bluuebunny/crossref_metadata_2025 huggingface dataset:
Prioritizing SARS-CoV-2 testing in a highly immunosuppressed patient population
Authors: Shackelford Jenna , Woolbert Michele , Sinaii Ninet , Decker Brooke , Palmore Tara , Odom Robin T
Published: May 2022

Background: The NIH Clinical Center implemented multiple testing protocols to facilitate early detection and isolation of SARS-CoV-2 infected patients and rooming-in family members (RIFMs). Beginning in February 2020, all symptomatic patients were tested; in March 2020, all patients were tested prior to aerosol-generating procedures (AGPs); and in May 2020, all patients and RIFMs were tested on admission. We sought to determine the value of SARS-CoV-2 testing practices in our hospital. Methods: Respiratory specimens collected March 2020 through June 2021 tested for SARS-CoV-2 by RT-PCR were reviewed, and corresponding patient clinical and demographic variables were collected. Repeated tests from SARS-CoV-2–positive persons were excluded from the data. Results associated with multiple testing indications were assigned the highest priority reason based on a predetermined hierarchy. Data were analyzed using the χ2 test and logistic regression. Results: Of 12,706 results from 5,704 patients, primary testing reasons were pre-AGP (n = 5,387, 43.0%), admission (n = 2,733; 21.8%), and symptomatic testing (n = 2,701; 21.6%). Overall, 159 tests (1.25%) were positive for SARS-CoV-2. Asymptomatic patients tested on admission were 1.8 times more likely to be positive than outpatients tested for any reason (P = .003) and 4.2 times more likely than asymptomatic inpatients tested prior to AGP (P = .003). Within asymptomatic pre-AGP testing, there was no difference between inpatients (0.46%) and outpatients (0.65%). Hispanic patients were 1.9 times more likely to be positive. (p Conclusions: At a hospital with a geographically broad referral base, admissions COVID-19 testing was far more fruitful than pre-AGP testing of inpatients. Pre-AGP used the most testing resources yet had the lowest yield. Admissions testing remains beneficial regardless of community transmission rates, while testing prior to AGP could be pared back when community rates of COVID-19 are low and redeployed when community rates rise. Conclusions: Our findings that Hispanic persons had higher risk and that transplant patients had lower risk of testing positive suggests differences in the extent to which each subgroup may have been able to shelter from COVID-19 in the community during this earlier phase of the pandemic. Keeping immunocompromised patients safe from COVID-19 while they undergo longitudinal care involves layered precautions in the hospital and in the community that must evolve in response to evidence and epidemiological trends.

Funding: None

Disclosures: None
Is your ice machine really clean? Uncovering the presence of opportunistic pathogens in hospital ice machines
Authors: Cazals Margot , Bedard Emilie , Prévost Michèle , Savard Patrice
Published: May 2022

Background: Ice is used in healthcare facilities for medical purposes and consumption by the medical staff and the patients, but some studies have revealed significant microbial contamination of ice machines leading to nosocomial outbreaks or pseudooutbreaks and infections by opportunistic pathogens, including the fungi Candida, the bacteria Pseudomonas aeruginosa, and nontuberculous mycobacteria (NTM). Although ice machines are complex devices that are prone to contamination, very little is known about their potential as vectors of infections for populations at risk in hospitals. Only few studies document efficient maintenance regimes, specifically cleaning procedures and microbial indicators that would ensure their safe use. Method: In this prospective study, combined samples of water and ice, and drain biofilm samples were collected from 36 ice and cold-water distribution machines of a recently built hospital, for a total of 72 samples. Physicochemical parameters (total and free chlorine, temperature, etc) were measured in water, and several opportunistic pathogens (ie, Candida spp, P. aeruginosa, NTM) and biological indicators (ie, heterotrophic plate counts (HPCs), total and viable bacteria and enterococci) were monitored in water and ice and biofilm. Culture methods were used for HPCs, Candida spp, P. aeruginosa, and enterococci, and total and viable bacterial populations were estimated using flow cytometry. NTM were monitored by quantitative polymerase chain reaction (qPCR). Results: We observed clear differences between the machines in terms of biological contamination, with frequent detection of NTM and presumed Candida. Thus, NTM were detected in the 36 samples of ice and water with concentrations from 0.5 to 2×104 gene copies/mL. Among the several species of fungi detected in the ice machines, some were identified as C. parapsilosis and C. guilliermondii, which are organisms of concern in healthcare facilities. Factors affecting the level of contamination in ice machines include the location of the machines and water quality (ie, temperature and chlorine residual concentration). Depending on the location in the building and the model of ice machine sampled, the biological indicators measurements indicated more or less significant contamination. No link was established between environmental strains recovered from the machines and clinical infections. Conclusions: Monitoring results showed that ice machines, while subject to few regulations and controls, can be reservoirs of unsuspected opportunistic pathogens that could lead to nosocomial infections of vulnerable patients. Cleaning procedures should be based on the disinfection of resistant opportunistic pathogens, such as Candida and NTM, and the use of general indicators, such as HPCs, should be questioned.

Funding: None

Disclosures: None
Susceptibility reporting and antibiotic prescribing for UTIs in the inpatient setting: A nudge toward improved stewardship
Authors: Ponder Madison , Kinlaw Alan , Daniels Lindsay , Norris Ashlyn , Alby Kevin
Published: May 2022

Background: Urinary tract infections (UTIs) are common in the inpatient, observation, and emergency department settings. Although many UTI-causing pathogens are susceptible to oral β-lactams, these agents are not tested directly, and susceptibility is extrapolated from other agents. To improve the use of these agents, the University of North Carolina Medical Center (UNCMC) added cephalexin to the susceptibility profile generated with urine culture results in the electronic health record (EHR). We evaluated prescribing trends of cephalexin, other oral β-lactams, fluoroquinolones, and other antibiotics for UTIs in the inpatient setting, before and after the susceptibility reporting change. Methods: An interrupted time-series analysis was conducted. Among 1,491 patients who had positive urine cultures with susceptibilities and received at least 1 antibiotic with a listed UTI indication during their inpatient stay at UNCMC, we measured the weekly prevalence (%) of patients who received each antibiotic group: cephalexin, other oral β-lactams (amoxicillin-clavulanate, cefdinir, cefuroxime), fluoroquinolones (levofloxacin, ciprofloxacin), and ceftriaxone. The study comprised a preintervention period (September 2018–March 2019) and a postintervention period (September 2019–March 2020). The prevalence of each antibiotic or group was plotted over time, and segmented linear regression was used to estimate the impact of the intervention on each antibiotic groups’ time trend. Results: At study baseline in September 2018, the weekly prevalence of antibiotic use was 11% for cephalexin, 26% for other oral β-lactams, 51% for ceftriaxone, and 29% for fluoroquinolones. Fluoroquinolone use decreased steadily throughout the study period, by 11% during the 7-month preintervention period (95% CI, −17% to −5%) and by 8% (95% CI, −13% to −3%) after the intervention (P for trend deflection, .70). In contrast, during the preintervention period, trends were flat for cephalexin, ceftriaxone, and other oral β-lactams (all P for nonzero preintervention slope were >.40). During the postintervention period, use increased for ceftriaxone (6%; 95% CI, 3%–9%). Post-intervention use also increased for cephalexin (5%; 95% CI, −3% to 12%) and other oral β-lactams (4%; 95% CI, −8%, 15%), but these trends were imprecise and not statistically significant at α = .05. Fig. 1 displays trends and raw data for each antibiotic group. Conclusions: The urine culture susceptibility reporting change was associated with small increases in cephalexin and ceftriaxone use, coincident with continued decreasing use of fluoroquinolones, for hospitalized patients with positive urine cultures and a listed UTI indication. Low-resource EHR-based interventions may confer considerable benefit for antimicrobial stewardship efforts in this clinical setting, and larger real-world studies are needed to replicate and contextualize these findings.

Funding: None

Disclosures: None
Impact of exposure to potentially contaminated hospital beds on risk of hospital-onset C. difficile infection
Authors: Witt Lucy , Howard-Anderson Jessica , Overton Elizabeth , Jacob Jesse
Published: May 2022

Background: Environmental contamination increases risk for Clostridioides difficile infection (CDI) given that spores can remain on a hospital bed, floor, sink, and light switch despite appropriate cleaning measures. Using real-time asset management software (AgileTrac, GE Healthcare) for beds we examined the risk of a patient developing hospital-onset CDI (HO-CDI) when staying in a hospital bed that had a previous occupant with CDI. Methods: We retrospectively identified all patients in tracked beds from April 2018 to August 2019 to identify hospital-onset CDI (HO-CDI), defined as a positive PCR test for C. difficile in a patient hospitalized for >3 days. A patient was defined as being exposed to a potentially “contaminated” bed if within the preceding 7 days from their HO-CDI diagnosis they resided in a hospital bed that, within the prior 90 days, had held an occupant with CDI (Fig. 1). We used multivariable logistic regression to evaluate the association between being exposed to a contaminated bed and HO-CDI. Model covariates were chosen a priori based on known risk factors for CDI. As a sensitivity analysis, we varied the length of time that a bed could stay contaminated from 90 to 60, 30, 14, and 7 days. Results: We analyzed 25,032 hospital encounters representing 18,860 unique patients; we identified 237 (0.9%) hospital encounters with HO-CDI (Table 1). The Elixhauser comorbidity score, being exposed to a contaminated bed, and receiving antibiotics or a proton pump inhibitor (PPI) during the hospital admission were all associated with HO-CDI in the univariable analysis (Table 2). In the adjusted multivariable model, being exposed to a contaminated bed remained a significant risk factor for HO-CDI (OR, 1.60; 95% CI, 1.22–2.08) even after controlling for known risk factors for CDI including age >65, elevated Elixhauser score, and recent antibiotic or PPI use (Table 2). In the sensitivity analysis in which we adjusted the time a bed was considered contaminated after CDI, being exposed to a contaminated bed remained a risk factor for HO-CDI, with a similar odds ratios as the original model (Table 2). Conclusions: Residing in a hospital bed that contained a previous occupant with CDI is a risk factor for developing HO-CDI. Hospital epidemiologists, infection control personnel, and environmental services staff should consider this association when developing CDI risk mitigation strategies.

Funding: None

Disclosures: None
Prescriptions patterns and appropriateness of usage of antibiotics in small and medium- sized hospitals in Korea
Authors: Kim Yong Chan , Park Ji Young , Kim Bongyoung , Kim Eu Suk , Ga Hyuk , Myung Rangmi , Park Se Yoon , Lee Myung Jin , Moon Song Mi , Park Sun Hee , Song Kyoung-Ho , Kim Hong Bin
Published: May 2022

Background: Although small- and medium-sized hospitals comprise most healthcare providers in South Korea, data on antibiotic usage is limited in these facilities. We evaluated the pattern of antibiotic usage and its appropriateness in hospitals with <400 beds in South Korea. Methods: A multicenter retrospective study was conducted in 10 hospitals (6 long-term care hospitals, 3 acute-care hospitals, and 1 orthopedic hospital), with <400 beds in South Korea. We analyzed patterns of antibiotic prescription and their appropriateness in the participating hospitals. Data on the monthly antibiotic prescriptions and patient days for hospitalized patients were collected using electronic databases from each hospital. To avoid the effect of the COVID-19 pandemic, data were collected from January to December 2019. For the evaluation of the appropriateness of the prescription, 25 patients under antibiotic therapy were randomly selected at each hospital over 2 separate periods. Due to the heterogeneity of their characteristics, the orthopedics hospital was excluded from the analysis. The collected data were reviewed, and the appropriateness of antibiotic prescriptions was evaluated by 5 specialists in infectious diseases (adult and pediatric). Data from 2 hospitals were assigned to each specialist. The appropriateness of antibiotic prescriptions was evaluated from 3 aspects: route of administration, dose, and class. If the 3 aspects were ‘optimal,’ the prescription was considered ‘optimal.’ If only the route was ‘optimal,’ and the dose and/or class was ‘suboptimal,’ but not ‘inappropriate,’ it was considered ‘suboptimal.’ If even 1 aspect was ‘inappropriate,’ it was classified as ‘inappropriate.’ Results: The most commonly prescribed antibiotics in long-term care hospitals was fluoroquinolone, followed by β-lactam/β-lactamase inhibitor (antipseudomonal). In acute-care hospitals, these were third-generation cephalosporin, followed by first-generation cephalosporin and second-generation cephalosporin. The major antibiotics that were prescribed in the orthopedics hospital was first-generation cephalosporin. Only 2.3% of the antibiotics were administered inappropriately. In comparison, 15.3% of patients were prescribed an inappropriate dose. The proportion of inappropriate antibiotic prescriptions was 30.6% of the total antibiotic prescriptions. Conclusions: The antibiotic usage patterns vary between small- and medium-sized hospitals in South Korea. The proportion of inappropriate prescriptions exceeded 30% of the total antibiotic prescriptions.

Funding: None

Disclosures: None
Antibiotic use in end-of-life care patients: A nationwide Veterans’ Health Administration cohort study
Authors: Marra Alexandre , Clore Gosia , Balkenende Erin , Goedken Cassie , Livorsi Daniel , Goto Michihiko , Vaughan-Sarrazin  , Broderick Ann , Perencevich Eli
Published: May 2022

Background: Antibiotic use during end-of-life (EOL) care is an increasingly important target for antimicrobial stewardship given the high prevalence of antibiotic use in this setting with limited evidence on safety and effectiveness to guide antibiotic decision making. We estimated antibiotic use during the last 6 months of life for patients under hospice or palliative care, and we identified potential targets (ie time points) during the EOL period when antimicrobial stewardship interventions could be targeted for maximal benefit. Methods: We conducted a retrospective cohort study of nationwide Veterans’ Affairs (VA) patients, 18 years and older who died between January 1, 2014, and December 31, 2019, and who had been hospitalized within 6 months prior to death. Data from the VA’s integrated electronic medical record (EMR) were collected including demographics, comorbid conditions, and duration of inpatient antibiotics administered, along with outpatient antibiotics dispensed. A propensity-score matched-cohort analysis was conducted to compare antibiotic use between patients placed into palliative care or hospice matched to patients not receiving palliative care or hospice care. Repeated measures ANOVA and repeated measures linear regression methods were used to analyze difference in difference (D-I-D) of days of therapy (DOT) between the 2 cohorts. Results: There were 251,822 patients in the cohort, including 23,746 in hospice care, 89,768 in palliative care, and 138,308 without palliative or hospice care. The median days from last discharge to death was 9 days. The most common comorbidities were chronic obstructive pulmonary diseases (50%), malignancy (46%), and diabetes mellitus (43%). Overall, 18,296 (77%) of 23,746 hospice patients, and 71,812 (80%) of 89,768 palliative care patients received at least 1 antibiotic, whereas 95,167 (69%) of 138,308 who were not placed in hospice or did not receive palliative care received antibiotics. In the primary matched cohort analysis that compared patients placed into hospice or palliative care to propensity-score matched controls, entry into palliative care was associated with a 11% absolute increase in antibiotic prescribing, and entry into hospice was associated with a 4% absolute increase during the 7–14 days after entry versus the 7–14 days before entry (Fig. 1). The stratified cohorts had very similar balanced covariates as the overall cohort. Conclusions: In our large cohort study, we observed that patients receiving EOL care had high levels of antibiotic exposure across VA population, particularly on entry to hospice or during admissions when they received palliative care consultation. Future studies are needed to identify the optimal EOL strategies for collaboration between antimicrobial stewardship and palliative care.

Funding: None

Disclosures: None
Rapid streptococcal pharyngitis testing and antibiotic prescribing before and during the COVID-19 pandemic
Authors: Seibert Allan , Stenehjem Eddie , Wallin Anthony , Willis Park , Brunisholz Kim , Kumar Naresh , Stanfield Valoree , Fino Nora , Shapiro Daniel , Hersh Adam
Published: May 2022

Background: Pharyngitis is 1 of the most common conditions leading to inappropriate antibiotic prescriptions. When personal protective equipment (PPE) was at first constrained during the COVID-19 pandemic, Intermountain Healthcare recommended limiting rapid group A streptococcal pharyngitis (GAS) testing in urgent-care clinics to preserve PPE. Notably, the percentage of pharyngitis encounters prescribed an antibiotic and that underwent GAS testing is a key Healthcare Effectiveness Data and Information Set (HEDIS) measure. We have described our experience with urgent-care pharyngitis encounters and the impact of temporarily reducing GAS testing on antibiotic prescribing before and during the COVID19 pandemic. Method: We identified all urgent care encounters between July 2018 and August 2021 associated with a primary diagnosis of pharyngitis using ICD-10 CM codes and a validated methodology. Pharyngitis encounters were assessed for antibiotic prescriptions ordered through the electronic health record (EHR) and the use of point-of-care rapid GAS tests. Pharyngitis encounters were analyzed monthly. We assessed the percentage of encounters associated with an antibiotic prescription regardless of testing and the percentage of encounters associated with an antibiotic prescription when a GAS test was or was not performed. We examined 3 periods relating to COVID-19 and GAS testing recommendations: the prepandemic period (July 2018–March 2020), the pandemic onset period (April 2020–June 2020), and the pandemic period (July 2020–August 2021). Results: Prior to the pandemic, the monthly percentage of pharyngitis encounters for which rapid GAS testing was performed was nearly 90% (Fig. 1). The average monthly percentage of urgent-care pharyngitis encounters prescribed an antibiotic was 38.9%, and the average percentage of monthly pharyngitis encounters prescribed an antibiotic that also underwent GAS testing was 90.4%. This HEDIS measure declined from 90.4% during the prepandemic period to 29.8% in the pandemic onset period when GAS testing was limited. Following resumption of routine testing practices the monthly percentage of urgent-care pharyngitis encounters for which rapid GAS testing was performed returned to levels ≥80% by July 2020 (Fig. 1). The average percentage of monthly pharyngitis encounters prescribed an antibiotic that also underwent GAS testing rose to 87.3% during this period. Conclusions: Limited PPE in our urgent care centers during the initial months of the COVID-19 pandemic was associated with a mandated substantial decline in rapid GAS testing. As testing volume decreased, we noted a simultaneous relative increase of >30% in antibiotic prescribing for pharyngitis. These findings suggest that rapid streptococcal testing promotes appropriate antibiotic prescribing.

Funding: None

Disclosures: None
Determining the effect of COVID-19 on antibiotic use in long-term care facilities across Tennessee
Authors: Adre Cullen , Ouedraogo Youssoufou , Evans Christopher , Wilson Christopher
Published: May 2022

Background: Nationally, a decrease in total antibiotic use in nursing homes during the COVID-19 pandemic was observed with an increase in select agents used for respiratory infections. Currently there is minimal data on antibiotic use in long-term care facilities (LTCFs) in Tennessee. To address this issue, the Tennessee Department of Health (TDH) developed a monthly point-prevalence survey of antibiotic use. Utilizing this tool, we sought to determine the effect the pandemic had on antibiotic use in Tennessee LTCFs. Method: We developed a REDCap questionnaire to collect information on selected antibiotics administered in Tennessee LTCFs. Antibiotic use percentage was determined by dividing the number of residents who received an antibiotic on the day of survey by facilities’ average censuses. Data were divided into a prepandemic period (January 2019–February 2020) and a period during the pandemic (March 2020–December 2021). Antibiotic prescriptions were grouped into 4 classes according to their most common uses: Clostridium difficile infections, urinary tract infections, skin and soft-tissue infections (SSTIs), and respiratory infections. Average percentage of residents on antibiotics were compared between study periods. Results: In total, 37 facilities participated in the survey during the prepandemic period and 32 facilities participated during the pandemic period; 14 participated during both periods. The average percentage of residents on antimicrobials before the pandemic was 16.3%, which decreased to 11.5% during the pandemic period (P = .04). During the prepandemic period, 40.2% of antibiotics prescribed were in the common for SSTI category and 38.3% were in the common for respiratory infections category (P = .01); during the pandemic period, 64.3% of antibiotics prescribed were in the common for SSTI category and 45.8% were in the common for respiratory infections category (P = .01). The 3 most prescribed antibiotics in the prepandemic period were amoxicillin (148 prescriptions), doxycycline (140 prescriptions), and levofloxacin (135 prescriptions). The 3 most prescribed antibiotics during the pandemic were doxycycline (141 prescriptions), levofloxacin (125 prescriptions), and trimethoprim–sulfamethoxazole (115 prescriptions). Conclusions: Survey results revealed that antibiotic prescriptions commonly used for respiratory infections increased 7.5% during the pandemic study period. Additionally, the average percentage of residents on antimicrobials fell 4.8% during this period. Both statistics reflect what has been seen nationally with a decrease in antibiotic use with an increase in respiratory antibiotics. This could be due to multiple factors including decreased reporting, a change in healthcare delivery during the pandemic, and facilities seeing an increase of respiratory tract infections. These data will be used to guide future TDH antibiotic stewardship efforts in the long-term care setting.

Funding: None

Disclosures: None
Penicillin allergy reinstatement in a cohort of patients previously delabeled following formal allergy assessment
Authors: Monday Lea , Goteti Ravitej , Michniak Jaclyn , Zoratti Edward , Weinmann Allison
Published: May 2022

Background: Penicillin allergies are frequently reported and are associated with adverse clinical and antimicrobial stewardship outcomes. Allergy delabeling, either by patient history or skin testing and oral challenge can facilitate removal of penicillin allergy label. However, penicillinallergies are often reinstated in the medical record and data is limited about how and why this occurs. In our center, the departments of allergy and infectious diseases utilize an allergist nurse practitioner for penicillin allergy delabeling. We investigated the prevalence of penicillin allergy reinstatement following removal and associated factors thereof. Methods: We performed a retrospective observational study of patients who previously had penicillin allergy removed by the allergist nurse practitioner between August 2020 and May 2021 (250 days). Patients were followed for a minimum of 8 months and up to 16 months after penicillin allergy removal. We then assessed whether the allergy was reinstated. Clinical characteristics were compared between patients with penicillin allergy reinstated and not reinstated using the χ2 and Mann-Whitney U test. The primary end point was prevalence of penicillin allergy reinstatement following removal. Results: During the study period, 81 patients had penicillin allergy removed, but it was later reinstated in 19 patients (23%) (Fig 1). Median time to reinstatement was 94 days. Allergies were reinstated most frequently by nurses (53%) and medical assistants (37%). Reinstatement occurred in both outpatient (53%) and inpatient (47%) settings. In 18 of 19 cases, there was no acknowledgment that a prior assessment had determined the patient was not allergic to penicillin. Only 1 patient experienced a reaction prompting reinstatement of penicillin allergy. Once the allergy was redocumented, it was subsequently mentioned in a median of 17 notes per patient. Comorbidities did not differ between patients with allergy reinstated versus those without (Table 1). Patients with penicillin allergy reinstated were more often originally delabeled via history rather than skin test followed by oral challenge and were more likely to have been readmitted subsequently. Conclusions: Penicillin allergies were redocumented in almost one-quarter of patients, most frequently by a nonphysician team member and without acknowledgement of prior removal. Patients who undergo skin testing may be less likely to continue to report a penicillin allergy to medical staff compared to those whose allergy is removed based on history. Increased interactions with the healthcare system may have contributed to having the allergy reinstated.

Funding: None

Disclosures: None
Racial and ethnic differences in penicillin allergy reporting and allergist referral
Authors: Bornmann Charles , Ortiz Christina , Guardado Rubeen , Gillis Joseph , Huang Kristin , Blumenthal Kimberly , Doron Shira , Campion Maureen , Wurcel Alysse
Published: May 2022

Background: Antimicrobial resistance (AMR) is a global public health crisis. A key strategy to combat AMR is to use targeted antibiotics, which is difficult in patients who report an allergy to penicillin. Increased risk for resistant infections, mortality, and healthcare costs are associated with penicillin allergies; however, up to 90% of those with a reported penicillin allergy do not have a true allergy. We investigated racial and ethnic differences related to penicillin allergy delabeling by analyzing rates of penicillin allergy reporting and referral for allergist consultation. Methods: Tufts Medical Center is a teaching medical center in Boston, Massachusetts. This study cohort contains all patients seen in 2019 by clinicians at Primary Care Boston, the main primary care practice at Tufts Medical Center. Demographic data, documented allergies, and referral history were collected from the electronic medical record. We performed univariate and multivariable analyses using logistic regression models. Covariates found to be statistically significant (P < .05) in the univariate analyses were included in the multivariable model. Results:In total, 2,391 (11%) patients reported a penicillin allergy, but only 249 (10%) were referred to an allergist (Table 1). Black patients and Asian patients were less likely to report a penicillin allergy than White patients. We detected no differences related to Hispanic ethnicity. Black patients with penicillin allergy were more likely to be referred to an allergist. Conclusions: There were low rates of allergist referral for penicillin allergy delabeling in this cohort. We identified racial differences in both penicillin allergy reporting and allergist referral. Allergist consultation is an important opportunity to combat AMR and should be considered for all patients reporting a penicillin allergy. Future work should evaluate equitable access to allergy delabeling resources.

Funding: None

Disclosures: None
Recommendations for antimicrobial stewardship during end-of-life patient care
Authors: Balkenende Erin , Goedken Cassie , Livorsi Daniel , Giannitrapani Karleen , McCaa Matthew , Perencevich Eli
Published: May 2022

Background: Antimicrobials are frequently used during end-of-life care and may be prescribed without a clear clinical indication. Overuse of antimicrobials is a major public health concern because of the development of multidrug resistant organisms (MDROs). Antimicrobial stewardship programs are associated with reductions in antibiotic resistance and antibiotic-associated adverse events. We sought to identify and describe opportunities to successfully incorporate stewardship strategies into end-of-life care. Methods: We completed semistructured interviews with 15 healthcare providers at 2 VA medical centers, 1 inpatient setting and 1 long-term care setting. Interviews were conducted via telephone between November 2020 and June 2021 and covered topics related to antibiotic prescribing for hospice and palliative-care patients, including how to improve antimicrobial stewardship during the end-of-life period. We targeted healthcare providers who are involved in prescribing antibiotics during the end-of-life period, including hospitalists, infectious disease physicians, palliative care and hospice physicians, and pharmacists. All interviews were recorded, transcribed, and analyzed using consensus-based inductive and deductive coding. Results: End-of-life care, particularly hospice care, was described as an underutilized resource for patients, who are often enrolled in their final days of life rather than earlier in the dying process. Even at facilities with established antimicrobial stewardship programs, healthcare providers interviewed believed that opportunities for antimicrobial stewardship in the hospice and palliative care settings were missed. Recommendations for how stewardship should be incorporated in end-of-life care included receiving feedback on antimicrobial prescribing, increasing pharmacist involvement in prescribing decisions, and targeted education for providers on end-of-life care, including the value of shared decision making with patients around antibiotic use. Conclusions: Improved antibiotic prescribing during end-of-life care is critical in the effort to combat antimicrobial resistance. Healthcare providers discussed antimicrobial stewardship activities during end-of-life patient care as a potential avenue to improve appropriate antibiotic prescribing. Future research should evaluate the feasibility and effectiveness of incorporating these strategies into end-of-life patient care.

Funding: None

Disclosures: None
Assessment of antibiotic appropriateness in hospitalized veterans with COVID-19 in the VA MidSouth Healthcare Network (VISN9)
Authors: Forster Derek , Johnson Morgan , Staub Milner , Bennett Jessica , Scheerenberger Hans , Kaucher Angela , Thomas-Gosain Neena , Davis Kelly
Published: May 2022

Background: Bacterial coinfections with COVID-19 appear to be rare, yet antibiotic use in this population is high. Limited guidance is available regarding the use of antibiotics in these patients. In response, a multidisciplinary group of physicians and pharmacists from 5 VISN9 facilities developed a guideline for the use of antibiotics with COVID-19 in July 2021. This guideline created a network-wide standard for antibiotic use and facilitates the assessment of antibiotic appropriateness in hospitalized veterans with COVID-19. Methods: In this observational, cross-sectional study, we reviewed veterans diagnosed with COVID-19 from August 1 through September 30, 2021, who were admitted to VISN9 facilities. Use of antibiotics was assessed during the first 4 days of admission. If antibiotics were prescribed, their use was determined to be appropriate or inappropriate based on the presence or absence of a finding concerning for bacterial coinfection as outlined in the guideline (Table 1). Additional data including procalcitonin results as well as positive sputum cultures were collected. Results: In total, 377 veterans were admitted for COVID-19 during the study period. Among them, 42 veterans (11%) received antibiotics for nonrespiratory infections and were removed from this analysis. Of the remaining 335 veterans, 229 (68%) received antibiotics and 116 (51%) of those met guideline criteria that were concerning for bacterial coinfection. Additionally, 32 (14%) of the 229 veterans who received antibiotics had >1 finding concerning for bacterial coinfection. Procalcitonin levels were obtained in 97 (42%) of 229. Only 33 veterans (14%) who received antibiotics had an elevated procalcitonin, and only 19 (8%) had a positive sputum culture. Conclusions: Antibiotic use was common in hospitalized veterans with COVID-19 in VISN9 facilities. This results are comparable to findings in the published literature. Among those receiving antibiotics early in their hospitalization, half were considered appropriate based on our guideline. Quality improvement initiatives are needed to improve implementation of the network guideline to reduce the overuse of antibiotics for management of COVID-19. Additionally, procalcitonin may be a helpful tool for hospitalized veterans with COVID-19.

Funding: None

Disclosures: None
Characteristics and Trend of Drug-Resistant Tuberculosis at a Major Specialized Hospital in Chongqing, China: 2016 Versus 2019
Authors: Zhang Huizheng , Zhang Ke , Yang Xin , Luo Ming , Li Chunhua , Wang Xiaoying , Hu Kui
Published: May 2022

Objective:

The epidemic of drug-resistant tuberculosis (DR-TB) has become a major concern in global TB control. This study aimed to investigate the patterns and trend of DR-TB epidemic between different time periods in Chongqing.

Methods:

A total of 985 and 835 culture positive TB patients with drug susceptibility testing (DST) results admitted to the hospital in 2016 and 2019, respectively, were included. Chi-square testing was used to compare the prevalence and trends of DR-TB in 2016 and 2019.

Results:

The proportion of previously treated TB cases with culture positivity was 45.7% in 2019, significantly higher than that in 2016 (39.1%, P = 0.004). The overall rate of drug resistance in 2019 was 43.1%, higher than that in 2016 (40.2%). The rates of multi-drug resistant TB (MDR-TB) and pre-extensively drug resistant TB (pre-XDR-TB) increased significantly from 2016 to 2019 among all TB cases (MDR: 25% vs 33.4%, P < 0.001 and pre-XDR: 7.1% vs 12.8%, P < 0.001, respectively) and previously treated TB cases (MDR: 46.5% vs 56%, P = 0.008 and pre-XDR: 13.2% vs 21.5%, P = 0.003, respectively).

Conclusions:

Our findings indicated that the prevalence of DR-TB remains high in Chongqing. The trend of resistance to anti-TB drugs beccame worse between 2016 and 2019. Moreover, acquired MDR may play a major role in MDR-TB epidemic in Chongqing. Therefore, rapid diagnosis and effective treatment of TB patients will be important to reduce the burden of DR-TB in Chongqing.
Development and Evaluation of Innovative and Practical Table-top Exercises Based on a Real Mass-Casualty Incident
Authors: Liu Jingjing , Huang Yan , Li Bingrui , Gui Li , Zhou Lingjun
Published: May 2022

Purpose:

The aim of this work was to develop a table-top exercise (TTX) program for mass-casualty incident (MCI) response based on a real incident to evaluate the program.

Methods:

The TTX program was developed based on the 8 TTX design steps. Convenience sampling was adopted to recruit recently graduated physicians in China. After the TTX training, the participants completed a self-designed questionnaire, as well as the Simulation Design Scale (SDS) and Educational Practices in Simulation Scale (EPSS).

Results:

In total, 148 valid questionnaires were collected. The difficulty score of the TTX program was 3.69 ± 0.8. The participants evaluated the program highly, with a score of 4.72 ± 0.54 out of 5. Both the SDS and the EPSS had average scores higher than 4.5. Guided reflection/feedback (M = 4.68, SD = 0.41) and fidelity (M =4.66, SD = 0.57) were the 2 highest-rated SDS subscales. For the EPSS, diverse ways of learning and collaboration were the 2 highest-rated subscales. Multivariate stepwise regression analysis showed that the participants’ evaluations of the TTX training course were related to the EPSS score, the difficulty rating, the evaluation of the instructional props, and the degree of participant involvement (F = 24.385, P < 0.001).

Conclusions:

A TTX program for MCIs was developed based on the 2014 Shanghai New Year Crush. The TTX kit is practical and sophisticated, and it provides an effective strategy for MCI training.
Food storage facilitates professional religious specialization in hunter–gatherer societies
Authors: Watts Joseph , Hamerslag Elise M. , Sprules Cassie , Shaver John H. , Dunbar Robin I. M.
Published: May 2022

Professional religious specialists centralised religious authority in early human societies and represented some of the earliest instances of formalised social leadership. These individuals played a central role in the emergence of organised religion and transitions to more stratified human societies. Evolutionary theories highlight a range of environmental, economic and social factors that are potentially causally related to the emergence of professional religious specialists in human history. There remains little consensus over the relative importance of these factors and whether professional religious specialists were the outcome or driver of increased socio-cultural complexity. We built a global dataset of hunter–gatherer societies and developed a novel method of exploratory phylogenetic path analysis. This enabled us to systematically identify the factors associated with the emergence of professional religious specialists and infer the directionality of causal dependencies. We find that environmental predictability, environmental richness, pathogen load, social leadership and food storage systems are all correlated with professional religious specialists. However, only food storage is directly related to the emergence of professional religious specialists. Our findings are most consistent with the claim that the early stages of organised religion were the outcome rather than driver of increased socio-economic complexity.
Long-wavelength equations of motion for thin double vorticity layers
Authors: Baker Gregory , Chang Ching , Llewellyn Smith Stefan G. , Pullin D.I.
Published: May 2022

We consider the time evolution in two spatial dimensions of a double vorticity layer consisting of two contiguous, infinite material fluid strips, each with uniform but generally differing vorticity, embedded in an otherwise infinite, irrotational, inviscid incompressible fluid. The potential application is to the wake dynamics formed by two boundary layers separating from a splitter plate. A thin-layer approximation is constructed where each layer thickness, measured normal to the common centre curve, is small in comparison with the local radius of curvature of the centre curve. The three-curve equations of contour dynamics that fully describe the double-layer dynamics are expanded in the small thickness parameter. At leading order, closed nonlinear initial-value evolution equations are obtained that describe the motion of the centre curve together with the time and spatial variation of each layer thickness. In the special case where the layer vorticities are equal, these equations reduce to the single-layer equation of Moore (Stud. Appl. Math., vol. 58, 1978, pp. 119–140). Analysis of the linear stability of the first-order equations to small-amplitude perturbations shows Kelvin–Helmholtz instability when the far-field fluid velocities on either side of the double layer are unequal. Equal velocities define a circulation-free double vorticity layer, for which solution of the initial-value problem using the Laplace transform reveals a double pole in transform space leading to linear algebraic growth in general, but there is a class of interesting initial conditions with no linear growth. This is shown to agree with the long-wavelength limit of the full linearized, three-curve stability equations.
Formation of a strong negative wake behind a helical swimmer in a viscoelastic fluid
Authors: Wu Shijian , Solano Tomas , Shoele Kourosh , Mohammadigoushki Hadi
Published: May 2022

We investigate the effects of helical swimmer shape (i.e. helical pitch angle and tail thickness) on swimming dynamics in a constant viscosity viscoelastic (Boger) fluid via a combination of particle tracking velocimetry, particle image velocimetry and three-dimensional simulations of the finitely extensible nonlinear elastic model with Peterlin approximation (FENE-P). The 3D-printed helical swimmer is actuated in a magnetic field using a custom-built rotating Helmholtz coil. Our results indicate that increasing the swimmer tail thickness and pitch angle enhances the normalized swimming speed (i.e. ratio of swimming speed in the Boger fluid to that of the Newtonian fluid). Strikingly, unlike the Newtonian fluid, the viscoelastic flow around the swimmer is characterized by formation of a front–back flow asymmetry that is characterized by a strong negative wake downstream of the swimmer's body. Evidently, the strength of the negative wake is inversely proportional to the normalized swimming speed. Three-dimensional simulations of the swimmer with the FENE-P model with conditions that match those of experiments, confirm formation of a similar front–back flow asymmetry around the swimmer. Finally, by developing an approximate force balance in the streamwise direction, we show that the contribution of polymer stresses in the interior region of the helix may provide a mechanism for swimming enhancement or diminution in the viscoelastic fluid.
Does the International Criminal Court Target the American Military?
Authors: KRCMARIC DANIEL
Published: May 2022

American policymakers have been wary of the International Criminal Court (ICC) since its founding. United States’ opposition is largely due to the fear that the ICC might initiate biased investigations that target members of the American military scattered across the globe. The recent ICC investigation into war crimes committed on Afghanistan’s territory during the American occupation has produced a new surge of interest in this topic. But do ICC investigations, in fact, target America’s military? Using a global sample of cases the ICC could plausibly investigate and data on the locations of all US foreign military installations, I examine how the presence of American troops in a country affects the likelihood of an ICC investigation. Contrary to the common narrative of anti-American bias, the estimated effects of US military presence are statistically indistinguishable from zero and substantively negligible. These results highlight the need to rethink America’s combative approach to the ICC.
Gadamer's Historically Effected and Effective Consciousness
Authors: Larrauri Pertierra Iñaki Xavier
Published: May 2022

Hans-Georg Gadamer argues that consciousness not only historically constrains experience but also allows strangeness to intelligibly speak to it. This historically effected and effective consciousness features in Gadamer's idea that a common language is unearthed for the interpretive horizons of those involved in dialogue with each other through a logic of question and answer. I argue, however, that this reveals a conceptual uncertainty about evaluating progress in interpretive understanding. Gadamer's failure to escape from this uncertainty risks the possibility of a problematic relativism. Effectively, even if sufficient interpretation occurs when horizons are infinitely structured, this does not preclude incoherence between a horizon's elements.
The timing of blueschist-facies metamorphism in the Makrotantalon Unit on Andros Island, Greece: Cretaceous and Eocene high-pressure/low-temperature events?
Authors: Bröcker Michael , Scherer Erik E. , Xypolias Paris , Höhn Melina
Published: May 2022

This study corroborates interpretations suggesting that the Makrotantalon Unit on Andros represents a tectonic slice with Pelagonian affinity in the nappe stack of the Cycladic Blueschist Unit. Previously reported Cretaceous 40Ar–39Ar dates of a garnet-glaucophane schist from the Makrotantalon Unit could not be reproduced by Rb–Sr geochronology, but this is not an indication of contamination with excess Ar. Instead, the newly dated samples record disturbance of the Rb–Sr isotope system by partial recrystallization. Subsets of these phengite populations, representing the smaller grain-size fractions, yielded low-precision dates ranging from c. 21 to c. 15 Ma that document deformation-related resetting and recrystallization of a presumably Cretaceous white mica population. Although these Miocene dates cannot be linked with blueschist-facies metamorphism, they provide time constraints on the formation of shear zones that overprinted the original thrust contact during exhumation. The geological relevance of a Cretaceous high-pressure event is confirmed by a Rb–Sr date of c. 121 Ma for an epidote-glaucophane schist collected further away from the tectonic contact. The occurrence of a second blueschist-facies event in the Eocene is verified by Rb–Sr dates of two epidote-glaucophane schists (c. 40 Ma and c. 44 Ma) that can unambiguously be assigned to the Makrotantalon Unit.