strains including both serine- and metallo-type carbapenemase-producers. We evaluated in vitro activity of CFDC and comparator agents against IMP-producing Enterobacterales isolated in Japan.

Methods

A total of 150 IMP-producing strains consisting of 48 Escherichia coli, 34 Klebsiella pneumoniae, 29 Klebsiella oxytoca, 21 Enterobacter cloacae, 7 Citrobacter freundii, 7 Serratia marcescens, 2 Providencia rettgeri, 1 Klebsiella aerogenes, and 1 Morganella morganii were tested. The minimum inhibitory concentrations (MICs) were determined for CFDC, ceftazidime-avibactam (CZA), ceftolozane-tazobactam (C/T), imipenem-relebactam (I-R), meropenem (MEM), and amikacin (AMK) by broth microdilution according to CLSI guidelines. CFDC was tested in iron-depleted cation-adjusted Mueller-Hinton broth.

Results

MIC50 and MIC90 of CFDC were 0.25 and 1 µg/mL, respectively. MICs of CFDC for all tested strains ranged from ≤ 0.03 to 4 µg/mL, which showed all strains were susceptible to CFDC based on the CLSI breakpoint (≤ 4 µg/mL). On the other hand, MIC90s of CZA, C/T, I-R, MEM, and AMK were > 32/4, > 32/4, 8/4, > 32, and 4 µg/mL, respectively. The susceptibilities were 98.0% for AMK, 66.0% for I-R, and < 10% for CZA, C/T and MEM.

Conclusion

CFDC had potent in vitro activity against IMP-producing Enterobacterales collected from Japan, indicating CFDC has high potential for treating infections caused by these difficult-to-treat strains.

Reference: 1. Logan, LK. et al., J Infect Dis. 2017 Feb 15;215(suppl 1):S28-S36.

Disclosures

Hidenori Yamashiro, Shionogi & Co., Ltd.: Employee Ryuichiro Nakai, n/a, Shionogi TechnoAdvance Research CO., LTD.: Employee Miki Takemura, n/a, Shionogi: Employee Yoshinori Yamano, PhD, Shionogi: Employee.
1743. Antimicrobial and Diagnostic Stewardship Targeting Urinary Tract Infections in the Emergency Department: A Pharmacist-driven Quality Improvement Project at a Tertiary Military Treatment Facility
Authors: Ayalew Memar , Admassu Hellena , Ressner Roseanne , Williams Robin , Crull Paulette , Brooks Daniel
Published: December 2022

Background

With the increasing interest in ambulatory stewardship, we designed a quality improvement project to enhance guideline concordant antimicrobial and diagnostic stewardship practices targeting urinary tract infections (UTI) in the ED of a Military Treatment Facility. Between two data collection phases (P1, P2), we provided education on national guidelines, local protocols and antibiograms, modified order-sets, and implemented enhancements targeting urine collection. The primary outcome was a change in guideline-concordant practices between P1 and P2.

Methods

This prospective pharmacist-driven study had two 3-month data collection periods including ED encounters that resulted in a urinalysis (UA), urine culture (UCx) and antibiotics for UTI upon discharge. We collected data on participant demographics, clinical course and therapy details via chart review. Culture callback and corresponding interventions were made within 72 hours. Based on P1 results, we broadened our scope in P2 to include a diagnostic stewardship arm (Figure 1). This project was IRB approved under a non-research determination.

Results

There were no significant changes in guideline-concordant prescribing or diagnostic practices between P1 and P2 (Figure 2). Inappropriate antibiotic selection was primarily due to use of cephalosporins and FQs as first line agents (Table 1). The primary pharmacy intervention was discontinuation of therapy (P1 29.1%, P2 39.8%). One-third of patients receiving antibiotics were asymptomatic, a majority of which had a positive UA (P1 68.4%, P2 73.3%). There was a high rate of UCx contamination which improved in P3 but did not reach statistical significance (P1 25.6%, P2 17.2%, p=0.19). Across all P2 encounters, 51.4% of UCx were deemed inappropriate.

Conclusion

Significant guideline-discordant prescribing persisted despite interventions. An overreliance on UA findings results in treatment of asymptomatic bacteriuria. Education and order-set modification alone are insufficient for a lasting impact on prescribing practices especially where there is a high rate of provider turnover. An EMR with embedded clinical and alert-based decision support capabilities are likely to make a sustained impact in curbing inappropriate treatment of asymptomatic bacteriuria.

Disclosures

All Authors: No reported disclosures.
1749. Nursing Home Providers’ Empiric Antibiotic Choices for Residents with Urinary Tract Infections: A National Survey
Authors: Taylor Lindsay , Irvine Jessica , Wilson Brigid , Massey Justin , Singh Mriganka , Jolles Sally , Kowal Corinne , Bej Taissa A , Furuno Jon P , Nace David , Jump Robin L , Crnich Christopher J
Published: December 2022

Background

Urinary tract infections (UTIs) are the most common indication for antibiotic prescriptions in nursing homes (NHs) and frequently result in fluoroquinolone (FQ) prescriptions. We performed a vignette-based survey of NH providers to better understand empiric UTI treatment decision-making.

Methods

Study participants were recruited nationally through professional organizations and snowball sampling from December 2021 to February 2022. Clinical vignettes depicting four UTI presentations in NH residents (1. simple cystitis, 2. pyelonephritis with cephalosporin allergy, 3. catheter-associated UTI and 4. cystitis with history of resistant organism) were developed and distributed via electronic survey. Respondents provided free-text antibiotic choice, which two physicians independently reviewed and implicitly determined if a preferred or not-preferred antibiotic was selected. A panel of three physicians adjudicated discrepancies between the primary reviewers. Analysis was performed in R.

Results

Of 86 respondents, 74% were physicians and 26% were advanced practitioners. Half of respondents (50%) had >10 years NH experience, 41% were geriatrics trained, and none were infectious disease trained. Figure 1 details antibiotic choices and preferred agents for each case. Overall, 70% of antibiotic choices were deemed preferred antibiotics, with the least number of preferred choices observed for case 3 depicting catheter-associated UTI (53%). FQs (43%) and nitrofurantoin (14%) were the most frequent non-preferred choices. Case 2 received the greatest proportion of FQ prescriptions (38%), but this was a preferred agent. In cases where FQs were not a preferred choice, they comprised 17% of antibiotic choices. There was no difference in FQ or preferred prescribing choices by role. Providers with >10 years NH experience, however, prescribed fewer FQs over the four cases than those with less NH experience (0.7 vs. 1.1, p=0.04).

Antibiotic Choice and Preferred Agents per Case

Antibiotic choices are ordered from highest to lowest cumulative frequency.

Conclusion

This sample of NH providers made mostly preferred empiric antibiotic choices, however, FQ use remained high, particularly in providers with less NH practice experience. Further exploration of decision-support tools for empiric antibiotic prescribing in this setting may improve antibiotic stewardship.

Disclosures

Robin L. Jump, MD, PhD, Merck: Grant/Research Support|Pfizer: Advisor/Consultant.
1764. Accuracy of Penicillin Allergy Risk Severity Documentation in Surgical Patients
Authors: Stickler Michelle , Heil Emily L , Noval Mandee
Published: December 2022

Background

Clinical guidelines for antimicrobial prophylaxis recommend use of cefazolin for most surgical procedures. Patients who are labeled penicillin (PCN) allergic are often prescribed second line agents, though cross-reactivity is less than 1%. PCN allergic patients have significantly higher rates of readmissions and healthcare-associated infections. Allergy documentation in the medical record is often incomplete or inaccurate, and many allergies can be de-labeled through history alone. Our study aimed to investigate accuracy of allergy risk assessment in PCN allergic patients and the impact on surgical antibiotic prophylaxis for quality improvement.

Methods

This was a retrospective observational cohort study among adult patients with a reported PCN allergy who underwent a surgical procedure from 3/2019-2/2020 at a single academic institution. The primary outcome was incidence of appropriate documentation of allergy risk severity. Secondary outcomes included receipt of beta-lactam for surgical prophylaxis and incidence of documentation to reflect tolerance. Allergy risk classification was considered appropriate if it aligned with institutional guidelines (Table 1).

Results

Of 2647 patients who underwent surgical procedures, 330 (12%) reported PCN allergy. Allergy risk severity was appropriately documented in 136 (41%) patients. 150 (45%) were mislabeled as “high” or “unknown” risk compared to reported reaction. 191 (58%) patients with reported PCN allergies received beta-lactam antibiotics peri-operatively. Allergy history had been updated to reflect tolerance in only 6% of patients who received cefazolin for surgical prophylaxis and in 21% who had received beta-lactams previously (Table 2). Table 2:Primary and Secondary Outcomes

Conclusion

Inaccurate documentation of allergy risk results in decreased first-line antimicrobial use in patients with reported PCN allergies. Documented PCN allergy risk severity was often incorrect and over 100 additional patients could have been labeled “low risk” based on reported reaction. 72% of patients could have received first-line beta-lactam prophylaxis per institutional guidelines. Interventions targeting allergy history documentation alone could positively impact antibiotic selection.

Disclosures

All Authors: No reported disclosures.
1768. Characteristics and Impact of Penicillin Allergy Mislabeling Among People with HIV
Authors: Sonners Christine , Hill Eddie , Kim Alexander , Wooten Darcy
Published: December 2022

Background

Rates of penicillin allergy mislabeling (PAM) are prevalent and lead to suboptimal antibiotic selection. However, data regarding PAM are lacking for people with HIV (PWH). We aimed to characterize the penicillin allergy labels for PWH at the University of California, San Diego’s (UCSD) HIV primary care clinic, evaluate the impact of penicillin allergy labels on treatment choice for syphilis and gonorrhea, and implement a quality improvement project to address PAM.

Methods

We conducted a cross-sectional study of PWH with a penicillin allergy label in their medical record who were seen in our clinic between 2018 and 2022. We collected demographic information, type of allergic reaction listed, whether patients tolerated other beta-lactam antibiotics, whether patients were referred for formal Allergy consultation, and, where relevant, what treatment they received for syphilis and/or gonorrhea.

Results

Among the 4,702 people with HIV receiving care in our clinic between 2018 and 2022, 427 (9.1%) had a penicillin allergy label in the medical record. This cohort reflected the demographics of the general clinic population (Table 1). Even though the majority of allergic reactions (327, 77%) were labeled as IgE-mediated, 282 (66%) patients tolerated another beta-lactam antibiotic (Table 2). Referrals to Allergy Clinic were rare (52, 12%). The majority of patients with syphilis (91/140, 65%) received 2nd line therapy with doxycycline. However, most patients with gonorrhea (65/88, 74%) were treated with a preferred ceftriaxone-based regimen. When relevant, we updated penicillin labels for 209/268 (77.9%) patients to indicate that they had tolerated other beta-lactam antibiotics and created a tiered referral process to prioritize the highest-risk patients for Allergy Clinic referral (Figure 1).

Conclusion

Penicillin allergy labels were prevalent in our cohort of PWH and often resulted in receiving 2nd line therapy for treatment of syphilis. We updated allergy labels for a substantial number of patients and created a triage system to refer patients to Allergy clinic for further testing based on risk in order to decrease PAM.

Disclosures

All Authors: No reported disclosures.
1781. Antibiotic Prescription Trends of Patients with COVID-19: Analysis of National Health Insurance Data in Republic of Korea
Authors: Choi Yunsang , Kang Minsun , Shin Dong Hoon , Jung Jongtak , Choi Seong Jin , Kim Nak-Hyun , Moon Song Mi , Song Kyoung-Ho , Kim Eu Suk , Jung Jaehun , Kim Hong Bin
Published: December 2022

Background

Although COVID-19 is a viral infection, it is known that antibiotics are often prescribed due to concerns about combined bacterial infection. Therefore, we aimed to analyze how many patients with COVID-19 received the antibiotic prescription as well as what kinds of factors contributed to it using the National Health Insurance database.

Methods

We retrospectively reviewed claims data for adults 19 years of age and older hospitalized for COVID-19 from December 1, 2019 to December 31, 2020. According to severity classification of the National Institutes of Health guidelines, we calculated not only the proportion of patients receiving antibiotics but also days of treatment per 1000 patient days. In addition, we investigated the factors contributing to antibiotic use by linear regression analysis.

Results

Of the 55,228 patients, 47% were male, 55% were older than 50 years of age, and most patients (89%) had no underlying diseases. The majority (84%, 46,576) were classified as having mild to moderate illness, with 11% (6,168) and 5% (2,484) having severe and critical, respectively. Antibiotics were prescribed in a total of 27% (15,081). While 74% of patients with severe illness and 88% of those with critical illness received antibiotic treatment, even 18% of mild to moderate cases were prescribed antibiotics. Fluoroquinolones were the most commonly prescribed antibiotics (8,348), followed by third generation cephalosporins (5,729) and beta-lactam/beta-lactamase inhibitors (3,822) as shown in Figure 1. Older age, severity of disease and underlying medical conditions contributed to overall prescription rates as well as days of antibiotic use significantly (Table 1).

Conclusion

Although most of COVID-19 patients had mild to moderate illness, more than a quarter were prescribed antibiotics. Judicious use of broad-spectrum antibiotics is necessary for COVID-19 patients, considering the severity of disease and the risk of bacterial co-infection.

Disclosures

All Authors: No reported disclosures.
1783. Appropriateness of antibiotics use for patients with asymptomatic bacteriuria or urinary tract infection: A retrospective observational multicenter study in Korea
Authors: Jung Jongtak , Kim Bongyoung , Kim Dong Youn , Lee Mi Suk , Park Se Yoon , Kim Tae Hyong , Lee Myung Jin , Park Ji Young , Jo Hee Bum , Lee Woo Joo , Kim Jin Yong , Mi Moon Song , Song Kyoung-Ho , Park Jeong Su , Suk Kim Eu , Kim Min Hyung , Park Yoon Soo , Kwak Yee Gyung , Kim Ji-Yeon , Park Jeanno , Kim Young Keun , Jeong Hye Won , Park Sun Hee , An Joon Hwan , Lee JaeHoon , Park Kyung-Hwa , Bae Sohyun , Chang Hyun-Ha , Kim Si-Ho , Son Deog-Hyeon , Lee HoJin , Moon Chisook , Heo Sang Taek , Jung Jaehun , Bin Kim Hong
Published: December 2022

Background

Antibiotic resistance threatens public health worldwide, and inappropriate use of antibiotics is one of the main causes. Antibiotic use for asymptomatic bacteriuria (ABU) has been defined as “antibiotics never events”, and urinary tract infection (UTI) is one of the most common infectious diseases for which antibiotics are prescribed in Korea. To establish an effective antimicrobial stewardship strategy, a qualitative assessment of antibiotic use in actual clinical syndrome is necessary.

Methods

Cases of positive urine cultures (≥105 CFU/ml), performed in inpatient, outpatient, and emergency departments in April 2021 were screened in 26 hospitals located throughout Korea. Cases were classified into ABU, lower UTI, and upper UTI. The appropriateness of antibiotic use was retrospectively evaluated by infectious disease specialists using quality indicators based on the domestic clinical guideline for ABU and UTI. Figure 1.Study flow diagram

Results

A total of 2697 cases of ABU or UTI were included. The appropriateness of antibiotic use was assessed in 1157 cases with asymptomatic bacteriuria, 677 and 863 cases with lower and upper UTI (Figure 1). Antibiotics were prescribed in 21.7% (251 of 1157) of ABU without appropriate indication. Of 66 ABU cases with appropriate indication in which prophylactic antibiotics were prescribed, the duration of antibiotics was adequate in only 34.8% (Table 1). For lower UTI, the appropriateness of empirical and definite antibiotics was 77.8% (527 of 677) and 68.0% (353 of 519). In terms of upper UTI, 86.3% (745 of 863) and 78.2% (583 of 746) was appropriate, respectively. The duration of antibiotics was adequate in 65.7% (421 of 641) of lower UTI and 77.9% (592 of 760) in upper UTI (Table 2, 3).

Conclusion

This nationwide qualitative assessment of antibiotic use in ABU and UTI revealed that a significant proportion of antibiotics were prescribed inappropriately and, furthermore the duration of antibiotics was prolonged unnecessarily. Interventions for appropriate antibiotic use in ABU and UTI at the national level are required.

Disclosures

All Authors: No reported disclosures.
1785. Assessment of Antimicrobial Prescription Trends Based on AWaRe Index Among COVID Patients as part of the Implementation of a Modified Antimicrobial Stewardship Audit for COVID Locations of Restricted Access in a South Indian Tertiary Care Center
Authors: Dipu T S , Kulirankal Kiran G , Mary Ann , Edathadathil Fabia , Raj Jina , Moni Merlin
Published: December 2022

Background

The advent of COVID pandemic disrupted routine antimicrobial stewardship(ASP) activities. We implemented a modified ASP audit in COVID locations using electronic stewardship forms inorder to monitor all antibiotics prescribed to COVID patients and assess them based on WHO AWaRe index.

Methods

Our prospective audit included all COVID inpatients who received antimicrobial prescriptions in 70 bedded covid area during the period from May 1st, 2021 to March 31st, 2022. All antimicrobial prescriptions were tracked using the daily review of the pharmacy consumption charts in Covid locations and prescriptions were categorised as per AWaRe index. For all reserve antimicrobial prescriptions link for REDCap based E – stewardship forms were sent to the physician in charge of the covid locations.

Results

Among 3484 COVID patients reviewed from May 1st 2021 to March 31st 2022, 2152 (61.7%) patients were prescribed with antimicrobials. The highest consumption of antimicrobials prescribed belonged to Watch group( 1937/2152, 90%) followed by Access (151/2152, 7.2%) and Reserve categories (64/2152, 3%) of WHO AWaRe index. Among the Watch group, the highest consumption was observed for Azithromycin (748/2152, 34.7%), followed by ceftriaxone(589/2152,27.3%) , piperacillin- tazobactam(400/2152,18.5%) and Meropenem(187/2152, 8.6%). Linezolid (22/2152, 1.0%) accounted for highest consumption among Reserve group, followed by Ceftazidime –Avibactam (17/2152, 0.7%) and colistin(14/2152, 0.6%).

Conclusion

The study successfully demonstrated the feasibility of implementing modified antimicrobial stewardship in Covid locations during the pandemic, especially in presence of unmet need for targeted strategies for driving antimicrobial stewardship

Disclosures

All Authors: No reported disclosures.
1791. Leveraging EMR Alerts for Vancomycin Time Outs
Authors: Lusardi Katherine , Bailey Brett , Awad Ramez , Jenkins Mitchell , Rico Crescencio Juan Carlos , Horak Matthew , Dare Ryan K
Published: December 2022

Background

Vancomycin represented the most used antibiotic at our academic medical center from 2014-2022. To enhance compliance with the “antibiotic time out” part of the CDC Core Elements for Stewardship, we designed an electronic medical record (EMR) best practice alert (BPA) to assist providers in identifying patients eligible for vancomycin discontinuation.

Methods

This is a single center, retrospective pre (06/01/14-2/24/20)/post (02/25/20-03/31/22) comparison of vancomycin utilization after the introduction of a locally validated automated vancomycin time-out. The BPA alerted on patients who had received vancomycin for 72h, had no microbiological evidence of methicillin resistant S. aureus, and had no infectious diseases consult. While other vancomycin reduction strategies had previously been implemented as part of the stewardship program, no other intervention debuted during the same time period. An interrupted time series analysis was performed to assess immediate and ongoing trend changes of institutional vancomycin use. Wilcoxon rank sum and chi2 analyses were also performed.

Results

There were 36,817 inpatient vancomycin orders placed. The BPA triggered during 1,881 (15.7%) orders in the post-BPA period, which was 49.6% of the 3,794 orders still active at 72h. After BPA introduction, there was an immediate decrease in vancomycin days of therapy (DOT)/1000 patient days (PD) ±SE (-8.5 ±3.6; P = 0.021) followed by a significant decrease in the monthly trend relative to the pre-intervention trend (-0.7 DOT/1000 PD ±0.2; P< 0.001). Median vancomycin DOT/1000 PD decreased from 145.9 (IQR 140.2-153.0) to 117.3 (IQR 107.7-122.6) in pre and post periods respectively (P< 0.001). Length of therapy (LOT) decreased, orders were more commonly discontinued by day 5, and orders were more likely to be discontinued prior to discharge. Separate analysis including only orders with >72h showed similar results (Table 1). Table 1Vancomycin length of therapy (LOT) pre and post-BPA Time Out.Figure 1Vancomycin days of therapy per 1000 patient days (DOT/1000PD) trends pre and post-BPA Time Out.

Conclusion

Introduction of an EMR automated vancomycin time out was an effective tool to decrease vancomycin utilization at an academic medical center.

Disclosures

All Authors: No reported disclosures.
1807. Tracking antibiotic de-escalation using a novel metric, days of antibiotic spectrum coverage (DASC)
Authors: Suzuki Hiroyuki , Heintz Brett , Livorsi Daniel J , Perencevich Eli N , Goto Michihiko
Published: December 2022

Background

In the United States, days of therapy (DOT) is the currently preferred method for measuring antibiotic consumption. A major disadvantage of DOT is that it does not account for the antimicrobial’s spectrum. Antibiotic de-escalation is therefore not well-captured by DOT. To overcome the limitation of DOT, we recently proposed a new metric, days of antibiotic spectrum coverage (DASC). DASC is calculated by multiplying DOT and the antibiotic spectrum coverage (ASC) score, which was assigned based on the activities of each antibiotic agent for 11 wild type bacteria and 5 acquired resistance patterns. Here we evaluate the performance of DASC using antibiotic consumption data where the main antimicrobial stewardship program (ASP) activity is daily prospective audit-and-feedback of all inpatients on antibiotics.

Methods

We analyzed the retrospective cohort of inpatient antibiotic use at Iowa City VA Health Care System from 2017 to 2021. Total monthly DOT was the aggregation of monthly DOT for each antibiotic. DASC for each antibiotic was calculated by multiplying ASC for each antibiotic to DOT. DASC for each antibiotic was aggregated to total monthly DASC. Days-present was used as a denominator for both metrics. Trends of total monthly DOT and DASC were analyzed by simple linear regression.

Results

There was no significant trend in monthly DOT (Figure A: beta= 0.30, 95%CI: -0.67 to 1.27, p=0.55), but there was a significant downward trend in monthly DASC (Figure B: beta= -6.89, 95%CI: -12.7 to -0.98, p=0.03).

Conclusion

While a significant downward trend was seen using monthly DASC, no trend was observed using monthly DOT. In contrast to DOT, which captures antibiotic consumption without considering the spectrum, DASC captures both antibiotic consumption and spectrum, suggesting DASC can add another dimension in tracking inpatient antibiotic use. DASC is easily calculated if DOT for each antibiotic is available. Metrics that don’t capture antimicrobial spectrum may not be able detect improvements in avoiding unnecessary use of broad-spectrum antimicrobials, an important target of ASPs.

Disclosures

Daniel J. Livorsi, MD, Merck & Co.: Grant/Research Support Michihiko Goto, MD MSCI, Merck & Co.: Grant/Research Support.
2312. Utility of Intrathecal Antibiotic Administration in the Reduction of Ventriculoperitoneal (VP) Shunt Infections in our Urban Referral Health Center
Authors: Abalos Charmaine Clarisse D , Jaber Tariq M , Bangash Salman , Jacobs Max W , Turk Michael , Bhanot Nitin , Min Zaw , Abdulmassih Rasha
Published: December 2022

Background

Infection is one of the primary causes of VP shunt failure, with an incidence rate of 7%-14%. Systemic antibiotics, administered intravenously (IV), are considered the standard of care (SOC) for perioperative prophylaxis. Prophylactic intrathecal (IT) administration of antibiotics, in addition to SOC, is practiced by some surgeons at our institution. Our objective was to study the impact of this modality on VP shunt infections.

Methods

A retrospective review of all VP shunt procedures at our institution from 2018–2020 was performed. Patients with active VP shunt infection were excluded. We compared the incidence of 90-day postoperative shunt infection in patients who received IT and SOC antibiotics (intervention group) to patients who only received SOC IV antibiotics (control group). Data collection included demographics, comorbidities, prophylactic antibiotics used, and pathogens implicated in shunt infections. T-test or Mann-Whitney U test was used for comparison of continuous variables; chi-square or Fisher’s exact test was used to assess the relationship between categorical variables. A value of p < 0.05, on two-tailed testing, was considered statistically significant.

Results

A total of 112 patients were included in the study. Control and intervention arms comprised 54 (48.2%) and 58 patients (51.8%), respectively. All patients received parenteral perioperative antibiotics. The most commonly used agent was cefazolin (83.9%). Patients in the intervention arm received 4 mg of gentamicin and 5 mg of vancomycin intrathecally.

Baseline characteristics were not statistically different between the groups.

Among the 112 patients, 12 (10.7%) developed shunt infection; 4 in the intervention and 8 in the control arm. Infection rates were not statistically different in these groups (χ2 (1) =1.83, p= 0.176). However, there was a statistically significant association between history of prior shunt (uninfected) placement and post-operative shunt infection (Fisher’s exact test, p = 0.025).

Conclusion

Our study did not reveal additional benefit of prophylactic IT antibiotic use in decreasing VP shunt infections. History of prior shunt placement was identified as risk factor, however. Limitations include relatively small sample size, retrospective, and a single-center study.

Disclosures

All Authors: No reported disclosures.
1811. Use of Procalcitonin and Antimicrobial Stewardship Intervention to Limit Antibiotic Utilization in Patients Admitted to a Community Hospital with SARS-CoV-2 Infection
Authors: Politis Paula A , Oravec Michael J , Hoisington Lisa , Tan Michael J , Agarwal Shanu , File Thomas M
Published: December 2022

Background

Patients admitted to the hospital with SARS-CoV-2 infection are often treated with antibacterial agents in addition to antivirals, although bacterial co-infection in this population is uncommon. Overuse of unnecessary antibiotics can lead to suboptimal outcomes, including increased bacterial resistance, adverse events, and costs. Our Antimicrobial Stewardship (AS) Program routinely provides recommendations for appropriate therapy based on molecular/microbiologic tests, clinical findings, and procalcitonin (PCT). PCT can assist in differentiating bacterial from viral respiratory infections, and can be useful in the decision to discontinue antibiotic therapy if viral monomicrobial infection is suspected. The purpose of our quality improvement project was to review the appropriateness of antibiotics utilized for patients admitted with SARS-CoV-2 and to promote optimal patient care and AS at our institution.

Methods

We performed a retrospective review of SARS-CoV-2 patients from our institution’s COVID-19 registry for patients hospitalized from March 2020-April 2021. We compared patients with PCT < 0.25 ng/mL to those with PCT > 0.25 ng/mL and assessed differences in patient characteristics and disease presentation, including: age, gender, WBC, serum creatinine, culture results, disease severity, patient location, duration of antibiotics, length of stay, 30 day readmission and mortality. Characteristics were compared using descriptive statistics and appropriate inferential statistics.

Results

Shown in Table 1. If prescribed antibiotics, median duration of antibiotic therapy was significantly reduced in the PCT < 0.25 group vs. the PCT > 0.25 group (2 days vs. 4.1 days). Median WBC, SOFA score, serum creatinine, and length of stay were significantly lower in the PCT < 0.25 group compared to the PCT > 0.25 group. Severity adjusted models showed significantly decreased duration and overall likelihood of antibiotic use for PCT < 0.25 vs. PCT > 0.25. 30 day readmission and 30 day mortality were significantly lower in the PCT < 0.25 group vs. the PCT > 0.25 group.

Conclusion

Antibiotic utilization was reduced in patients admitted with SARS-CoV-2 infection and PCT < 0.25, and if prescribed antibiotics, duration was significantly shorter vs. those in the PCT > 0.25 group.

Disclosures

Michael J. Tan, MD, FACP, FIDSA, Pfizer: Honoraria|Thermo Fisher Scientific: Honoraria Thomas M. File, Jr., MD, MSc, MACP, FIDSA, Nabriva Therapeutics: Advisor/Consultant|Nabriva Therapeutics: Honoraria.
1812. Impact of removing ESBL testing report on the selection of antibiotics for the treatment and 30-day mortality of patients infected with ESBL-producing organisms
Authors: Waeuseng Sofia
Published: December 2022

Background

The rising burden of carbapenem-resistant organisms is well recognized as a global crisis. Several studies have identified preceding carbapenem use as a risk factor for the subsequent development of infections with carbapenem-resistant, gram- negative organisms. We characterized the impact of removal of the ESBL designation from microbiology reports on inpatient antibiotic prescribing.

Methods

A historical control study, interventional analysis study was conducted at Ramathibodi Hospital) to compared 1 year before removal ESBL designation (period1, August 1, 2019 to July 31, 2020) and 1 year post removal ESBL designation (period 2, August 1, 2020 to July 31, 2021) on inpatient antibiotic prescribing. Categorical variables were compared using the Fisher exact test. Continuous variables were evaluated using the Wilcoxon rank-sum test. All statistical tests were 2-tailed, and a P < .05 was considered statistically significant.

Results

The primary outcome definitive prescribing of carbapenems decreased from 56.5% to 41.3% afterward (P= .01). Prescription of cefepime was also decreased from 13.6% to 3.5% (P< .05), respectively. Whereas piperacillin-tazobactam use significantly increased from 10.4% to 28.7% (P< .05). Trimethoprim-sulfamethoxazole was prescribed more frequently, i.e., increased from 0 to 2.8%, but this change was not statistically significant. The secondary outcome 30-day mortality from any cause was no different between the two groups, with 22 of 154 patients (14.3%) in group 1 and 24 of 143 (16.8%) in group 2 (P = .55).

Conclusion

Definitive prescribing of carbapenems was decreased and β-lactam–β-lactamase inhibitor combination was increased after removal ESBL report. Our findings confirm the importance of collaboration between microbiology and antimicrobial stewardship programs.

Disclosures

All Authors: No reported disclosures.
1825. Comparative Effectiveness of Ampicillin versus Vancomycin or Daptomycin for the Treatment of Ampicillin-Susceptible Enterococcus spp. Bloodstream Infections
Authors: Chua Hubert C , Phe Kady
Published: December 2022

Background

Treatment options against Enterococcus spp., a common nosocomial pathogen, are limited due to intrinsic resistance to multiple antibiotics. Ampicillin is considered drug of choice if susceptible, but data comparing outcomes between ampicillin, daptomycin, and vancomycin for ampicillin-sensitive Enterococcus spp. bacteremia are limited.

Methods

This was a single-center retrospective cohort study of adults with confirmed ampicillin-sensitive Enterococcus spp. bloodstream infection (BSI) who received definitive treatment with intravenous ampicillin, daptomycin, or vancomycin from January 2013 to December 2021. Polymicrobial BSI were excluded. Definitive treatment was defined as the active antibiotic used for more than 50% of the total treatment duration following availability of susceptibility results. The primary outcome was 28-day all-cause hospital mortality; secondary outcomes were 90-day readmission due to microbiological recurrence and all-cause hospital mortality. Multivariate Cox regression analysis was performed to identify independent risk factors for 28-day hospital mortality.

Results

A total of 199 patients (ampicillin, n = 141; daptomycin, n = 17; vancomycin, n = 41) were evaluated. Overall in-hospital all-cause mortality was 15.1% (n = 30). Twenty-eight-day hospital mortality was numerically lower with ampicillin and daptomycin compared to vancomycin (9.2%, 11.8%, and 22%, respectively; p = 0.088). Ninety-day readmission due to microbiological recurrence (4.3%, 5.9%, and 7.3%; p = 0.722) and all-cause hospital mortality (12.8%, 17.6%, and 22%; p = 0.335) were not significantly different between treatment groups. Independent risk factors for 28-day hospital mortality included age (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.02 to 1.09; p = 0.003), E. faecium BSI (HR 3.94, 95% CI 1.39 to 11.1; p = 0.010), and definitive treatment with vancomycin (HR 2.54, 95% CI 1.04 to 6.21; p = 0.040).

Conclusion

Vancomycin used as definitive therapy for ampicillin-sensitive Enterococcus spp. bacteremia was found to be an independent risk factor for 28-day mortality. Further studies evaluating the role of daptomycin in this setting are warranted.

Disclosures

All Authors: No reported disclosures.
1827. Comparison of clinical outcomes for glycopeptides and beta-lactams in methicillin-susceptible Staphylococcus aureus bloodstream infections
Authors: La Yeon Ju , Kim Hye Rim , Oh Dong Hyun , Ahn Jin Young , Kim Yong Chan
Published: December 2022

Background

Several studies demonstrated the inferiority of glycopeptides as definitive antibiotics for MSSA BSI compared to anti-staphylococcal beta-lactam antibiotics. However, almost all of them were retrospective observational studies and no randomized controlled. Therefore, there remains the problem of bias in treatment selection and the possibility of residual confounding factors. In this study, we compare the therapeutic effects of glycopeptides and anti-staphylococcal beta-lactams in the treatment of MSSA BSI using inverse probability of treatment weighting (IPTW) analysis.

Methods

This is a retrospective cohort study performed in double-center from January 1, 2010 to December 31, 2018. Patients (age ≥18 years) with MSSA identified in the blood culture were included. Patients were classified into two groups according to definite antibiotics used, the beta-lactam (nafcillin or cefazolin) group and the glycopeptide (vancomycin or teicoplanin) group. Figure 1.Flow chart of the study population

Results

During the study period, 643 patients had MSSA bacteremia. Among them, 203 were treated with beta-lactam group and 156 were treated with glycopeptide group as definite therapy. (Figure 1). Comparison of clinical characteristics of patients between the beta-lactam and glycopeptide groups are shown in Table 1. After IPTW, baseline characteristics of the two groups were well balanced except for the primary focus of bacteremia. Although persistent bacteremia was less common in glycopeptide group (17.9% vs 4.0%; OR, 0.28; 95% CI, 0.14 – 0.60; P < 0.001), the glycopeptide group had higher overall mortality rate (15.9% vs 39.6%, P = 0.024), 7-day mortality rate (2.1% vs 14.1%, P < 0.001), and 28-day mortality rate (7.7% vs 30.9%, P = 0.012) (Table 2) than those of the beta-lactam group. When IPTW was augmented by multivariable logistic regression analyses to minimize remnant confounding, glycopeptide use for the treatment of MSSA BSI was associated with significant risk for 28-day mortality (adjusted OR, 3.37; 95% CI, 1.71–6.61; P < 0.001) (Figure 2). Figure 2.Adjusted ORs and 95% CIs for the primary end point in main analysis and various subgroups

Abbreviations: CI, confidence interval; OR, odds ratio; IPTW, inverse probability of treatment weighting.

aUnadjusted OR

Conclusion

Definitive therapy with beta-lactams in patients with MSSA BSI was associated with lower 28-day mortality when compared with definitive therapy with glycopeptides. This study provides compelling evidence of anti-staphylococcal beta-lactam use for MSSA BSI treatment.

Disclosures

All Authors: No reported disclosures.
1828. Dalbavancin Utilization and Associated Clinical Outcomes: A Case-Series
Authors: Greckel Meagan N , Footer Brent , Christensen Alyssa , Christensen Alyssa , Tallman Gregory B , Edwards Lea
Published: December 2022

Background

Dalbavancin is an intravenous (IV) long acting lipoglycopeptide approved for use in acute bacterial skin and skin structure infections (ABSSSI). However, given the prolonged half-life, there is interest in using this agent as an alternative therapy for patients unable or unwilling to comply with conventional IV therapy. These include off-label treatment of deeper-seated infections such as infective endocarditis or osteomyelitis. This case series assesses the efficacy and safety of dalbavancin and its role as an alternative therapy in serious gram-positive infections.

Methods

Retrospective case series of hospitalized adult patients who received at least one dose of dalbavancin at one of the eight hospitals within the Providence Oregon health system between December 2019 through January 2022. Eligible patients had appropriate follow-up within the 90-day period after the last dose was given. Patients who received dalbavancin as empiric therapy or had a vancomycin-resistant isolate were excluded. Clinical cure was defined as no clinical, laboratory, or microbiological evidence of persistent or recurring infection during the 90-day follow-up period.

Results

110 patients were included in this analysis; 41% were IV drug (IVDU) users. The average age was 50.5 years, and the most common organism was Methicillin-sensitive Staphylococcus aureus (48.2%). Bacteremia occurred in 50% of the cases, and the most common infection site was osteomyelitis or native joint infections (31.8%). 30-day all-cause readmission, recurrence, and mortality occurred in 12.7% (2/110), 1.8% (14/110), and 0%, respectively. 30 to 90-day all-cause readmission, recurrence, and mortality occurred in 14.5% (16/110), 7.3% (8/110), and 1.8% (2/110), respectively. Adverse events occurred in 4.5% (5/110) of the cases, where infusion related reactions were most common. Presumed clinical cure occurred in 89% (98/110).

Conclusion

A high percentage of patients in this case series were bacteremic, which differs from prior reports. Overall, dalbavancin appears to be a safe and effective treatment alternative for deeper-seated infections, including those with concomitant bacteremia.

Disclosures

All Authors: No reported disclosures.
1829. Dalbavancin versus standard of care as directed therapy for Staphylococcus aureus bacteremia in patients unable to receive OPAT
Authors: Frazier J , Stoudenmire Laura , Wagner Jamie , Thomas Geren , Henao-Martínez Andrés F , Franco-Paredes Carlos , Chastain Daniel B
Published: December 2022

Background

The purpose of this study was to compare dalbavancin to standard of care (SOC) for patients with S. aureus bacteremia (SAB) who were unable to receive outpatient parenteral antimicrobial therapy (OPAT) and would otherwise remain hospitalized or require placement into post-acute care facilities.

Methods

This retrospective cohort compared readmission rates related to the index infection between patients treated with dalbavancin or SOC for SAB between January 1, 2016, and August 31, 2021. Patients at least 18 years old seen by the ID consult service who received at least one dose of dalbavancin or at least one week of SOC parenteral antibacterials as directed therapy for SAB at the time of discharge were included. The SOC group consisted of patients transferred from the main hospital to one of the post-acute care facilities in a surrounding county to complete parenteral antibacterials. Patients were excluded if they were treated for polymicrobial infections with organisms other than S. aureus, had a creatinine clearance less than 30 mL/min, or required renal replacement therapy. The primary outcome was readmission rates within 30 days after completion of therapy. Secondary outcomes included readmission rates within 90 days after completion of therapy as well as antibacterial regimen adherence defined as achieving goal duration of therapy deemed appropriate by the ID consult service.

Results

During the study period, 27 patients received dalbavancin, and 27 patients received SOC. Baseline demographics were comparable between groups, though more patients in the SOC group had indwelling prostheses or hardware (4% vs 22%). The majority of SAB was caused by MSSA in both groups (56% vs 59%). The most common source was osteoarticular (15% vs 30%) and source control was attempted in a higher percentage of the SOC group who had an identified source (53% vs 86%). Readmission rates in the dalbavancin group were similar to those in the SOC group within 30 days (15% vs 22%, p=0.484) and 90 days (19% vs 22%, p=0.735) after completion of therapy. However, adherence was significantly higher among patients treated with dalbavancin (85% vs 44%, p < 0.05).

Conclusion

Dalbavancin offers similar clinical outcomes to SOC for patients with SAB who are unable to receive OPAT.

Disclosures

All Authors: No reported disclosures.
1840. Implementation of a daptomycin dosing nomogram and assessment of clinical outcomes across a large health system
Authors: Terravecchia Ariana , Gopinathan Vineet , Minor Sarah B
Published: December 2022

Background

Daptomycin (DAP) is frequently used for a gram-positive infections with conflicting guidance on optimal dosing, especially dosing weight in obese patients. With newer commercially available vial sizes and limited supporting evidence pointing to an optimal dosing strategy and dosing weight (e.g., actual, ideal, adjusted), we seek to explore the impact of a standardized DAP nomogram (Figure 1) on both clinical and safety outcomes across a large health system. Figure 1.Standardized Daptomycin Dosing Nomogram

Methods

This retrospective cohort study evaluated patients receiving DAP across 7 campuses within AdventHealth between Sep 1, 2020 to Dec 31, 2020 (pre-implementation with standard mg/kg dosing) and Dec 1, 2021 to Jan 31, 2022 (post-implementation with nomogram dosing). Inclusion criteria: age ≥18, invasive infection (e.g., bone/joint, bacteremia, complicated cellulitis, endocarditis), hospital admission, and duration of DAP ≥72hr. Exclusion: DAP in ambulatory setting, duration of DAP < 72hr, and non-invasive infection, defined as uncomplicated cellulitis not requiring surgical intervention. Primary outcome was clinical success, defined as improvement in signs/symptoms at end of therapy or discharge and absence of repeat positive cultures. Secondary outcomes included mean length of therapy (LOT), adherence to nomogram-guided DAP dosing, and occurrence of adverse events.

Results

100 patients were included in each group. Average age was 58 years and most were male (54%). Most common indication for DAP was bacteremia (46%) and S. aureus was isolated in 28% of all cultures. Thirty-four percent of patients in each group were on concomitant statin therapy and average BMI was similar between groups (31.4 kg/m2 vs. 31.9 kg.m2). Clinical success (Figure 2) occurred in 74% of patients in the post-implementation group compared to 70% in the pre-implementation group (p=0.529). Average LOT was similar (10.9 days vs. 9.15 days, p=0.191). Pharmacist adherence to the nomogram was high at 91%. Rates of adverse events were similar between groups, with CPK elevations > 200 units/L occurring in 12% of patients in the pre-implementation group compared to 14% of patients in the post-implementation group (p=0.674).

Conclusion

A standardized DAP nomogram led to a safe and effective process for treating invasive gram-positive infections.

Disclosures

All Authors: No reported disclosures.
1855. Risk factors for early mortality in patients with carbapenem-resistant Acinetobacter baumannii bacteremia
Authors: Lee Chan Mi , Kim Chung-Jong , Kim Seong Eun , Park Kyung-Hwa , Bae Ji Yun , Choi Hee Jung , Jung YoungHee , Lee Seung Soon , Choe Pyoeng Gyun , Park Wan Beom , Suk Kim Eu , Song Je Eun , Kwak Yee Gyung , Hee Lee Sun , Lee Shinwon , Cheon Shinhye , Kim Yeon Sook , Kang Yu Min , Bang Ji Hwan , Jung Sook-In , Song Kyoung-Ho , Bin Kim Hong
Published: December 2022

Background

Although many deaths due to carbapenem-resistant Acinetobacter baumannii (CRAB) bacteremia occur within a few days after the onset of bacteremia, risk factors for early mortality (EM) have not been deeply investigated. We aimed to determine the risk factors for EM and the difference between risk factors associated with EM and late mortality (LM) in CRAB bacteremia.

Methods

All patients with CRAB bacteremia in 10 hospitals during a 1-year study period were identified. We prospectively collected patients’ clinical data, including microbiological and demographic data, underlying comorbidities, origin of bacteremia, severity of illness, antibiotic therapy, and mortality. Among the cases with mortality within 30 days, EM and LM were defined as death within 3 and more than 5 calendar days from the first positive blood culture, respectively.

Results

A total of 212 CRAB bacteremia cases were included in the analysis. Of 122 (57.5%) patients with 30-day mortality, EM was observed in 75 (61.5%) patients and LM in 39 (32.0%) patients. The proportion of severe sepsis or septic shock, Pitt score, and Sequential Organ Failure Assessment (SOFA) score were significantly higher in 30-day deaths than 30-day survivors. These factors of clinical severity were also significantly higher in patients with EM than those with LM. While urinary tract infection as the factor of site of infection and the severity of illness were independent predictors of LM, only factors representing the severity of illness were independent risk factors for EM. Appropriate empirical antibiotic therapy was associated with reduced risk of EM.

Conclusion

The difference between risk factors for EM and LM was identified in this study. Our data suggest that a large proportion of CRAB bacteremia with high severity progress to a rapidly fatal course, regardless of the underlying diseases or source of infection. Further studies might be needed to investigate the microbiological factors associated with CRAB and pathogen-host interaction in patients with EM.

Disclosures

All Authors: No reported disclosures.