bluuebunny/crossref_metadata_2025 huggingface dataset:
1693. Risk Factors and Outcomes of Histologic Acute Graft Pyelonephritis following Kidney Transplantation
Authors: Powers Harry Ross , Hellinger Walter , Cortese Cherise , Elrefaei Mohamed , Khouzam Samir , Spiegel Matthew , Wadei Hani M
Published: January 2021

Background

Histologic acute graft pyelonephritis (HAGPN) is a complication of kidney transplantation (KT) diagnosed serendipitously by renal biopsy. A retrospective review of 1391 patients who underwent KT at our institution between 2008 and 2017 identified 46 cases (cumulative incidence 5%). Rejection was present in 50% of biopsies demonstrating HAGPN, complicating management. The aims of this study were to identify risk factors and outcomes of HAGPN.

Methods

Recipient, donor, operative and post-transplant characteristics of 46 cases of HAGPN and 138 controls randomly selected from the 1345 patients who underwent KT between 2008 and 2017 were assessed in univariable and multivariable Cox regression models. Associations of HAGPN with death or graft failure were assessed in univariable models.

Results

In univariable analysis, characteristics associated with increased risk of HAGPN in order of decreasing hazard ratio (HR) were rejection (HR 10.82, 5.66-20.72), urinary tract infections (UTI) or asymptomatic bacteriuria (ASB) (HR 6.28, 3.43-11.50), urologic malfunction (UM) within 30 days of KT, (HR 5.34, 2.85-10.02), less than 4 matches at HLA A/B/DR loci (HR 3.74, 1.19-11.76), delayed graft function (DGF) (HR 2.1, 1.47-3.00), basiliximab induction (HR 1.59, 1.05-2.42), diabetes mellitus (DM) at KT (HR 1.52, 1.07-2.16), operative time (HR 1.11, 1.03-1.19) and cold ischemic time (CIT) (HR 1.05, 1.02-1.06). UM, rejection and UTI or ASB were the most significant risk factors based on clinical and statistical importance, and after adjusting for them, DM, transplant type, CIT, ureteral stent placement and DGF remained significant risk factors. In univariable analysis, ureteral stent placement at transplant (HR 0.60, 0.43-0.88) and living-related donor (HR 0.18, 0.04-0.78) were each associated with reduced risk of HAGPN which persisted after multivariable analysis. In univariable analysis, HAGPN was associated with death (HR 17.04, 7.93-39.31) and graft failure (HR 3.77, 1.73, 8.20).

Conclusion

HAGPN is an infrequent, unanticipated, clinically significant complication of renal transplantation. Post-transplant dysfunction of the allograft collection system may be a modifiable risk factor.

Disclosures

All Authors: No reported disclosures
1696. The Black Box of Using Health Claims-Based Analyses to Estimate UTI Prevalence in Community-Dwelling Women
Authors: Stapleton Ann E , Wolfson Julian , Zhang Jianqiu , Smith Ariana , Newman Diane , Talley Kristine , Wyman Jean
Published: January 2021

Background

Urinary tract infections (UTIs) are common in women but most epidemiology studies occurred in specialized settings (university health clinics) or used outdated methods (random digit dialing). Currently, women receive UTI care in systems with electronic health records (EHR), thus documenting care of a wider female demographic in real-world settings. We estimated the prevalence of acute, uncomplicated UTIs in community-dwelling women in a health claims database using various operational definitions of UTI.

Methods

We conducted a retrospective analysis of claims data from the OptumLabs® Data Warehouse (OLDW), a de-identified claims and clinical information repository for privately insured and Medicare Advantage enrollees in a large, private US health plan. Non-pregnant female patients ≥ 15 years of age with two years of continuous enrollment between 2007-2015 and a visit encounter in an outpatient office, urgent care, or emergency department were included. Women with lower urinary tract disease/abnormalities, neurological disease, urological treatment, procedures or urinary catheter use, cancer or HIV treatment were excluded. Decision rules for identifying UTIs were derived using one or more combinations of: relevant ICD-9 codes, UTI symptom diagnosis codes, positive urine test results, and/or antibiotic prescription recorded in the EHR and claims. Prevalence rates were calculated for each decision rule.

Results

Of the 7,337,700 females in the claims database, 947,041 (12.97%) had an index UTI diagnosis or symptoms and met eligibility criteria. The table below illustrates prevalence rates according to each decision rule. As shown, applying decision rules based on common UTI definitions resulted in large differences in prevalence rates.

Table

Conclusion

Using common definitions for UTI to analyze claims data from an insurer of large proportions of the US, we obtained significantly different prevalence rates. This study highlights major limitations in using EHR and claims data for UTI quality initiatives such as tracking of practices associated with antimicrobial stewardship and lends credibility to proposals to track these infections as a reportable disease.

Disclosures

All Authors: No reported disclosures
1697. The Burden Of Multidrug-Resistant Urinary Tract Infections
Authors: Hammami Fatma , Koubaa Makram , Chakroun Amal , Rekik Khaoula , Smaoui Fatma , Elleuch Emna , Marrakchi Chakib , Jemaa Mounir Ben
Published: January 2021

Background

Urinary tract infections (UTIs) are the most common reason for consultation and for antibiotic use. Many factors interfere and increase the risk for antimicrobial resistance. We aimed to study the clinical, laboratory and evolutionary particularities associated with multidrug-resistant (MDR) UTIs.

Methods

We conducted a retrospective study including all patients hospitalized for UTIs in the infectious diseases department between 2011 and 2018.

Results

A total of 867 cases of UTIs were included in the study, among which 407 cases (46.9%) were MDR. There were 306 males (35.3%). The mean age was 53±21 years. Overall, MRD UTIs were significantly associated to male gender (39.1% vs 32%; p=0.02). Patients aged ≥65 years were significantly more affected with MRD UTIs (54.5% vs 36.5%; p< 0.001). Previous medical history of diabetes (38.1% vs 24.6%; p< 0.001), antibiotic consumption (30.7% vs 13%; p< 0.001) and surgical intervention of the urinary tract (13% vs 5.4%; p< 0.001) were significantly associated with MDR UTIs. The mean delay to hospitalization was significantly longer among MDR UTIs cases (5[3-10 days] vs 3[2-7 days]; p< 0.001). In total, MDR UTIs were more frequently documented to Klebsiella pneumoniae (19.4% vs 12%; p=0.002). Comparison of the disease evolution showed that MRD UTIs were significantly associated with complications (9.1% vs 5.2%; p=0.02), recurrence (4.4% vs 1.5%; p=0.01) and death (2.2% vs 0.4%; p=0.02). As to laboratory investigations and antibiotic duration, no significant difference was noted.

Conclusion

Our study showed that MDR UTIs were associated with not only complications, but also with a poor prognosis. The continuous surveillance for antimicrobial resistance and the rational use of antibiotics are crucial in order to improve the prognosis.

Disclosures

All Authors: No reported disclosures
1703. Hematologic Toxicity of Valganciclovir Prophylaxis in Solid Organ Transplant Recipients as a Function of Weight-adjusted Ganciclovir Exposure
Authors: Campanella Toni A , Roy Amanda , Gintjee Thomas J , Donnelley Monica , MacDougall Conan , Gallagher Jason C
Published: January 2021

Background

Valganciclovir (VGC), an oral prodrug of ganciclovir (GCV), is 60% bioavailable. Manufacturer-recommended doses are adjusted for creatinine clearance (CrCl), but not weight (wt), while GCV doses are adjusted for CrCl and wt. Patients exposed to excess GCV by not wt-adjusting VGC doses may be at risk of hematologic toxicity. The purpose of this study was to investigate the impact of body weight on VGC toxicity in solid organ transplant (SOT) recipients.

Methods

This was a multicenter retrospective study at three academic medical centers of adult SOT recipients who received VGC for CMV prophylaxis between January 2016 and August 2019. The primary outcome was first occurrence of leukopenia within six months post-transplant. The primary predictor was the ratio between the patient’s estimated GCV exposure based on the initial VGC dose prescribed and the equivalent prophylactic GCV dose accounting for the patient’s CrCl and wt (rVGC:GCV).

Results

The study included 231 patients, mostly lung (59%) and kidney (KT, 28%) transplants (Table 1). The rVGCV:GCV was 4.4 (range, 0.6-25.1, SD 4.5), and was significantly higher in KT (7.7 vs 3.0, p < 0.001). Leukopenia occurred in 133 patients (57.5%). After adjustment for type of transplant, rVGC:GCV ratio was not associated with increased odds (OR 0.97, 95% CI 0.91-1.04) or hazard of (HR 0.99, 95% CI 0.95-1.04) leukopenia. Exploratory analysis suggested threshold effects and interaction with transplant type: a rVGCV:VGC of > 3 was associated with time to leukopenia (HR 2.02, 95% CI 1.09-3.74) among non-KT patients but not KT patients (HR 0.99, 95% CI 0.56-1.76) (Figure 1).

Table 1

Figure 1

Conclusion

Initial doses of VGC used for SOT CMV prophylaxis are estimated to result in significantly higher GCV exposures than IV GCV doses. A relationship with risk of leukopenia was only seen in non-KT patients, possibly because of rapid recovery of renal function and dose adjustment in KT patients.

Disclosures

Jason C. Gallagher, PharmD, FIDP, FCCP, FIDSA, BCPS, Allergan (Consultant)Astellas (Consultant)Merck (Consultant, Grant/Research Support)Nabriva (Consultant)Qpex (Consultant)scPharmaceuticals (Consultant)Shionogi (Consultant)Spero (Consultant)Tetraphase (Consultant)
1707. Clinical Profile of Human T-Lymphotropic Virus Type I Infection in Pediatric Population in a Referral Hospital in Colombia
Authors: Mejia- Mertel Juliana , Rojas -Hernandez Juan P
Published: January 2021

Background

The Human T-lymphotropic virus type 1 (HTLV-1), affects around ten to twenty million people worldwide, predominantly in intertropical regions (Africa, Japan, Melanesia, Australia, and South America Pacific Coast). The most common disorders associated are T-cell leukemia/lymphoma (ALT) and HTLV-1-associated myelopathy (HAM). Studies have reported other clinical manifestations in HTLV-1, still studies are needed in pediatric population to improve diagnosis and treatment of infected patients.

Methods

Descriptive, retrospective cohort study, conducted in our referral pediatric hospital in Cali, Colombia. Included pediatric patients (1 to 18 years of age) diagnosed with HTLV-1 infection, between January 2017 to March 2020.

Results

Twelve patients were included, seven males and five females. Eleven patients were from and resided in the Colombian Pacific coast. Ten patients showed nutritional deficiencies.

None showed clinical or laboratory signs of ALT, neither neurological symptoms or physical exam suggesting HAM. In terms of associated diseases and opportunistic infections, none had a positive HIV ELISA test, and stool tests were all negative for Strongiloydes. Four presented infective dermatitis, and two showed lesions suggesting scabies.

Eight patients presented respiratory symptoms with chest CT scans showing signs of chronic inflammation, bronchiectasis, and subpleural bullae as the major findings. Additional tests were carried out in bronchoalveolar fluid, four had positive galactomannan test,suggesting pulmonary aspergillosis, two exhibited positive gene PCR testing for Mycobacterium tuberculosis.

Regarding inflammatory diseases, one patient presented with symptoms of Inflammatory Bowl Disease, with biopsy confirming Crohn’s disease. Another patient presente abrupt vision loss, diagnosed with Vogt Koyanagi Hadara Syndrome after ophthalmological evaluation.

Summary features HTLV-1 patients

Ground-glass opacity diffusely distributed in both lungs with multiple bronchiectasis involving predominantly lung bases. Cystic images diffusely distributed in both lungs, some subpleural and other centrilobular.

Conclusion

It is important to consider alternative manifestations of HTLV-1 infection in the pediatric population, including pulmonary disease, opportunistic co-infections, and inflammatory disorders. It is crucial to diagnose this disease in childhood to reach a better control of this neglected infection that affects predominantly vulnerable population in low-income countries.

Disclosures

All Authors: No reported disclosures
1708. Impacts of age and season on rates of hospitalization for respiratory syncytial virus (RSV) in infants in the United States and their use of mechanical ventilation and charges
Authors: Shepard Donald S
Published: January 2021

Background

Respiratory Syncytial Virus (RSV) infection is the leading cause of hospitalization in infants below age 12 months and highest below age 6 months. Despite considerable evidence on the clinical predictors of RSV hospitalizations, little is known about their cost, its drivers and their relation to age and season.

Methods

We used the National Inpatient Sample to examine RSV inpatient admissions and their average charge from 2009 to 2011. This 3-year data set includes a large, nationally representative all-payer sample of 37,376 RSV admissions of infants in the US under age 12 months recorded by month. We calculated the rate per 1000 infants of RSV hospitalizations, the share receiving mechanical ventilation (MV), and the mean charge per admission (separated by use of MV) with 95% confidence intervals by age and season, excluding incomplete data. We adjusted charges to Jan 2020 based on the medical care Consumer Price Index.

Results

These data confirm that rates of hospitalization by age were highest for infants 1 month of chronological age (2.42 times the annualized average) and declined steadily thereafter. The percentage of hospitalizations with MV declined from months < 1 to 4, with subsequent fluctuations (Fig 1). Charges exceeded the annual average only for infants aged < 1 and 1 month (Fig 2). In 2020 prices, hospitalization charges per episode averaged $175,211 with MV vs. $17,313 without MV, totaling $1.51 billion annually for the birth cohort of 4.04 million infants ($374 per infant). As only 4.5% of hospitalizations had MV, those without MV comprised 67.5% of aggregate yearly charges. Admissions were highly seasonal, with the rate in the highest month (Feb) 341 times that in the lowest month (July). However, utilization of MV (Fig 3) tended to be lower in the RSV season but depended mostly on age. While average charges were higher outside the RSV season, their seasonal pattern was similar for admissions with and without MV.

Fig. 1. Share of hospitalizations with RV (bars) vs. rate of RSV hospitalizations (line) by age

Fig. 2. Charges (bars) vs. rate of RSV hospitalizations (line) by age

Fig. 3. Utilization of MV (bars) vs RSV hospitalization rate (line) by season

Conclusion

RSV in infants under one year generate substantial hospital charges. While each of the small share of infants receiving MV is expensive, infants with MV are not the main driver of costs (Fig 4). Rather, the large number and share (94.5%) of hospitalizations without MV is the major determinant of aggregate charges (Fig 5).

Fig. 4. Relation between use of mechanical ventilation (MV) [bars] and RSV hospitalization rate [lines] by season and age (in months)

Fig. 5. Hospitalization charges (bars) vs RSV hospitalization rate (line) by season

Disclosures

Donald S. Shepard, PhD, Sanofi Pasteur (Grant/Research Support)
1715. Influenza-like Illness (ILI) Experience Among Healthcare Workers in Military Treatment Facilities: An Offshoot of the Pragmatic Assessment of Influenza Vaccine Effectiveness in the DoD (PAIVED) Study
Authors: Colombo Rhonda , Richard Stephanie , Schofield Christina , Collins Limone , Ganesan Anuradha , Geaney Casey , Hrncir David , Lalani Tahaniyat , Markelz Ana E , Maves Ryan C , McClenathan Bruce , Mende Katrin , Modi Jitendrakumar , Montgomery Jay R , Seshadri Srihari , Skerrett Catherine , Spooner Christina , Utz Gregory , Warkentien Tyler , Burgess Timothy , Burgess Timothy , Coles Christian L
Published: January 2021

Background

Healthcare workers (HCWs) are at heightened risk of exposure to respiratory pathogens. There are limited published data on influenza-like illness (ILI) experience among HCWs, and the few available studies were hampered by incomplete vaccination histories. PAIVED, a multicenter, multiservice study assessing influenza vaccine effectiveness in the Department of Defense, provides a unique opportunity to describe ILI experience among vaccinated HCWs compared to vaccinated non-HCWs.

Methods

PAIVED participants were randomized to receive either egg-based, cell-based, or recombinant-derived influenza vaccine then surveyed weekly for ILI. At enrollment, participants provided key demographic data including whether they were HCWs with direct patient contact. ILI was defined a priori as 1) having cough or sore throat plus 2) feeling feverish/having chills or having body aches/fatigue. Participants with ILI completed a daily symptom diary for seven days and submitted a nasal swab for pathogen detection.

Results

Of 4433 eligible participants enrolled during the 2019-20 influenza season, 1551 (35%) were HCWs. A higher percentage of HCWs experienced an ILI than non-HCWs (34% vs 26%, p< 0.001). Overall, HCWs were more likely to be female (42% vs 32%), age 25-34 years (39% vs 28%), active-duty military (81% vs 62%), non-smokers (88% vs 75%), and physically active (92% vs 85%). Self-reported race differed between HCWs and non-HCWs; a higher proportion of HCWs identified as White (63% vs 56%) or Asian (8% vs 5%). Similar demographic differences existed among HCWs and non-HCWs with ILI. HCWs were more likely to respond to at least 50% of weekly surveillance messages, irrespective of ILI status. HCWs with ILI had less severe lower respiratory symptoms (p< 0.001) and a shorter duration of illness (12.4±8.1 days vs 13.7±9.0, p=0.005) than non-HCWs. Pathogen data is pending.

Conclusion

HCWs in PAIVED were more likely to report ILI than their non-HCW counterparts yet tended to have lower illness severity, possibly reflecting a higher level of baseline health or enhanced awareness of early ILI symptoms. The important epidemiologic position HCWs occupy for ILI has been apparent in the COVID-19 pandemic. Exploring ways to mitigate ILI risk in HCWs beyond influenza vaccination is warranted.

Disclaimer

Disclosures

All Authors: No reported disclosures
1718. Respiratory Syncytial Virus (RSV) Surveillance in the Department of Veterans Affairs (VA), 2010-2018
Authors: Lucero-Obusan Cynthia , Schirmer Patricia , Oda Gina , Holodniy Mark
Published: January 2021

Background

Respiratory Syncytial Virus (RSV) is an increasingly recognized cause of acute respiratory illness in older adults, leading to an estimated 177,000 hospitalizations and 14,000 deaths each year in the US. In adult populations, diagnostic testing for RSV has historically been underutilized. Herein, we examine national trends in RSV testing and infection across the Veterans Affairs (VA) healthcare system.

Methods

Electronic RSV laboratory testing results, ICD-coded hospitalizations and outpatient encounters were obtained from VA’s Praedico Surveillance System (1/1/2010-12/31/2018). Patients were reviewed for positive results, repeat testing, and demographics. Antibody tests were excluded.

Results

A total of 102,251 RSV results were included. Overall, 4,372 (4.3%) specimens from 4,263 unique individuals were positive with a median age of 67 years (range 0-101) and 90% were male. 1,511 individuals (35.4%) also had an RSV-coded hospitalization. RSV type was specified for only 7.8% of positives (Table). During 2010-2018 there were 2,522 RSV-coded hospitalizations (median length of stay = 4 days) among 2,444 unique individuals, which included 413 ICU stays (16.4%) and 98 deaths (3.9%) during the RSV-coded hospitalization. Approximately 78% of RSV-coded hospitalizations within VA (excluding all non-VA hospitalizations) had a documented positive test result. A greater than 15-fold increase in RSV tests performed, hospitalizations and outpatient encounters was observed from 2010-2018, although the percent testing positive remained relatively stable (Figure, Table).

Figure. Testing for Respiratory Syncytial Virus (RSV), Department of Veterans Affairs, 2010-2018.

Table. Select RSV Surveillance Metrics, Department of Veterans Affairs, 2010-2018

Conclusion

RSV testing and identification of patients with RSV infection increased dramatically during the time period analyzed, likely due to increased availability of PCR-based multi-pathogen panels and duplex assays. While the percentage of tests positive for RSV remained relatively stable, the rise in coded hospitalizations may be due to increased testing for RSV among hospitalized Veterans with severe respiratory infections. These surveillance data may allow for further characterization of RSV disease burden estimates which can help inform clinical management and development of interventions for adults, such as vaccines and antiviral therapies.

Disclosures

All Authors: No reported disclosures
1719. Respiratory Syncytial Virus-Associated Hospitalization Rates among US Infants: A Systematic Review and Meta-Analysis
Authors: McLaughlin John M , Khan Farid L , Schmitt Heinz-Josef , Agosti Yasmeen , Jodar Luis , Simões Eric , Swerdlow David L
Published: January 2021

Background

Understanding the true magnitude of infant respiratory syncytial virus (RSV) burden is critical for determining the potential public-health benefit of RSV prevention strategies. Although global reviews of infant RSV burden exist, none have summarized data from the United States or evaluated how RSV burden estimates are influenced by variations in study design.

Methods

We performed a systematic literature review and meta-analysis of studies describing RSV-associated hospitalization rates among US infants. We also examined the impact of key study characteristics on these estimates.

Results

After review of 3058 articles through January 2020, we identified 25 studies with 31 unique estimates of RSV-associated hospitalization rates. Among US infants < 1 year of age, annual rates ranged from 8.4 to 40.8 per 1000 with a pooled rate= 19.4 (95%CI= 17.9–20.9). Study type was associated with RSV hospitalization rates (P =.003), with active surveillance studies having pooled rates per 1000 (11.1; 95%CI: 9.8–12.3) that were half that of studies based on administrative claims (21.4; 95%CI: 19.5–23.3) or modeling approaches (23.2; 95%CI: 20.2–26.2).

Conclusion

Applying the pooled rates identified in our review to the 2020 US birth cohort suggests that 73,680 to 86,020 RSV-associated infant hospitalizations occur each year. To date, public-health officials have used conservative estimates from active surveillance as the basis for defining US infant RSV burden. The full range of RSV-associated hospitalization rates identified in our review better characterizes the true RSV burden in infants and can better inform future evaluations of RSV prevention strategies.

Disclosures

John M. McLaughlin, PhD, Pfizer (Employee, Shareholder) Farid L. Khan, MPH, Pfizer (Employee, Shareholder) Heinz-Josef Schmitt, MD, Pfizer (Employee, Shareholder) Yasmeen Agosti, MD, Pfizer (Employee, Shareholder) Luis Jodar, PhD, Pfizer (Employee, Shareholder) Eric Simões, MD, Pfizer (Consultant, Research Grant or Support) David L. Swerdlow, MD, Pfizer (Employee, Shareholder)
145. Monthly Antibiotic Prescribing Peer Comparison Combined with In-person Education Decreases Antibiotic Prescribing for Acute Respiratory Infections
Authors: Kolo Shelby J , Taber David J , Washburn Ronald G , Pleasants Katherine A
Published: January 2021

Background

Inappropriate antibiotic prescribing is an important modifiable risk factor for antibiotic resistance. Approximately half of all antibiotics prescribed for acute respiratory infections (ARIs) in the United States may be inappropriate or unnecessary. The purpose of this quality improvement (QI) project was to evaluate the effect of three consecutive interventions on improving antibiotic prescribing for ARIs (i.e., pharyngitis, rhinosinusitis, bronchitis, common cold).

Methods

This was a pre-post analysis of an antimicrobial stewardship QI initiative to improve antibiotic prescribing for ARIs in six Veterans Affairs (VA) primary care clinics. Three distinct intervention phases occurred. Educational interventions included training on appropriate antibiotic prescribing for ARIs. During the first intervention period (8/2017-1/2019), education was presented virtually to primary care providers on a single occasion. In the second intervention period (2/2019-10/2019), in-person education with peer comparison was presented on a single occasion. In the third intervention period (11/2019-4/2020), education and prescribing feedback with peer comparison was presented once in-person followed by monthly emails of prescribing feedback with peer comparison. January 2016-July 2017 was used as a pre-intervention baseline period.

The primary outcome was the antibiotic prescribing rate for all classifications of ARIs. Secondary outcomes included adherence to antibiotic prescribing guidance for pharyngitis and rhinosinusitis. Descriptive statistics and interrupted time series segmented regression were used to analyze the outcomes.

Results

Monthly antibiotic prescribing peer comparison emails in combination with in-person education was associated with a statistically significant 12.5% reduction in the rate of antibiotic prescribing for ARIs (p=0.0019). When provider education alone was used, the reduction in antibiotic prescribing was nonsignificant.

Conclusion

Education alone does not significantly reduce antibiotic prescribing for ARIs, regardless of the delivery mode. In contrast, education followed by monthly prescribing feedback with peer comparison was associated with a statistically significant reduction in ARI antibiotic prescribing rates.

Disclosures

All Authors: No reported disclosures
148. Post-Extraction Infection and Antibiotic Prescribing Among Veterans Receiving Dental Extractions
Authors: Caniff Kaylee E , Young Lisa R , Truong Shawna S , Gretchen Gibson , Jurasic Marianne M , Poggensee Linda , Fitzpatrick Margaret A , Evans Charlesnika T , Suda Katie J
Published: January 2021

Background

Dentists prescribe 10% of outpatient antibiotics in the United States, equating to 24.5 million prescriptions annually. However, there is a paucity of data regarding adjunctive antibiotic use in tooth extractions. This study compared post-extraction infections following dental extractions with and without adjunctive antibiotics. Post-extraction infection risk factors and antibiotic prescribing patterns were also investigated.

Methods

This was a retrospective cohort of Veterans with tooth extraction(s) in any Veterans Affairs dental clinic from 1/1/17-12/31/17. A stratified random sample was selected by geographic region, type of extraction (surgical/non-surgical) and post-extraction antibiotic receipt to ensure inclusion of subjects in each of these categories. Subjects who received an antibiotic were compared to those who did not for the occurrence of post-extraction infection as documented in the health record by infectious signs/symptoms or diagnosis. Multivariable regression was performed to identify factors associated with antibiotic receipt.

Results

A sample size of 374 was needed to achieve statistical power based on a 10% risk of infection post-extraction. Nationally, 69,610 patients met inclusion criteria, of which 404 were randomly selected for inclusion. Antibiotics were prescribed to 154 patients (38.1%). There was no difference in post-extraction oral infection among subjects who did and did not receive antibiotics (4.5% vs. 3.2%, p=0.59). Risk factors for post-extraction infection could not be identified due to the low frequency of this outcome. Subjects who received antibiotic prescriptions were more likely to have a greater number of teeth extracted (OR=1.1; 95% CI 1.03–1.2), documentation of acute infection at time of extraction (OR=3.0; 95% CI 1.6–5.8), molar extraction (OR=1.8; 95% CI 1.1–2.9) and extraction performed by an oral maxillofacial surgeon (OR=2.3; 95% CI 1.5–3.6) or specialty dentist (OR=5.8; 95% CI 2.1–16.2).

Conclusion

Infectious complications were not significantly different among Veterans undergoing tooth extraction who did and did not receive post-extraction antibiotics. Antibiotic prescribing for tooth extraction may be a potential area of focus for outpatient antimicrobial stewardship efforts.

Disclosures

All Authors: No reported disclosures
150. Using audit-and-feedback to improve antibiotic-prescribing in Emergency Departments: a quasi-experimental study across 4 sites in the Veterans Health Administration
Authors: Livorsi Daniel J , Nair Rajeshwari , Dysangco Andrew , Aylward Andrea , Alexander Bruce , Smith Matthew , Kouba Sammantha , Perencevich Eli N
Published: January 2021

Background

Antibiotic-prescribing in Emergency Departments (EDs) is often inappropriate. In this study, we evaluated whether audit-and-feedback could improve antibiotic use in EDs.

Figure 1. Comparison of antibiotic-prescribing between the pretest and intervention periods at 2 intervention EDs and 2 control EDs

Methods

We pilot tested an audit-and-feedback intervention using a quasi-experimental study design at 2 intervention and 2 matched-control EDs with a 12-month pretest and a 12-month intervention period. At intervention sites, 27 of 31 (87.1%) clinicians were enrolled; at baseline, they received 1) one-on-one education about antibiotic-prescribing and 2) individualized feedback with comparisons to local peers. Feedback included personalized antibiotic-prescribing data for all ED visits and specifically for viral acute respiratory infections (ARIs); feedback was updated quarterly. The primary outcome was the antibiotic-prescribing rate for ED visits not resulting in hospitalization, and it was assessed using a segmented regression analysis of monthly time series data. Manual chart reviews were performed to assess guideline-concordant management (i.e. prescribing an antibiotic when indicated and not prescribing when not indicated) for 5 ARIs plus cystitis.

Results

In the pre-test and intervention periods, intervention sites had 28,146 and 27,396 visits compared to 31,439 and 32,295 visits at control sites. After implementation started, intervention sites saw an immediate decrease in antibiotic use (-10.3%, p=0.15) compared to a 1.5% increase (p=0.88) at control sites. By the end of the intervention period, there was an 8.9% decrease in antibiotic use at intervention sites compared to a 3.4% decrease at control sites [relative risk ratio (RRR) -3.3% (95% CI, -8.4 to +1.7), Figure 1]. Guideline-concordant management improved from 52.1% to 72.2% (p< 0.01) at intervention sites compared to 51.3% to 58.2% (p=0.13) at control sites. Intervention and control sites had similar changes in 30-day outcomes, including late antibiotic prescriptions and hospitalizations.

Conclusion

After the implementation of audit-and-feedback at 2 EDs, antibiotic use did not significantly decrease compared to 2 control EDs but guideline-concordant management improved. Future studies should include more study sites to improve statistical power and also evaluate the effectiveness of more frequent and specific feedback.

Disclosures

Daniel J. Livorsi, MD, MSc, Merck and Company, Inc (Research Grant or Support) Rajeshwari Nair, PhD, Merck and Company, Inc. (Research Grant or Support)
153. Development of a Pathway for Removal of Inappropriate Penicillin Allergy Labels in Hospitalized Patients
Authors: Shweta Fnu , Gurram Pooja , Almeida Natalia E Castillo , Challener Douglas , Cano Edison J , Park Miguel , Narayanan Prasanna , Skrupky Lee , Volcheck Gerald , Virk Abinash
Published: January 2021

Background

More than 90% of reported penicillin allergies are found inaccurate when formally assessed. These allergy labels lead to decreased utilization of first-line beta-lactam antibiotics, and adverse clinical outcomes. The objective of this study was to develop a multi-disciplinary approach to decrease inaccurate labeling among hospitalized patients with documented penicillin allergy.

Methods

A team of clinicians, pharmacists, and nurses utilized the DMAIC quality strategy to improve accuracy of penicillin allergy labeling. Allergic reactions were stratified to develop a penicillin allergy de-labeling algorithm (Figure 1). Admission to the intensive care unit (ICU) for anaphylaxis was defined as a balancing measure. We reviewed baseline data from patients with a documented penicillin allergy admitted to a single inpatient floor at Mayo Clinic, Rochester between June and October 2019. A cause and effect diagram was used to conduct a root cause analysis. The intervention was then applied to patients who reported penicillin allergy admitted to the same floor from November 2019 to January 2020. Study data were collected and basic descriptive statistics generated.

Figure 1: Penicillin allergy delabeling algorithm

Results

96 patients were included in the control group with mean age of 71 years (range 65–84 years) and 55% females. Breakdown of documented allergic reactions are represented in Figure 2. 58 (60%) received an antibiotic for a median duration of 1.5 days (IQR: 0 – 6). Of these, 7(12%) received penicillin-class antibiotics, and 41 (70.6%) received non-beta-lactam antibiotics. 2 (2%) of these patients were de-labeled without any penicillin skin tests. Detailed metrics of each PDSA cycle are shown in Table 1. During PDSA cycle 2, inaccurate penicillin documentation was removed in 9/19 (47.4%) of hospitalized patients. There were no ICU admissions for anaphylaxis.

Figure 2: Graphic representation of proportion of type of documented allergic reactions to penicillin

Table 1: Metrics and outcomes at baseline and during successive PDSA cycles

Conclusion

Various factors contribute to penicillin allergy mislabeling. Our comprehensive algorithm addresses nuances of penicillin allergic reactions and increased accurate penicillin allergy labeling in 47.4% of the cases. Beta-lactam use also increased to 37% through our pilot project while maintaining patient safety. A multi-disciplinary and patient-centered approach aligned with institutional workflows is necessary to improve patient outcomes.

Disclosures

All Authors: No reported disclosures
154. Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Adults with Acute Pharyngitis
Authors: Lautenbach Ebbing , Hamilton Keith W , Grundmeier Robert , Neuhauser Melinda M , Hicks Lauri , Jaskowiak Anne , Cressman Leigh , James Tony , Omorogbe Jacqueline , Frager Nicole , Menon Muida , Kratz Ellen , Gerber Jeffrey
Published: January 2021

Background

Although most antibiotic use occurs in outpatients, antibiotic stewardship programs (ASPs) have primarily focused on inpatients. A major challenge for outpatient ASPs is lack of accurate and accessible electronic data to target interventions. We developed and validated an electronic algorithm to identify inappropriate antibiotic use for adult outpatients with acute pharyngitis.

Methods

In the University of Pennsylvania Health System, we used ICD-10 diagnostic codes to identify patient encounters for acute pharyngitis at outpatient practices between 3/15/17 – 3/14/18. Exclusion criteria included immunocompromising conditions, comorbidities, and concurrent infections that might require antibiotic use. We randomly selected 300 eligible subjects. Inappropriate antibiotic use based on chart review served as the basis for assessment of the electronic algorithm which was constructed using only data in the electronic health record (EHR). Criteria for appropriate prescribing, choice of antibiotic, and duration included positive streptococcal testing, use of penicillin/amoxicillin (absent b-lactam allergy), and 10 days maximum duration of therapy.

Results

Of 300 subjects, median age was 42, 75% were female, 64% were seen by internal medicine (vs. family medicine), and 69% were seen by a physician (vs. advanced practice provider). On chart review, 127 (42%) subjects received an antibiotic, of which 29 had a positive streptococcal test and 4 had another appropriate indication. Thus, 74% (94/127) of patients received antibiotics inappropriately. Of the 29 patients who received appropriate prescribing, 27 (93%) received an appropriate antibiotic. Finally, of the 29 patients who were appropriately treated, 29 (100%) received the correct duration. Test characteristics of the EHR algorithm (compared to chart review) are noted in the Table.

Conclusion

Inappropriate antibiotic prescribing for acute pharyngitis is common. An electronic algorithm for identifying inappropriate prescribing, antibiotic choice, and duration is highly accurate. This algorithm could be used to efficiently assess prescribing among practices and individual clinicians. The impact of interventions based on this algorithm should be tested in future work.

Test Characteristics of Electronic Algorithm for Inappropriate Prescribing, Agent, and Duration

Disclosures

All Authors: No reported disclosures
157. A Multidisciplinary Approach to Carbapenem Stewardship at a Large Community Hospital in Brooklyn, New York
Authors: Simon Samuel , Li Rosanna , Lin Yu Shia , Mayer Suri , Chapnick Edward , Ghitan Monica
Published: January 2021

Background

Carbapenem-resistant gram-negative organisms are a continuously mounting threat, underscoring the need for effective antimicrobial stewardship interventions to improve the use of carbapenems. We sought to implement several multidisciplinary antimicrobial stewardship interventions beginning in January 2019 in an effort to reduce unnecessary meropenem use and the incidence of carbapenem-resistant gram-negatives.

Methods

Prospective audit and feedback was utilized daily in combination with weekly stewardship rounds between an Infectious Diseases pharmacist and physician in the Intensive Care Units. A second Infectious Diseases physician attended weekly interdisciplinary rounds on meropenem high-use units. Meropenem Days of Therapy (DOT) per 1,000 patient days and the incidence of meropenem resistant Pseudomonas aeruginosa and Klebsiella pneumoniae were compared by the chi-square test of proportions.

Results

Between 2018 and 2019 the institution’s meropenem DOT per 1,000 patient days decreased 33%, from 57 to 38 days per 1,000 patient days (difference, 19 days per 1,000 patient days; p< 0.001). In the hospital antibiogram, the meropenem susceptibility of Pseudomonas aeruginosa over the same time period increased from 71% to 77% of isolates (difference, 6%; p = 0.009). A non-significant decrease in the susceptibility of meropenem to Klebsiella pneumoniae was also observed from 92 to 90% (difference, 2%: p = 0.1658).

Conclusion

These data support the need for antimicrobial stewardship efforts targeting broad-spectrum antimicrobials such as meropenem. In the setting of a sustained decrease in meropenem use over 12 months, we observed a significant improvement in the percent susceptibility rate of Pseudomonas aeruginosa to meropenem for the first time in five years.

Disclosures

All Authors: No reported disclosures
159. A Novel Framework to Guide Antibiotic Stewardship Nursing Practice
Authors: Manning Mary Lou , Pogorzelska-Maziarz Monika , Carter Eileen , Monsees Elizabeth
Published: January 2021

Background

In 2017, the International Council of Nurses - a federation of more than 130 national nurses associations, representing the more than 20 million nurses worldwide - issued a statement supporting the position that nurses “play a central role in patient care and interdisciplinary communication and, as such, are in a key position to contribute to reducing antimicrobial resistance and critical for the function of antimicrobial stewardship (AS) programs.” Evidence suggests that frontline nurses are enthusiastic to participate in AS activities but lack context and a non-antibiotic prescriber frame of reference.

Antibiotic Stewardship Nursing Practice: The SCAN-P Framework®

Methods

Drawing from a review of the antibiotic, environmental, and social sciences stewardship literature and interviews with AS thought leaders, we developed a framework to provide context and to guide AS nursing practice and education. Over a six month period, the framework was vetted with over 30 nurse and non-nurse clinicians and critiqued by frontline nurses engaged in AS patient care activities. The framework went through more than ten iterations, resulting in the SCANP framework (shown in Figure).

Results

The novel SCANP Framework consists of three concentric circles, sharing a common core to prevent patient harm and optimize antibiotic use. The outer circle - S - represents scope and standards of nursing practice and nursing code of ethics. Nursing practice is guided by individual country’s standards and codes. The second ring - C - culture and context represents organizational culture and local-level social/behavioral context. The extent to which nurses can successfully engage in AS with their interdisciplinary colleagues is highly dependent on how nursing is positioned within the organization. The third ring - ANP - represents current and emerging AS Nursing Practices that support the safe and responsible use of antibiotics.

Conclusion

Recommendations to expand AS programs to include nurses have generated national and international support. But nurse engagement in AS has received limited contextual attention. To fill the gap, we created a practical, globally applicable AS organizing framework to guide nurses, and leaders charged with nursing development and education, foster interdisciplinary dialogue on advancing AS endeavors.

Disclosures

All Authors: No reported disclosures
162. Assessment of Beta-lactam Allergies as Rationale for Receipt of Vancomycin for Surgical Prophylaxis
Authors: Tucker Kendall J , Ham YoungYoon , Holmer Haley K , McCracken Caitlin M , Sukerman Ellie , Lewis James , McGregor Jessina C
Published: January 2021

Background

Beta-lactam (BL) antibiotics are first-line agents for most patients receiving antimicrobial prophylaxis in surgical procedures. Despite evidence showing low cross-reactivity between classes of BLs, patients with allergies commonly receive vancomycin as an alternative to avoid allergic reaction. The objective of this study was to identify potentially inappropriate use of vancomycin surgical prophylaxis among patients with reported BL allergies.

Methods

Adult patients (≥18 years) receiving vancomycin for surgical prophylaxis with a reported penicillin and/or cephalosporin allergy at our institution between August 2017 to July 2018 were retrospectively evaluated for potential eligibility for penicillin allergy testing and/or receipt of standard prophylaxis. Surgery type and allergy history were extracted from the electronic medical record. Per our institution’s penicillin-testing protocol, patients with IgE-mediated reactions < 10 years ago were eligible for penicillin skin testing (PST), mild reactions or IgE-mediated reaction > 10 years ago were eligible for direct oral amoxicillin challenge, and severe non-IgE mediated allergies were ineligible for penicillin allergy evaluation or BL prophylaxis.

Results

Among 830 patients who received vancomycin for surgical prophylaxis, 196 reported BL allergy and were included in the analysis (155 with penicillin allergy alone; 21 with cephalosporin allergy; 20 with both cephalosporin and penicillin allergy). Approximately 40% of surgeries were orthopedic. Six patients were ineligible for BL prophylaxis. Per institutional protocol, 73 of 155 patients (48%) may have qualified for PST; 81 of 155 (52%) patients may have received a direct oral amoxicillin challenge. Only 3 of 22 patients with history of methicillin-resistant Staphylococcus aureus appropriately received additional prophylaxis with vancomycin and a BL.

Conclusion

Patients with BL allergies often qualify for receipt of a first-line BL antibiotic. An opportunity exists for improved BL allergy assessment as an antimicrobial stewardship intervention. Future studies should evaluate outcomes associated with BL allergy evaluation and delabeling in patients receiving surgical prophylaxis.

Disclosures

All Authors: No reported disclosures
164. Avoiding Complacency: Assessing the Perceived Impact and Value of Antimicrobial Stewardship at a Academic Medical Center
Authors: Lee Matthew S , McCoy Christopher
Published: January 2021

Background

Multi-disciplinary engagement and education remain key measures for Antimicrobial Stewardship Programs (ASPs). Over 3 years, our ASP has undergone key changes to pre-authorization review, post-prescriptive activities, and core team members, coinciding with a 30% increase in stewardship interventions.

The objectives of this study were to evaluate the familiarity of Nursing, Pharmacy and Prescribers at our academic medical center regarding ASP activities and services, as well as perceived impact on patient care and value. Secondary objectives were to determine what resources are currently utilized and areas for improvement.

Methods

Distinct surveys were distributed to three participant groups: Nurses, Pharmacists, and Prescribers (Housestaff, Advanced Practice Providers, and staff physicians). Questions were developed to assess familiarity, perceived value, and overall satisfaction with the ASP. Additional items included questions on the current use of ASP resources and educational engagement. Survey results were compared to a similar survey conducted 3 years amongst the same participant groups.

Results

The survey was delivered electronically to 3367 Prescribers, Nurses and Pharmacists. 403 responders completed the survey (208 Nurses, 181 Prescribers, and 18 Pharmacists). Familiarity was lowest amongst Nurses, but almost doubled compared to 2016 (Figure). Prescribers cited “restricted antibiotic approval”, “de-escalation”, and “alternative therapies relative to allergies” as the three most common interaction types, similar to 2016. ASP interactions continued to be rated “moderate” or “high” value (88.4% vs 89.15% in 2016), however, face-to-face interactions were preferred by only 4% of responders (unchanged compared to 2016). Prescribers also responded uncommon use of ASP online resources (20%) and clinical decision support tools (34%). 78% of responders expressed desire for increased ASP-related education.

Conclusion

As ASPs evolve, it is important to constantly evaluate impact and value, and identify areas for growth. Despite ASP familiarity being high and interactions valued, we need to further optimize ASP provided resources, clinical support tools, and educational offerings.

Disclosures

All Authors: No reported disclosures