bluuebunny/crossref_metadata_2025 huggingface dataset:
P-1544. Outcomes of Multi-Drug Resistant Acinetobacter Baumannii (MDR-AB) Management in a Tertiary Care Hospital in Saudi Arabia: Retrospective Observational Study
Authors: Aljuzair Zahrah H , AlMahasnah Reem A , Sait Afrah , Atta Manal
Published: January 2025

Background

Nosocomial infections caused by multi-drug resistant Acinetobacter baumannii (MDR-AB) are widespread and have been linked to numerous infections, resulting in high rates of morbidity and mortality globally. It has a mortality rate of 17.5%, a resistance rate of 74% to carbapenems, and has been found primarily in immunocompromised patients in Saudi Arabia. There is a lack of a defined treatment standard of care with a limited number of alternatives. To gain additional insight into managing MDR-AB, this study aimed to evaluate the clinical efficacy of various antibiotic regimens and compare the outcomes of monotherapy with those of antibiotic combinations

Methods

A five-years (2018 to 2023) retrospective observational study was conducted at a tertiary care hospital in Saudi Arabia. All patients with positive Acinetobacter baumannii culture were screened. Adult patients ( ≥ 18 years ) with MDR-AB isolated and had received a minimum of 72 hours of antibiotic treatment were included. The primary end point was clinical improvement. Adverse drug events and the 30-day overall mortality rate were evaluated as secondary end points

Results

One hundred patients met the study inclusion criteria. Of those, 45% were oncology or transplant patients and 80% were admitted to the intensive care unit. MDR-AB was associated with several infectious syndromes, including 44% pneumonia, 42% bacteremia, and 13% urinary tract infections. 30% of patients were given meropenem as an empiric treatment, with varying dosage regimens; 26% were given piperacillin/tazobactam. Based on culture sensitivity, 68% of the patients were treated with tigecycline, while 28% were retained on meropenem, despite the fact that 98% of the isolates were carbapenem-resistant. Antibiotic monotherapy has been given only to 39% of patients. Clinical improvement was reported in 66% of the patients with 80% achieved complete improvement. The 30-day mortality rate was 50%. Adverse drug events were rare, with only 3% GI symptoms

Conclusion

MDR-AB in our patients is mainly causing two infectious syndromes in 86%. A combination of antibiotics was used in 61%. High clinical improvement with a simultaneous high 30-day mortality rate highlighted the need for standardized guidelines for the management of MDR-AB infections

Disclosures

All Authors: No reported disclosures
P-1553. Impact of Urinary Tract Infection due to Carbapenem Resistant Gram Negative Bacteria in Patients with Kidney Transplant
Authors: Baldissera Giulia Soska , Gregory Vinicius da Silva , da Silva Pitombeira Maria Helena
Published: January 2025

Background

Carbapenem resistance is a fearsome reality, especially in transplant patients, and urinary tract infections may cause severe illness and graft loss.

Methods

In this 10-year retrospective cohort we analyzed kidney transplanted patients with gram-negative carbapenem-resistant urinary tract infection (UTI). We evaluated overall prevalence, risk factors for 14-day clinical response and development of acute kidney injury or graft loss during infection. Patients ≥ 18 years old with symptomatic infections or loss of renal function attributed to UTI were included. We excluded patients with kidney abscesses or intra-abdominal complications, death within 24 h, non-active antimicrobial treatment.

Results

From urocultures collected from 2013 – 2023, 11.583 isolated gram-negative bacteria, of which 14.2% were carbapenem resistant. From these, 87 patients were included. 72.4% were male, aged 56.9 ± 13.6 years old and median transplant time was 15.8 (2 - 89.6) months; 83.9% had upper UTI. The most prevalent bacteria was Klebsiella pneumoniae, with 75 samples (86.2%). 41 (47.1%) were carbapenemase producers: 29.8% serino and 18.3% metallo-beta lactamases. Patients were treated with: amikacin (58.6%) polymyxin B (47.1%), polymyxin E (32.2%), tigecycline (5.7%) ceftazidime-avibactam (8.0%). In 46.0% of the cases, these drugs were combined. 82.8% had complete resolution of symptoms and negative follow-up urine cultures in 14 days. Independent risk factors for non-response were baseline hemodynamic instability (p< 0.01) and polymyxin B treatment (p< 0.01). Control urocultures were collected from 79 (90.8%); 15 (18.9%) had the same bacteria. Sixty-eight patients (79.1%) who were not in dialysis at baseline were evaluated for AKI,from which 45 (66.1%) developed AKI during therapy and 8 (11.7%) had renal graft loss. 12 (13.8%) patients died in 30-days.

Conclusion

Carbapenem resistant bacteria are increasingly prevalent in renal transplant patients and associated to AKI and graft loss potentially due to the use of nephrotoxic drugs. Polymyxin B and hemodynamic instability were independent preditors non-clinical response in 14-days, which should be further evaluated due to the non-urinary concentration of this antibiotic.

Disclosures

All Authors: No reported disclosures
P-1569. Healthcare Disparities Between Racial, Ethnic, and Socioeconomic Backgrounds in Urinary Tract Infection Patients
Authors: Moazamian Ryan J , Amundson Ashley , Fraimow Henry S , Palacios Carlo Foppiano
Published: January 2025

Background

Numerous studies have highlighted persistent health disparities: chronic disease rates, access to care, and outcomes across diverse races, ethnicities, and socioeconomic backgrounds. To address underlying healthcare disparities, we explored differences in outcomes of patients with urinary tract infections (UTIs).Table 1Results of Statistical Analysis

Methods

Patients treated at Cooper University Hospital for UTI between 2019 and 2021 were identified using ICD codes. Inclusion criteria was age over 18, inpatient admissions longer than 48 hours, and diagnosis of UTI. Patient demographics, culture results, treatment, discharge outcomes, and outcomes at 30 and 90 days. Additionally, we collected individual indicators of socioeconomic status, including census tract data associated with American Community Survey, Area Deprivation Index (ADI: ranked on a scale 1 to 10, with 10 being most disadvantaged), and Social Vulnerability Index (SVI: ranked on a scale of 0 to 1, with 1 being most vulnerable). Descriptive statistics, Chi-square, and Kruskal-Wallis tests were performed.

Results

495 patients with UTI were analyzed: mean age was 67±19 years, 54% were White, and 20% were Latino. Social Mean state ADI was 8.7±2.0, and mean CDC SVI was 0.63±0.24. Social determinants of health were common among patients with UTI: 60% did not have independent level of function, 19% lived alone, 18% had prior mental health history, 14% did not speak English, 8% had history of substance abuse, 2% had housing insecurity. Statistical analysis showed no meaningful difference in patient outcomes for hospital mortality or mortality at 30- or 60-days post discharge. Readmission at 30 or 60 days was associated with census tract median household income, household income less than 10 thousand dollars, per capita income, education with bachelor’s degree, taking public transportation, not having a car, unemployment, and Medicaid coverage (Table 1).

Conclusion

We found no differences in mortality outcomes among patients with UTI across various socioeconomic parameters within our institution. However, hospital readmissions were more likely among patients who lived in census tracts with increased hardships. Future studies should evaluate possible interventions to decrease readmission disparities.

Disclosures

All Authors: No reported disclosures
P-1577. Healthcare utilization, antibiotic spectrum index, and outcomes associated with complicated urinary tract infections in the United States
Authors: Advani Sonali , Zhang Helen L , Ohnuma Tetsu , Spellman Alexandria A , Raghunathan Karthik , Krishnamoorthy Vijay , Anderson Deverick J , Schmader Kenneth , Scales Charles
Published: January 2025

Background

Despite a recent increase in the burden of complicated urinary tract infections (cUTI), contemporary data on healthcare utilization, outcomes and antimicrobial use related to cUTIs are lacking. We describe healthcare utilization, inpatient antibiotic use, and mortality associated with cUTI across a nationwide US hospital network.

Methods

This cohort study included inpatients aged ≥18 years with cUTI (using ICD-10 diagnostic codes) from 240 hospitals in the Premier Healthcare Claims Database between January 2016 – June 2020. Demographics, clinical characteristics, antibiotic use, and healthcare utilization measures were evaluated. In addition to antibiotic days of therapy, we calculated daily average Antibiotic Spectrum Index (ASI) which measures the spectrum of antimicrobial action based on number of organisms susceptible to that drug (total = 14 organism categories, e.g. ASI of penicillin is 2 while meropenem is 10, validated by Gerber et. al, PMID: 28560946). Primary outcome of inpatient mortality was assessed in a multivariable logistic regression model.

Results

In this cohort of 16,011 inpatients with cUTI, median age was 67 years (IQR 54- 77], 52.6% (N=8419) were female and 76.1% (N=12181) were white (Table 1). Over two thirds of patients with cUTI required intensive care unit care, while over 25% were bacteremic and required vasopressors. Median duration of antimicrobial therapy was 11 days [IQR: 7, 18] and median daily ASI was 10.40 [IQR: 7.80, 13.87]. Inpatient mortality was 6.4% and 30 day readmission rates were 17.7%. On multivariable analysis, significant risk factors for inpatient mortality in patients with cUTI included increasing age, with highest risk over 80 years of age (adjusted odds ratio (aOR) 3.25 (2.50 - 4.23); higher Charleston’s comorbidity index (aOR 1.05 (1.04 - 1.06)); admission from skilled nursing facility (aOR 1.39 (1.11 - 1.76) and higher ASI (aOR 1.05 (1.04 - 1.05, Table 2)).

Conclusion

In our cohort of 240 US hospitals, older adults and men experienced more than half of inpatient cUTIs. A large proportion of cUTIs were associated with high severity of illness requiring higher acuity of care. Older age, more comorbidities, and higher ASI were associated with increased mortality in patients with cUTI.

Disclosures

Sonali Advani, MBBS, MPH, FIDSA, Biomerieux: Advisor/Consultant|GSK: Advisor/Consultant|Locus Biosciences: Advisor/Consultant|Sysmex America: Advisor/Consultant Charles Scales, MD MSHS, BMS: Grant/Research Support|Exelixis: Grant/Research Support|Flume Catheter: Grant/Research Support|Lilac Therapeutics: Advisor/Consultant|Merck: Grant/Research Support|Pfizer: Grant/Research Support
P-1578. Impact of a Pharmacist-Driven Carbapenem De-escalation Algorithm for Hospitalized Patients with Urinary Tract Infections
Authors: Gauthier Timothy , Diaz Susana , Williams Kelsey , Dittmar Erika , Cua Jefferson
Published: January 2025

Background

This study aims to assess the impact of a pharmacist-driven carbapenem de-escalation algorithm on the use of antibiotics in hospitalized patients with urinary tract infections (UTIs).

Carbapenem De-escalation Algorithm

Methods

This was a single-center, retrospective chart review of patients who received carbapenems with a diagnosis of UTIs before (phase I, Aug – Nov 2022) and after (phase II, Dec 2022 – Mar 2023) implementation of a pharmacist-driven carbapenem de-escalation algorithm. Pharmacists made recommendations based on the algorithm but changes to therapy was at the discretion of the ordering provider. Patients aged ≥ 18 years who were receiving carbapenems for the treatment of UTI without concomitant bacteremia were included. Patients who received carbapenems for other indications, had a urinary stent, had abnormal genitourinary anatomy, or presented with renal calculi were excluded. The primary outcome was the percentage of qualifying patients who were de-escalated from carbapenem to non-carbapenem agent before and after the implementation of the algorithm.

Baseline Characteristics

Results

During phase I, 40 of 60 (67%) patients were found eligible for de-escalation based on the algorithm, while 37 of 60 (62%) were eligible during phase II. Table 1 shows demographic data and baseline characteristics. De-escalation occurred in 27 (68%) versus 33 (90%) (95%Cl 0.03 - 0.38) during phase I and II, respectively. De-escalation was attributed to the intervention in 15 (41%) of the phase II group, with a recommendation acceptance rate of 79%. Approximately 35 minutes of pharmacist daily workload was allocated to review and intervene as appropriate. Median duration of carbapenem therapy pre and post intervention was 72 versus 58 hours (p=0.4237) respectively. Median duration of antibiotic therapy in phase I was 7 days, while in phase II it was 6.7 days (p=0.6745).

Results

Conclusion

Intervention guided by a pharmacist-driven carbapenem de-escalation algorithm for patients with UTI can expedite carbapenem de-escalation without significantly impacting duration of antibiotic therapy and hospital length of stay.

Disclosures

Timothy Gauthier, PharmD, BCPS, BCIDP, AbbVie Pharma: Advisor/Consultant|Antimicrobial Therapy, Inc: Advisor/Consultant|Ferring Pharma: Advisor/Consultant|Firstline Mobile Health: Advisor/Consultant|Gilead Pharma: Advisor/Consultant|GoodRx: Advisor/Consultant|GSK Pharma: Advisor/Consultant|Melinta Pharma: Advisor/Consultant|Pattern Biosciences: Advisor/Consultant|Pfizer Pharma: Advisor/Consultant|ProCE: Honoraria|WWW.LearnAntibiotics.com: Ownership Interest
P-1580. Evaluation of Shorter Versus Longer Antifungal Treatment Durations for Candida Urinary Tract Infections
Authors: Kufel Wesley D , Govel Jacob C , Seabury Robert , Gutierrez Ramiro , Asiago-Reddy Elizabeth
Published: January 2025

Background

Infectious Diseases Society of America guidelines recommend 14 days of antifungal therapy for Candida urinary tract infections (UTIs). For bacterial UTIs, studies have demonstrated that shorter antibiotic durations have comparable outcomes to longer durations. To our knowledge, there are no data to compare shorter (7 days) versus longer (14 days) antifungal durations for Candida UTI.

Methods

This was a single-center, retrospective cohort study between 1/1/15 and 1/1/24 at a 752-bed academic medical center. Inclusion criteria were hospitalized adults with >1 urine culture with Candida spp. and symptoms (dysuria, increased frequency/urgency, hematuria, costovertebral angle tenderness, and/or fever) who received >1 antifungal dose within 96 hours of index culture (IC). Patients were excluded if Candida spp. were isolated from another culture site, received antifungals for a suspected non-UTI, or did not have any UTI symptoms. The primary outcome was to compare symptom resolution between shorter versus longer antifungal durations. Secondary outcomes included hospital readmission due to Candida UTI, candiduria recurrence, and all-cause mortality within 90 days of IC. Categorical and continuous variables were compared using Chi-square/Fisher exact test and the Mann-Whitney U test, respectively.

Results

There were 2399 patient encounters with candiduria screened. After inclusion and exclusion criteria were applied, 103 patients were included for analysis with 45 and 58 in the >14 day and < 14-day cohorts, respectively. No significant differences were identified between cohorts in demographics, urologic procedures, urinary devices, nephrolithiasis, vasopressor use, mechanical ventilation, or hospital length of stay. ID consultation occurred in 60% and 62.1% of the >14 day and < 14-day cohorts, respectively, and all recommended antifungal treatment. Median (IQR) fluconazole duration was 14 days (14-14) and 7 days (5-7). No significant differences were identified in the primary and secondary outcomes (Table 1).

Conclusion

No significant differences in treatment outcomes were identified between patients who received a median of 7 days versus 14 days of fluconazole for Candida UTI supporting shorter antifungal durations.

Disclosures

Wesley D. Kufel, Pharm.D., BCPS, BCIDP, Merck & Co.: Grant/Research Support|Shionogi, Inc: Grant/Research Support Elizabeth Asiago-Reddy, MD, Abbvie: Grant/Research Support|GSK/Viiv: Grant/Research Support|Pfizer: Grant/Research Support|Theratechnologies, Inc.: Grant/Research Support
P-1585. The Impact of MRSA Nasal PCR on Antibiotic De-escalation
Authors: Silverman Adam , Gautam-Goyal Pranisha , Gandhi Shivanthidevi , Oppenheim Michael , Ramirez Guillermo , Karkenny Gabriel , Sohail Rubab
Published: January 2025

Background

The MRSA nasal PCR is a screening tool that may help decrease the use of antimicrobials. The MRSA PCR as a screening test has shown a high negative predictive value associated with various infections - including pneumonia, intra-abdominal infections, wounds, and bacteremia. Despite this, MRSA PCR has been under-utilized for the purposes of deescalating antibiotics targeting MRSA.

Odds Ratios

Methods

This was a retrospective, observational, single-center cohort study within the Northwell Health system, approved by the Institutional Review Board. Data was collected from the electronic medical record between January 1, 2020, to December 1, 2021. We included adults admitted for inpatient care who had a MRSA PCR performed during the admission and were receiving antimicrobial therapy directed at treating MRSA. Clinical and demographic data were collected, in addition to the type of anti-MRSA therapy the patient was receiving, date the MRSA PCR resulted, date the anti-MRSA therapy was discontinued, and total days of anti-MRSA therapy. The primary objective was to determine if a negative MRSA PCR led to the discontinuation of anti-MRSA therapy within 48 hours of the result. Secondary objectives included the total days of anti-MRSA therapy, acute kidney injury (AKI) as discharge diagnosis, and hospital length of stay (LOS).

Results

Of the 5,047 patients included for analysis, 89% (n = 4505) had a negative MRSA PCR result. The odds of anti-MRSA therapy discontinuation were 264% greater among subjects with a negative PCR compared to subjects with a positive PCR result (OR: 3.64, 95% CI: 3.03 – 4.37, p< 0.0001). After adjusting for covariates, this observation remained statistically significant, with the odds of anti-MRSA therapy discontinuation being 274% greater among subjects with a negative PCR compared to subjects with a positive PCR result (OR: 3.74, 95% CI: 3.04 – 4.59, p< 0.0001).

Conclusion

A negative MRSA PCR result was significantly associated with anti-MRSA therapy discontinuation within 48 hours, both before and after adjusting for covariates. MRSA PCR is being increasingly recognized as a powerful antimicrobial stewardship tool and should continue to be utilized to help guide clinical decision making.

Disclosures

All Authors: No reported disclosures
P-1589. Characterization of Blood Culture Ordering Practices at a Single Veterans Affair Medical Center
Authors: Stegall Cassidy J , Dao Tina H , Liang Nicholas , Bowden Jarred , Mitchell Anna , Yn Louis , Zhang Peter , Bennett Jessica G
Published: January 2025

Background

Blood culture (BCx) is the gold standard for definitive diagnosis of bacteremia and fungemia, but there is limited guidance for ordering practices. Unnecessary BCx increases the risk of false positives which can lead to increased length of stay, antibiotic use (AU), and additional testing. Diagnostic stewardship aims to optimize the use of diagnostic tests to improve patient management and outcomes. This study aimed to describe the current practice of BCx ordering at a single facility and identify areas for intervention.

Methods

This was a retrospective review of BCx ordered from 11/01/23 to 12/31/23. BCx were excluded if there was no encounter 5 days before or 2 days after BCx collection or initial BCx were drawn at another facility. Labs, vitals, BCx order date/time, ordering provider, location and results, AU and antibiotic indication were extracted from the Corporate Data Warehouse. Indications for BCx and endovascular infection risk were determined via chart review. Appropriateness of BCx was determined by an algorithm denoting low, intermediate, or high risk of bacteremia associated with an infectious disease state (Figure 1). Intermediate and high risk were deemed appropriate. Endpoints were analyzed with descriptive statistics.

Results

243 BCx were evaluated and 215 were analyzed. 156/215 (73%) were ordered in the Emergency Department (ED) (Table 1). 113/215 (53%) of BCx were appropriate with the most common indications including sepsis, intra-abdominal infection, and severe community acquired pneumonia (CAP) (Table 2). The rate of appropriateness was similar across clinical departments (Figure 2). For inappropriate BCx, 41 had no suspected infection documented, and CAP, cellulitis, and cystitis were the most documented indications (Table 2). 17/215 (8%) of BCx were positive, 6/102 in low risk, and 11/113 in intermediate/high risk group. 4/6 in the low risk were identified as contaminants.

Conclusion

This study found ∼50% of BCx were ordered unnecessarily, and there was both low positivity rate and false positives in this group reflecting current literature. Similar BCx ordering practices were identified across services. These findings highlight the need for intervention system wide to promote strong diagnostic stewardship and appropriate BCx ordering practices.

Disclosures

All Authors: No reported disclosures
581. Enhancing Diversity, Equity, Inclusion, Access, and Justice (DEIAJ) Teaching in Infectious Diseases: Current State and Future Directions in Faculty Development
Authors: Nielsen Hailee , Abdoler Emily
Published: January 2025

Background

Infectious Diseases (ID) clinicians occupy a unique position at the interface of clinical medicine and social justice. Medical education in ID therefore presents a rich opportunity for trainees to cultivate critical consciousness in Diversity, Equity, Inclusion, Access, and Justice (DEIAJ). Research has focused on improving DEIAJ education for ID fellows and attendings (Gleeson et al., 2023, Vasishta et al., 2023 ), but little is known about ID faculty members’ perceptions of DEIAJ teaching. We aim to explore ID faculty members’ attitudes and experiences discussing DEIAJ topics when teaching clinically.

Methods

Clinical ID attendings at the University of Michigan were invited to complete an anonymous survey. Open-ended questions assessed which ID-related DEIAJ topics faculty members believe are most important for students to learn. Likert-style questions evaluated comfort and preparedness regarding DEIAJ teaching, while multiple choice questions explored barriers to covering this content and faculty development preferences.

Results

Survey response rate was 81% (22/27), with a 63% completion rate. Faculty comfort with DEIAJ teaching was high, while reported preparedness was only moderate (Figures 1, 2). Common perceived barriers to DEIAJ teaching were lack of facilitation skills (50%) and fear of trainee criticism (42%). Preferred modes for faculty development were DEIAJ integration in conferences (85%), facilitation training (57%), and access to DEIAJ teaching cases (50%). Respondents identified common and important DEIAJ teaching topics that arise in ID clinical practice (Figure 3).

Conclusion

This single-institution study reveals that ID attendings are comfortable addressing DEIAJ topics in their clinical teaching despite not feeling optimally prepared. Identifying this comfort-preparation gap in our division, as well as preferred faculty development modalities and prioritized DEIAJ topics within ID, is the first step in creating integrated professional development opportunities that capitalize on faculty members’ dedication to DEIAJ teaching. Exploration of this issue on a national scale could support development of a customizable professional development toolkit for the broader ID community.

Disclosures

All Authors: No reported disclosures
P-1596. Procalcitonin: A Promising Tool in Post COVID-19 Antibiotic Prescribing at a Community Teaching Hospital
Authors: Nothdurft Elizabeth , Philip Nirmol , Giblin Brenden
Published: January 2025

Background

A rise in antibiotic use was universally observed during the COVID-19 pandemic. Use of procalcitonin (PCT) in understanding the bacterial burden of disease both in the context of COVID-19 and other infections continues to be associated with much debate. Our hospital saw a precipitous rise in antimicrobial use during COVID-19, despite ongoing efforts of antimicrobial stewardship. We looked to PCT to help curb antibiotic overprescribing following the COVID-19 pandemic.

Hospital wide SAAR

Methods

This was a single-center, before and after study to evaluate the impact of PCT implementation at a 500-bed community teaching hospital on antimicrobial usage. Education was provided to all providers before and during PCT implementation. A lab order was added to the existing sepsis clinical pathway and a pocket card detailing the appropriate use of PCT for approved indications (lower respiratory tract infections and sepsis) was provided to clinicians.

For the primary outcome, we evaluated the standardized antimicrobial administration ratio (SAAR) before and after PCT implementation. Secondary outcomes included antibiotic consumption as described by days of therapy (DOT) per 1000 days present (DP), change in antimicrobial cost, appropriateness of testing and adherence to the PCT prescribing algorithm included in the pocket guide.

ICU SAAR

Results

Since becoming available at our hospital, PCT has been ordered on average 583 times per month. On average, monthly SAARs were 8.4% lower during post-PCT period (1.06 vs 0.98; p=0.0011) (Figure 1). A decline was observed in both intensive care units (ICU) as well as non-ICU inpatient wards (Figure 2, 3). Total antimicrobial utilization decreased by 8.5% (550 vs 503 DOT/1000 DP), which translated to a 19.3% reduction in antimicrobial spending. Appropriateness of the initial PCT testing was 74% and appropriate discontinuation of antibiotics based on PCT algorithm was 80% during 18-months of PCT use.

Non-ICU SAAR

Conclusion

Our findings suggest that appropriate use of PCT added to antimicrobial stewardship can be a valuable tool in both ICU and non-ICU settings.

Disclosures

Elizabeth Nothdurft, PharmD, BCPS, BCIDP, Abbvie: Honoraria Nirmol Philip, MD, MPH, Nestle: Honoraria
P-1599. Evaluating the Impact of Pneumococcal Urinary Antigen on Antibiotic Prescribing in an Urban Safety Net Health System
Authors: Bhatia Mehak , Kim Paul , Inampudi Jyothik , Shapoo Mazhar , Scipione Marco R , Dhar Sorabh , Monday Lea
Published: January 2025

Background

Pneumococcal urinary antigen (UAg) testing is for certain high-risk community acquired pneumonia (CAP) patients. Prior studies evaluating antibiotic de-escalation practices in patients with positive UAg are mixed1,2.

Methods

We performed a retrospective cohort study of adult patients admitted with CAP who had a UAg test result over a 2-month period. Patients with an alternative diagnosis or with risk factors for healthcare associated infections that would impact de-escalation were excluded (Fig1). Patients with and without a positive UAg test result were compared. Rates of empiric versus final antibiotic prescribing and duration of empiric coverage for Pseudomonas and Methicillin-resistant Staphylococcus aureus (MRSA), were recorded. Primary outcome was whether UAg positivity impacted antibiotic de-escalation practices.

Results

268 CAP patients were included in the analysis (235 UAg negative and 33 UAg positive). Cohorts were evenly matched in terms of illness severity, comorbidities, and readmission rates (Table 1). Empiric coverage for Pseudomonas and MRSA was above 40% in both cohorts. Patients started on empiric azithromycin, doxycycline, vancomycin, cefepime, or any anti-pseudomonal ß-lactam were often de-escalated, regardless of whether UAg was positive or negative (P< 0.05 in both cohorts) (Fig2). Empiric quinolones were more often de-escalated in UAg positive patients, though sample size was small (P=0.021). Definitive use of a narrow spectrum penicillin (PCN) or ß-lactam was low, even in UAg positive patients (Fig2). Duration of empiric anti-pseudomonal use was lower in UAg positive versus negative patients (median 2.5 versus 5 days, respectively)( P=0.0391). Shorter empiric Anti-MRSA durations were also seen in UAg positive patients (median 1 versus 4 days, respectively) (P=0.0201).

Conclusion

Patients treated for CAP in an urban safety net hospital often had their empiric antibiotics de-escalated regardless of pneumococcal UAg result. However, positive UAg likely facilitated sooner discontinuation of anti-MRSA and anti-Pseudomonal coverage since median durations were lower in this group. Efforts to increase use of a narrow spectrum PCN or ß-lactam in such patients are an opportunity for future stewardship interventions.

Disclosures

All Authors: No reported disclosures
P-1618. Real-world Evaluation of Multiplex Pneumonia Panel Performance and its impact on Antibiotic Utilization
Authors: Swaminathan Neeraja , Imlay Hannah , Earl Ali , Fong Karen , Spivak Emily S
Published: January 2025

Background

Gaps exist in understanding how molecular syndromic testing aligns with culture-based diagnostics and if clinicians use this information to optimize antimicrobial use. The Biofire FilmArray® Pneumonia panel (PN-panel) includes 15 bacterial, 3 atypical, and 8 viral targets as well as antimicrobial resistance genes. We assessed performance and utilization of this panel in the absence of antimicrobial stewardship program (ASP) oversight post-implementation.Figure 1Antibiotic de-escalation criteria

Methods

We audited 79 specimens (49 bronchoalveolar lavage & 30 endotracheal aspirates) from 67 patients (August 1, 2023, to November 30, 2023). Demographics, pneumonia panel testing, and concurrent respiratory culture results were recorded. Concordance between PN-panel and culture was defined as identical organisms or dominant organism matching. Instances where culture showed normal oral flora/no growth while PN-panel was negative were also considered concordant. We categorized pre- and post- PN-panel antibiotic selection as escalation, no change, or degrees of de-escalation (defined in Figure 1). De-escalation was evaluated between three infectious disease clinicians to reach consensus.Figure 2Performance of PN-panel compared to culture-based diagnostics

Results

The mean age was 57 years, with 67% male and 34% female. PN-panel testing was positive in 30/79 patients including 11 polymicrobial specimens, 5 with viral targets and 5 with resistance gene detections. 20.3% (16/79) of specimens had positive cultures. Concordance of PN-panel and culture results was 86.1% (68/79) with PN-panel demonstrating a PPV of 53.3% and an NPV of 100% (Figure 2). Analysis of antibiotic prescribing post- PN-panel was done separately for immunocompromised and non-immunocompromised cohorts (Table 1), revealing significant opportunity for de-escalation in both groups, particularly prominent in the non-immunocompromised subset. Even after exclusion of patients with other microbiologically confirmed infections, only 41.6% of eligible non-immunocompromised patients de-escalated antibiotics.Table 1Analysis of post PN-panel Antibiotic prescribing

Conclusion

Despite the PN-panel’s high sensitivity and NPV, antibiotic de-escalation occurred only in a minority of patients. Collaboration with ASP teams is likely to enhance its clinical utility by guiding result interpretation and antibiotic management.

Disclosures

All Authors: No reported disclosures
P-1629. Reduction in Clostridioides difficile Over-diagnosis Following Suppression of C. difficile Target from Multiplex Molecular Stool Assay in a Pediatric Healthcare System
Authors: Most Zachary M , Sceeles Kayla , Filkins Laura , Kidd Mehgan
Published: January 2025

Background

Clostridioides difficile testing by polymerase chain reaction (PCR) does not differentiate asymptomatic colonization from infection, and children are frequently colonized with toxigenic strains of C. difficile. Over-diagnosis of C. difficile infections can lead to adverse patient outcomes and poorer quality metrics for hospitals.Figure 1:C. difficile PCR orders following change in GI PCR Panel, Interrupted Time Series

Methods

In January 2023 our pediatric health system enacted multimodal changes to the electronic ordering of stool tests for C. difficile and other gastrointestinal pathogens. A multiplex PCR test for stool was updated to suppress testing for toxigenic C. difficile. The only remaining method to test for C. difficile by PCR in house was a C. difficile toxin gene specific PCR. Additionally, appropriate clinical criteria with a hard stop were added to the C. difficile PCR order (all of: no laxatives in the past 24 hours, at least 3 liquid stools in the past 24 hours, at least one risk factor for C. difficile infection, and patient at least one year old). If providers still sought C. difficile testing without meeting these criteria, infectious disease specialist approval was required. We analyzed the effect of this intervention using interrupted time series analysis and pre-post aggregate rates from January 2019 through February 2024.Figure 2:C. difficile positive rate following change in GI PCR Panel, Interrupted Time Series

Results

There were 4426 stool PCR tests performed for C. difficile in the pre-intervention period and 622 in the post-intervention period. The mean (± sd) age of those tested was 7.8 years (± 6.1 years). After the intervention, there was an immediate 61% decrease in C. difficile testing incidence (95% CI [53% - 67%], Figure 1) and 51% decrease in C. difficile diagnosis incidence (95% CI [26% - 67%], Figure 2). There was no significant immediate change or change in slope in the C. difficile antibiotic treatment incidence or HFO C. difficile incidence, but there was a trend towards lower rates of healthcare facility onset C. difficile after the change (aggregate rate 4.13 per 10,000 non-NICU patient-days prior to intervention vs. 3.39 after, P = .28).

Conclusion

Removing C. difficile from multiplex PCR assays and adding required clinical criteria to the electronic order reduces the number of C. difficile tests and diagnoses in a pediatric health system.

Disclosures

Laura Filkins, PhD, Avsana Labs: Board Member|Avsana Labs: Stocks/Bonds (Private Company)|Biofire Diagnostics: Grant/Research Support
P-1631. Implementing an Effective Antibiotic Prescribing Feedback Intervention in a Large Primary Care Network with Emphasis on Bacterial Sinusitis
Authors: Pomakov Alexander , Venci Jineane V , Lopa Samia H , Fortuna Robert J , Yamshchikov Alexandra
Published: January 2025

Background

Education and feedback interventions are a key aspect of antibiotic stewardship in outpatient settings. We examined effectiveness of an antibiotic prescribing feedback intervention in a large primary care network with emphasis on bacterial sinusitis.Figure 1.Letter Template for Prescribing and Benchmarking Feedback to Primary Care Network Providers

Methods

We examined prescriptions written by 237 network primary care clinicians between 9/1 -11/31/2022 (baseline n=23048) and 12/1/2023 -2/29/2024 (post intervention n=18885). Feedback was given via individualized letters (Fig 1) comparing providers’ antibiotic prescribing rates and guideline concordant prescribing for sinusitis against network peers and national data. Guideline concordance was defined from local antibiograms and national guidelines. Primary outcomes were rate of antibiotic prescriptions and percentage of guideline concordant sinusitis prescriptions. Data were analyzed in GraphPad and SAS v9.4 with generalized linear mixed model to account for correlation between repeated provider data.Table 1.Rates of Antibiotic Prescriptions by Provider Designation Before and After Feedback Intervention

Results

Average rates of antibiotic prescriptions before and after intervention were 13.9 and 13.4/100 visits, a 0.5% absolute reduction and 4.0% relative reduction (p = 0.13). Among providers with baseline >1 standard deviation (SD) antibiotic utilization, average prescribing decreased from 27.7 to 19.7/100 visits (p=0.0002), with increase among those with lowest (> 1 SD) utilization, 5.3 to 7.16/100 visits (p = 0.0048). Physicians’ rates remained lower than non-physician providers (p< 0.0001), and reduction post intervention was similar in both provider groups (p = 0.87, Table 1). Bacterial sinusitis remained most common antibiotic indication (Fig 2). Guideline concordant sinusitis prescriptions pre and post intervention were 69.7% and 83.2% respectively, a 13.5% absolute increase and 19% relative increase (p = < 0.0001) Degree of increase did not differ by provider group (p = 0.76). Antibiotic distribution shifted away from azithromycin, with increases in amoxicillin and doxycycline (Fig 3).Figure 2.Most Common Indications for Prescribing Antibiotics within URMC Primary Care Network Before and After Feedback Intervention

Conclusion

A prescription feedback intervention in a large primary care network reduced antibiotic prescription rates and non-guideline concordant prescriptions for bacterial sinusitis. The impact of the intervention was most pronounced in prescribers with highest antibiotics utilization pre-intervention.Figure 3.Characterization of Most Common Antibiotics Prescribed by PCN Providers Before and After Feedback Intervention

Disclosures

All Authors: No reported disclosures
585. Effects of Legislation Restricting Reproductive and LGBT+ Rights on Infectious Disease Fellowship Match Rates
Authors: Chen Michael Z , Hutchison Alan L , Hazra Aniruddha , Czapar Anna
Published: January 2025

Background

Over the last decade, infectious disease (ID) fellowship match rates have declined despite increasing workforce need. Many factors may influence rates, including effects of local political climate. Since 2022, many states have restricted reproductive and/or LGBT+ rights. As 43% of ID physicians identified as women in 2021 (AMA) and 6% of graduating medical students entering medicine residencies identified as lesbian, gay, or bisexual from 2016-2019 (Mori, 2021), there is a need to examine impact of local politics on match rates.Table 1.Match Rates of Programs in States with and without Restrictions on Reproductive and LGBT+ Rights

Methods

Match rates for ID fellowship programs from 2019-2024 were tabulated by state based on publicly available NRMP data. States were categorized as reproductively-restrictive if they enacted laws limiting abortion and/or LGBT+ restrictive if they enacted laws limiting gender expression, LGBT+ healthcare or curriculum after 2022 based on reporting from the NYTimes and the Trevor Project. States without any laws were categorized as permissive. Differences in match rates in states with both restrictions, one restriction, or no restrictions were compared using two-sample z-tests of proportion.

Results

From 2019-2024, overall ID fellowship match rates declined from 81% to 68%, but permissive states (n = 121) consistently had higher match rates than restrictive states (n = 76) (Table 1). Match rates were significantly higher in LGBT-permissive states than restrictive ones in 2021 (p = .034) (Fig 1), in reproductively-permissive states than restrictive ones from 2021-2023 (p = .022, .015, .014) (Fig 2), and in states without any restrictions than states with both restrictions from 2021-2023 (p = .032, .025, .017) (Fig 3). There were no significant differences in match rates when comparing programs based on restrictions in 2019, 2020, and 2024.

Conclusion

Significant differences in match rates from 2021-2023 between programs in states with and without restrictions of rights suggests that political climate may have a measurable impact. However, all match rates converged at their lowest in 2024 regardless of program location. This may indicate a basal match rate across states, and political climate may influence match rates above this level. Longitudinal study of application volumes and match rates and surveys to assess applicant attitudes are warranted.

Disclosures

Aniruddha Hazra, MD, Gilead Sciences: Advisor/Consultant|Gilead Sciences: Grant/Research Support|ViiV Healthcare: Advisor/Consultant
P-1636. Real World Outpatient Utilization of Novel Anti-MRSA Antimicrobials: Patterns in Prescribing and Cost of Oral and Long-Acting Injectable Anti-MRSA Therapies in United States Medicaid Beneficiaries
Authors: O’Neil Jessica C , Lautenbach Ebbing
Published: January 2025

Background

Methicillin Resistant Staph Aureus (MRSA) isolates with resistance to traditional oral anti-MRSA antimicrobials represent a major public health concern. Since 2014, the United States (US) Food and Drug Administration (FDA) approved three oral (tedizolid [2014], delafloxacin [2017], omadacycline [2018]) and two long-acting injectable (LAI) antimicrobials (dalbavancin [2014], oritavancin [2014]) with potent activity against MRSA. Little has been reported about the real-world outpatient utilization and cost of these important therapies.

Methods

We conducted a retrospective analysis of utilization and cost of these 5 antimicrobials between January 1st, 2014 and December 31st, 2022 in the Medicaid State Drug Utilization Database (SDUD). The SDUD contains all covered outpatient medications excluding those reimbursed under bundled services and suppresses medication data for years with fewer than 11 prescriptions. Annual cost was calculated as the sum of Medicaid and non-Medicaid reimbursement. We approximated the annual per prescription cost (APPC) as the quotient of total cost and prescription count.

Results

Trends in utilization, total cost and APPC are depicted in Figures 1, 2 and 3 respectively. There was a 1–2-year lag between FDA approval and utilization. Dalbavancin utilization and cost rose from 13 prescriptions and $26,224 in 2014 to 4970 prescriptions and $16,403,304 in 2022, while oritavancin increased from 27 to 566 prescriptions and from $62,309 in $944,657costs. The dalbavancin APPC increased over the study period ending in 2022 at $3,300 while the oritavancin APPC declined to $1669 in 2022. Of the oral antimicrobials, tedizolid utilization and total cost peaked in 2019 at 755 prescriptions and $3,193,571, after which total cost and utilization fell to 283 prescriptions and $1,773,238 by 2022. Delafloxacin utilization and total cost remained low while omadacycline had an increasing trend in utilization, total cost and APPC in the three years it was included.

Conclusion

Utilization and total cost of dalbavancin rose substantially over the study dwarfing that of oritavancin and the novel oral antimicrobials by the latter half of the study period. Omadacycline, the newest approved antimicrobial included, demonstrated a prompt rise in utilization and total cost.

Disclosures

All Authors: No reported disclosures
P-1645. Appropriateness of Ambulatory Antibiotic Prescriptions Given Outside of Formal Patient-Clinician Encounters
Authors: Shively Nathan R , Carr Dustin R , Moffa Matthew A , BCHECH G E O R G E , Rothman Ryan , Appiah-Kubi Edmund , Barber Sophia , Kalu Vivian , Nagel James J , Bremmer Derek N , Buchanan Carley , Trienski Tamara , Zhu Shenjun , Walsh Thomas L
Published: January 2025

Background

There are limited published data on the frequency and appropriateness of outpatient antibiotic prescriptions ordered outside of formal patient-clinician encounters.

Methods

A random sample of oral antibiotics prescribed to adult patients from 4 primary care practices were manually reviewed for appropriateness. The need for any antibiotic, as well as the appropriateness of agent selection and duration, were compared between visit-based (formal in-person, video, or telephone encounters) and non-visit-based encounters.

Results

Of the 859 prescriptions reviewed, 543 (63.2%) were generated from visit-based encounters (48.2%, 13.2% and 1.9% were from in-person, video, and telephone visits, respectively) and 316 (36.8%) were non-visit-based. Overall, 29.7% of prescriptions were written despite no antibiotic indication (Table). Antibiotics were indicated in 382/543 (70.3%) of visit-based encounters, vs 165/316 (52.2%) of non-visit-based encounters (P< 0.0001). When an antibiotic was indicated, agent selection was more frequently appropriate in visit-based encounters (88.7% vs 81.8%, P=0.006), with no difference in appropriate duration (81.9% vs 89.7%, P=0.49). When duration was inappropriate, it was too long in 94.5% of cases. Among visit-based prescribing, antibiotic prescriptions were indicated more frequently from in-person encounters as compared to virtual (combined video and telephone) encounters (73.4% vs 60.5%, P=0.008). Compared to visit-based antibiotic prescriptions, significantly fewer non-visit-based antibiotic prescriptions were associated with any diagnosis code (543/543 (100%) vs 189/316 (59.8%), P< 0.0001). Azithromycin and fluoroquinolones were more likely to be inappropriately chosen agents compared to other antibiotics (46.7% vs 12.4%, P< 0.0001, and 45.5% vs 12.4%, P< 0.0001, respectively).

Conclusion

Compared to antibiotic prescriptions from formal patient-clinician encounters, antibiotic prescriptions generated from non-visit-based encounters were significantly less indicated, with less appropriate agent selection, and were frequently not associated with a diagnosis code. Outpatient stewardship efforts should target non-visit-based encounters.

Disclosures

Dustin R. Carr, PharmD, BCPS, BCIDP, Merck: Advisor/Consultant Derek N. Bremmer, PharmD, BCIDP, Thermo Fischer Scientific: Expert Testimony
P-1647. Prevalence of Unnecessary Antibiotic Prescribing for Acute Respiratory Illnesses in U.S. Outpatient Settings, 2022
Authors: Schwarze Tessa , McDonald Emily , Kim Christine , Kabbani Sarah , Hersh Adam , Hicks Lauri A
Published: January 2025

Background

Antibiotics are commonly prescribed for acute respiratory illnesses (ARIs) in outpatient settings, yet up to 50% of antibiotics prescribed for ARIs are unnecessary. We aimed to estimate the prevalence of outpatient antibiotic prescribing for ARIs with no clinical indication for antibiotics (“No Antibiotics Indicated ARIs” or “NAI-ARIs”) and compare it to previously published estimates.

Methods

Patients ages 0–64 years and ≥ 65 years with medical and prescription drug coverage were identified from Merative MarketScan commercial claims and Medicare Part B claims and Part D event files, respectively. We included outpatient visits in 2022 associated with a NAI-ARI diagnosis of asthma/allergy, bronchitis/bronchiolitis, COVID-19, influenza, non-suppurative otitis media, respiratory syncytial virus (RSV) or viral upper respiratory infection (URI). We calculated the visit rate per 1,000 patient-years and proportion of visits resulting in an oral antibiotic for each diagnosis stratified by age group and outpatient setting. The proportion of unnecessary prescribing for individuals ages < 65 years was compared to published proportions from 2011 and 2018; no comparable prior estimates are available for adults ages ≥ 65 years.

Results

The proportion of NAI-ARI visits resulting in an antibiotic was 18% for adults ages ≥ 65 years, 11% for adults ages 20–64 years, and 8% for children ages 0–19 years. The overall proportion of prescribing for individuals ages < 65 years was lower in 2022 compared to both 2011 and 2018 (Figure 1). Across all age groups, bronchitis/bronchiolitis had the highest proportion of visits with an antibiotic, while viral URI had the highest rate of visits with an antibiotic (Table 1). Urgent care settings had the highest proportion of visits with an antibiotic across outpatient settings, irrespective of age (Figure 2 and Figure 3).

Conclusion

Among patients ages < 65 years, the proportion of unnecessary antibiotic prescribing for NAI-ARIs declined over the past decade, possibly due to antibiotic stewardship activities. Continued efforts to improve outpatient antibiotic use should focus on viral URI, bronchitis/bronchiolitis, and emphasize reducing unnecessary prescribing in older adults and urgent care settings.

Disclosures

All Authors: No reported disclosures