bluuebunny/crossref_metadata_2025 huggingface dataset:
1353. Pediatric Urinary Tract Infections: A Choosing Wisely Initiative to Advance Antimicrobial Stewardship and Diagnostic Accuracy in the Emergency Department
Authors: Prodanuk Michael , Foong Yen , Singh Valene , Morrissey Laura , Science Michelle , Ostrow Olivia
Published: January 2021

Background

Urinary tract infection (UTI) is a common diagnosis in the pediatric emergency department (ED) that often results in empiric antibiotic treatment prior to culture results. A 2016 cohort study from our centre found that 47% of children diagnosed with a UTI and prescribed antibiotics had a negative urine culture. None of these patients were notified of the misdiagnosis or told to discontinue antibiotics.

Figure 1: Choosing Wisely pediatric urinary tract infection diagnostic algorithm

Figure 2: Patients included/excluded with exclusion criteria

Methods

Institutional approval was obtained for a quality improvement project in our quaternary pediatric ED. For uncomplicated pediatric UTIs, the aim was to reduce misdiagnosis by 50% and promote antimicrobial stewardship over a 24-month period. Using the Model for Improvement, two interventions were implemented using PDSA cycles: (1) a UTI diagnostic algorithm embedded in the electronic medical record, (2) a urine culture callback system. Outcome measures included the percentage of patients with UTI misdiagnosis (urine culture negative) and antibiotic-days saved. Process measures included adherence to the UTI algorithm and callback system as well as antibiotic duration standardization. As a balancing measure, patients developing positive urine cultures without UTI diagnosis were reviewed for potential harm.

Figure 3: Run chart of urinary tract infection misdiagnosis rate

Figure 4: Callback system - Percent patients contacted and antibiotics-days saved

Results

From June 2017-April 2020, 2,183 children (0.97% of all visits) were diagnosed with a UTI in the ED. 1,381 (63.3%) met inclusion criteria for analysis. Following UTI algorithm launch, median UTI misdiagnosis decreased by 20% (52.5% vs. 32.5%), median correct antibiotic duration increased by 30% (45.2% vs. 75.1%), and algorithm adherence was 78.9%. With implementation of the callback system, 1,678 antibiotic-days were saved as mean patients contacted to discontinue antibiotics increased from 0% to 76.8%. Of 106 patients with positive urine cultures with missed UTI diagnosis over a 29-month period, 8 patients returned to the ED within 72 hours and 2 patients required admission for intravenous antibiotics.

Conclusion

Implementation of a UTI diagnostic algorithm and urine culture callback system for uncomplicated pediatric UTIs reduced UTI misdiagnosis and promoted antimicrobial and resource stewardship in the ED. Future directions include improving UTI algorithm adherence through targeted clinician audit and feedback, plus sustainability planning.

Disclosures

Olivia Ostrow, MD, Choosing Wisely Canada (Advisor or Review Panel member)
1354. Reducing vancomycin utilization rate in a level 4 NICU
Authors: Chang Millie R , Mongkolrattanothai Kanokporn , Chin Steven , Li Yijie , Orbach Regina , Stach Leslie , Nair Srikumar , Milisavljevic Vladana
Published: January 2021

Background

Vancomycin is frequently used empirically in suspected sepsis in neonatal intensive care unit (NICU). However, inappropriate or unnecessary use can lead to additional morbidities and emergence of drug resistant pathogens. Standardization of vancomycin use is imperative for safer and more efficient patient care.

Methods

This study was part of a QI initiative to optimize vancomycin use by revising a standardized late onset sepsis (LOS) guideline with defined indications and criteria for empiric vancomycin. The implementation was started in 9/19 after completion of providers’ education. To reduce seasonal variations, 1/19-3/19 (pre-guideline) and 12/19-2/20 (post-implementation) data was retrospectively compared, including demographics, antibiotic indications, days of therapy/1000 patient days (AUR), positive cultures, isolated pathogens and resistance profiles. Clinical outcomes and adherence to the guideline were evaluated. Wilcoxon rank sum test was applied for continuous variables and Pearson chi-square test was applied for categorical variables. p< 0.05 was considered significant.

Results

There were 53 LOS antibiotic courses in 35 patients pre-guideline and 113 in 64 patients post-implementation. We found an overall increase in vancomycin AUR in the post-implementation period (66.92 vs. 70.72, respectively, p=0.79), however, largely due to appropriate use of vancomycin for documented infections with gram-positive pathogens (including CONS and MRSE). Mortality was not statistically significant between two periods (Table 1 and 2). Vancomycin was ordered significantly less empirically, as per guideline, in the post implementation period (71.43% vs 46.15%, p=0.02). Adherence to the LOS antibiotics guideline was 69%.

Table 1: Demographic characteristics of infants pre and post-guideline

Table 2: Therapy indication, medication exposure and clinical outcomes 30 days after LOS treatment pre and post-guideline

Conclusion

Development of a standardized guideline for empiric antibiotic therapy is important to reduce unnecessary and inappropriate use of vancomycin. We demonstrated that use of a guideline significantly decreased vancomycin ordering as an empiric antibiotic. Further analysis is needed in order to identify safety of the guideline’s criteria, factors contributing to unnecessary vancomycin use, as well as educational needs to ensure appropriate antibiotic use.

Disclosures

All Authors: No reported disclosures
1357. Urinary Symptom Management in Children with Neuropathic Bladder Presenting to the Emergency Department
Authors: Curley Tara , Forster Catherine , Pohl Hans G , Chamberlain James , Hamdy Rana F
Published: January 2021

Background

Children with neuropathic bladders are at high risk for developing urinary tract infections (UTIs). The accurate diagnosis of UTI is complicated by altered sensation and the ubiquity of bacterial colonization. As a result, overdiagnosis and overtreatment for presumed UTIs is common. The objective of this study is to estimate potential overdiagnosis and unnecessary antibiotic treatment in children with neuropathic bladder presenting to the Emergency Department (ED) with urinary symptoms.

Methods

Retrospective cohort study of patients with neuropathic bladder presenting to the Children’s National Hospital ED between October 2008 and December 2019. Chart review was used to determine presenting symptoms, urinary evaluation, and antibiotic treatment. We used the validated urinary symptoms questionnaire (USQNB-IC) to categorize ED visits as ‘evaluation warranted’ if the patient presented with at least one of the actionable symptoms on the USQNB-IC. We used the Spina Bifida Association’s (SBA) published definitions for UTI to determine which patients warranted presumptive antibiotic treatment.

Results

There were 211 visits by 82 patients (43% female), with a mean of 4.6 visits per patient (IQR 6). Mean age at ED visit was 5.2 years (SD 4.2 years). The most common presenting symptoms were fever (57%), emesis (32%), abdominal pain (24%), foul-smelling urine (11%), and cloudy urine (8%). Of the total visits, 122 (58%) had a urinary evaluation and 31% were treated with antibiotics. Sixteen ED visits (8%) resulted in a urinary evaluation that was not warranted. Of the 122 ED visits with urinary evaluation, 32 patients (26%) did not meet SBA criteria for UTI but were treated empirically with antibiotics.

Table 1: Urinary evaluation in children with neuropathic bladder seen in CNH ED between October 2008 and December 2019.

Table 2: UTI treatment in children with neuropathic bladder seen in CNH ED between October 2008 and December 2019.

Conclusion

Most children with neuropathic bladder presenting to the ED were appropriately evaluated and treated for presumed UTI. One-quarter of evaluated children received empiric antibiotics despite not meeting SBA criteria for UTI, indicating this may be a target for educational initiatives to promote antibiotic stewardship. Further research is needed to generate and validate clinical guidelines for emergency department providers to limit unnecessary testing and antibiotic therapy in this population.

Disclosures

All Authors: No reported disclosures
109. Impact of Accelerate PhenoTM System on Time to De-escalation of Antimicrobial Therapy
Authors: Powers Caroline , Moenster Ryan P , Linneman Travis W
Published: January 2021

Background

The Accelerate PhenoTM system yields identification (ID) and antimicrobial susceptibility testing (AST) within 7 hours of growth in blood culture. The objective of this study was to determine its impact on time to de-escalation of antimicrobial therapy.

Methods

This retrospective quasi-experimental, observational cohort study included patients hospitalized at the St. Louis VA who received intravenous antibiotics for a positive blood culture. Patients with blood cultures positive for polymicrobial growth or fungi or those requiring antibiotics for other infections were excluded. The primary endpoint was time to de-escalation of antimicrobial therapy from before and after implementation of Accelerate PhenoTM (September 2017 to August 2018 and September 2018 to August 2019, respectively). Secondary outcomes included time to ID and AST, length of hospital stay, and days of antimicrobial therapy. The variables of gram-positive infections, use of Accelerate PhenoTM, and presence of infectious diseases consult and/or pharmacist antimicrobial stewardship note were included in a univariate analysis. Variables with a p-value< 0.2 were included in a multivariate regression.

Results

168 patients were included, with 92 patients in the pre-implementation and 76 in the post-implementation group. Overall, mean age was 67 years and 162 (96%) were men. Staphylococcus spp. and Escherichia coli were the most common causative organisms. Time to de-escalation did not differ significantly between the post-implementation and pre-implementation groups (65 vs. 61 hours, p=0.47). Time to organism ID was decreased by 16 hours using Accelerate PhenoTM (50 vs. 66 hours, p=0.016). However, no difference was found in time to AST or length of hospital stay. Days of antimicrobial therapy while hospitalized was also similar between groups (6.8 vs. 5.9 days, p=0.256). Only gram-positive infections and presence of antimicrobial stewardship notes were included in the multivariate regression. Neither were independently associated with de-escalation within 48 hours.

Conclusion

Accelerate PhenoTM system did not impact time to de-escalation of antimicrobial therapy.

Disclosures

All Authors: No reported disclosures
1358. Using natural language processing to optimize case ascertainment of acute otitis media in a large, state-wide pediatric practice network
Authors: Herigon Joshua C , Kimia Amir , Harper Marvin
Published: January 2021

Background

Antibiotics are the most commonly prescribed drugs for children and frequently inappropriately prescribed. Outpatient antimicrobial stewardship interventions aim to reduce inappropriate antibiotic use. Previous work has relied on diagnosis coding for case identification which may be inaccurate. In this study, we sought to develop automated methods for analyzing note text to identify cases of acute otitis media (AOM) based on clinical documentation.

Methods

We conducted a cross-sectional retrospective chart review and sampled encounters from 7/1/2018 – 6/30/2019 for patients < 5 years old presenting for a problem-focused visit. Complete note text and limited structured data were extracted for 12 randomly selected weekdays (one from each month during the study period). An additional weekday was randomly selected for validation. The primary outcome was correctly identifying encounters where AOM was present. Human review was considered the “gold standard” and was compared to ICD codes, a natural language processing (NLP) model, and a recursive partitioning (RP) model.

Results

A total of 2,724 encounters were included in the training cohort and 793 in the validation cohort. ICD codes and NLP had good performance overall with sensitivity 91.2% and 93.1% respectively in the training cohort. However, NLP had a significant drop-off in performance in the validation cohort (sensitivity: 83.4%). The RP model had the highest sensitivity (97.2% training cohort; 94.1% validation cohort) out of the 3 methods.

Figure 1. Details of encounters included in the training and validation cohorts.

Table 1. Performance of ICD coding, a natural language processing (NLP) model, and a recursive partitioning (RP) model for identifying cases of acute otitis media (AOM)

Conclusion

Natural language processing of outpatient pediatric visit documentation can be used successfully to create models accurately identifying cases of AOM based on clinical documentation. Combining NLP and structured data can improve automated case detection, leading to more accurate assessment of antibiotic prescribing practices. These techniques may be valuable in optimizing outpatient antimicrobial stewardship efforts.

Disclosures

All Authors: No reported disclosures
1360. Variation in Duration of Antibiotic Therapy for Central-line Associated Blood Stream Infections Caused by Gram Negative Bacilli in Hospitalized Children
Authors: Whitmer Grant R , Scardina Tonya , Sun Shan , Zheng Xiaotian , Patel Sameer
Published: January 2021

Background

Central-line associated bloodstream infections (CLABSIs) are associated with increased morbidity, mortality, and duration of hospitalization in children. Existing guidelines recommend a broad range (7-14 days) for duration of antibiotic therapy. Unnecessarily prolonged therapy may be associated with emergence of antibiotic resistance and adverse events.

Methods

We performed a retrospective review of all patients diagnosed with CLABSIs caused by Gram negative bacilli (GNB) at our institution from August 2009 to April 2019. CLABSI was defined as isolation of a GNB from the blood >48 hours after hospital admission with presence of a central venous catheter. Children who died before completion of treatment were excluded. Data collection variables included severe neutropenia (defined as absolute neutrophil count < 500), immunocompromised status (defined as receipt of bone marrow transplant, solid organ transplant, or immunosuppressive medication), and catheter removal. The duration of effective antibiotic therapy was calculated from the date of last positive culture to discontinuation. Effective therapy was defined as use of an agent to which the isolated organism was susceptible by antimicrobial susceptibility testing. The primary outcome was microbiological recurrence of the same organism and/or all-cause mortality within 30 days of discontinuation.

Results

Overall, 95 CLABSIs were included. Of 92 patients, 46 (50%) were immunocompromised. For patients with catheters removed prior to the end of therapy (n=48), the median duration of effective therapy was 13.5 days (IQR: 8.75-16 days). For patients who retained catheters throughout treatment (n=47), the median duration of effective therapy was 13 days (IQR: 9-15 days). Of these 95 CLABSIs, one patient (retained catheter) had microbiological recurrence within 30 days. Seven patients died (without microbiological recurrence), with range of duration of therapy of 6-14 days.

Conclusion

There was a wide variation in length of therapy for CLABSIs caused by GNB in children. Microbiological recurrence was rare, and mortality was unrelated to microbiological recurrence. Future studies should evaluate standardization of shorter duration therapy to avoid unnecessarily prolonged antibiotic exposure.

Disclosures

Sameer Patel, MD MPH, Merck (Grant/Research Support)Nexogen (Consultant)
1363. Assessment and Quantification of Nasopharyngeal Streptococcus pneumoniae Colonization Does Not Discriminate Between Children with Viral and Bacterial Respiratory Infection
Authors: Pernica Jeffrey , Inch Kristin , Alfaraidi Haifa , Van Meer Ania , Carciumaru Redjana , Luinstra Kathy , Smieja Marek
Published: January 2021

Background

Pediatric uncomplicated pneumonia can be caused by viruses, bacteria, and atypical pathogens. Unfortunately, readily-available diagnostics do not reliably identify which cases of uncomplicated pneumonia have a bacterial etiology. It has been suggested that measuring pneumococcal nasopharyngeal carriage can discriminate between viral and bacterial disease. The objective of this study was to determine if nasopharyngeal pneumococcal carriage differed between children with definite viral disease, definite bacterial disease, and respiratory disease of indeterminate etiology.

Methods

Three cohorts were recruited. Cohort 1 consisted of children with acute respiratory illness admitted to the pediatric intensive care unit; Cohort 2 consisted of previously healthy children with acute respiratory illness admitted to the general pediatric ward; and Cohort 3 consisted of previously healthy children diagnosed with non-severe community-acquired pneumonia in the emergency department. Children were categorized into the following disease categories: a) viral infection syndrome, b) pneumonia complicated by effusion/empyema, or c) ‘indeterminate’ pneumonia. Study subjects’ nasopharyngeal swabs (NPS) underwent quantitative PCR testing for S. pneumoniae.

Results

There were 206 children in Cohort 1, 122 children in Cohort 2, and 179 children in Cohort 3. The median subject age was 2.5 y (25-75%ile 1.3-4.9 y). Only a minority (227/507, 45%) had pneumococcal carriage detected; in those participants, there was no association of quantitative genomic load with age, cohort, or disease category. In multivariate logistic regression, NPS pneumococcal carriage (positivity >3 log copies/mL) was associated with younger age and cohort of recruitment, but not with disease category (all those with indeterminate non-severe pneumonia were from Cohort 3).

Table 1. Comparison of subjects in different cohorts

Table 2. Comparison of subjects in different disease categories

Table 3. Associations with nasopharyngeal pneumococcal colonization >3 log copies/mL.

Conclusion

The nasopharyngeal S. pneumoniae carriage patterns of subjects with definite viral infection were very similar to those with definite bacterial infection and to those with indeterminate pneumonia. It would therefore appear that assessment and quantification of nasopharyngeal pneumococcal colonization is not useful to discriminate between acute viral and bacterial respiratory disease in children in North America.

Disclosures

All Authors: No reported disclosures
1365. How Severe Are Rickettsial Infections Among Children
Authors: Hammami Fatma , Koubaa Makram , Chakroun Amal , Rekik Khaoula , Smaoui Fatma , Elleuch Emna , Marrakchi Chakib , Jemaa Mounir Ben
Published: January 2021

Background

Rickettsial infections (RI) usually mimic benign viral infection due to similarities in clinical symptoms. However, severe forms and complications have been reported with rickettsiosis. Children can be affected as well. We aimed to study the particularities of RI among children.

Methods

We conducted a retrospective study including all patients aged ≤ 18 years hospitalized for RI between 2000 and 2018. The diagnosis was confirmed by serologies (seroconversion).

Results

In total, we encountered 59 children with confirmed RI, among whom 45 were male (76.3%). The mean age was 14 ±3 years. Forty children had a close contact with animals (71.4%). All patients consulted for a febrile maculopapular skin rash, which was associated to headache in 45 cases (76.3%), vomiting in 28 cases (47.4%) and cough in 8 cases (13.5%). Physical examination revealed an eschar in 13 cases (22%) and meningeal syndrome in 11 cases (18.6%). Laboratory investigations showed thrombocytopenia (31 cases; 52.5%) and liver cytolysis (26 cases; 44%). Severe forms of RI were represented by meningitis in 11 cases (18.6%), pneumonia in 2 cases (3.3%) and myocarditis in one case (1.6%). The treatment was based on doxycycline in 42 cases (71.2%), fluoroquinolones in 10 cases (17%) and macrolide in 7 cases (11.8%) for children aged less than 8 years. The mean duration of treatment was 9 ±3 days. The disease evolution was favourable in all cases.

Conclusion

The diagnosis of RI among children should be largely based on high index of suspicion, careful clinical and laboratory results. Prompt diagnosis is crucial in order to start antibiotics and avoid, therefore, fatal untreated forms.

Disclosures

All Authors: No reported disclosures
1366. Microbiology of Acute Hematogenous Osteomyelitis in Hospitalized Children
Authors: Hu Nina , Hamdy Rana F , Martin Benjamin
Published: January 2021

Background

Acute hematogenous osteomyelitis affects 1 in 5,000 children in the U.S. and Staphylococcus aureus is the most common bacterial cause. At our institution, clindamycin is used empirically for osteomyelitis, despite increasing clindamycin-resistance over the years. The objective of this study is to describe microbiologic results and antibiotic resistance patterns in children hospitalized with acute hematogenous osteomyelitis.

Methods

This was a single-center retrospective cohort study of patients < 21 years of age with acute osteomyelitis hospitalized between 1/1/2010 and 5/31/2019 at Children’s National Hospital. We excluded patients with recent orthopedic surgery, hardware infection, penetrating trauma, or with an underlying immunocompromising condition. We performed chart review to collect data on location of infection; blood, synovial fluid, or surgical site cultures; culture results, and susceptibilities.

Results

Of the 162 encounters of acute osteomyelitis that met inclusion criteria, the average patient age was 8.3 years. Lower extremity infections were most common (105, 64.8%), followed by upper extremity (31, 19.1%), pelvis (14, 8.6%), spine (7, 4.3%), shoulder (4, 2.5%), rib (1, 0.6%) and mandible (1, 0.6%). Almost half of cases (73, 45%) had no positive cultures, and 89 cases (55%) had at least one positive culture from blood or local source (Figure 1). The most common pathogen was methicillin susceptible S. aureus (MSSA) followed by methicillin resistant S. aureus (MRSA) comprising 60 (67%) and 19 (20%) of culture-positive infections respectively. Other isolated pathogens included S. pyogenes (5, 5.6%) Salmonella species (2, 2.2%), S. pneumoniae (1, 1.1%), S. agalactiae (1, 1.1%), and Kingella kingae (1, 1.1%) (Figure 1). Among S. aureus infections, 69 (87%) were susceptible to clindamycin (85% among MSSA, 95% among MRSA).

Categorized Blood and Wound Culture Results

Conclusion

Almost half of all children with acute hematogenous osteomyelitis did not have any microbiologic data to guide antibiotic usage. S. aureus was the most common (87%) isolate, with more MSSA (74%) than MRSA (24%). Non-S. aureus isolates were more likely to grow from surgical specimen cultures than from blood cultures. Clindamycin resistance was more commonly seen in MSSA than in MRSA osteomyelitis.

Disclosures

All Authors: No reported disclosures
1370. Three of Hearts: A Case Series and Literature Review of Pediatric Purulent Pericarditis
Authors: Estes Alyssa , Resident Pediatric , Crews Jonathan , Appachi Elumalai , Care Pediatric Critical
Published: January 2021

Background

Purulent pericarditis is rare in the pediatric population. Three children with purulent pericarditis complicated by tamponade were seen at a children’s hospital from 2018-2019. A review of the literature was conducted to investigate the clinical significance and features of purulent pericarditis.

Methods

Cases of purulent pericarditis in children (age < 18 years) published in English from 2000 to 2020 were reviewed. Patients were included if there was presence of purulent pericardial fluid or if a bacterial pathogen was isolated from pericardial fluid.

Results

Three children with purulent pericarditis and tamponade with associated pneumonia were cared for at our institution. These infections were caused by methicillin-susceptible Staphylococcus aureus, Haemophilus influenzae, and Streptococcus pyogenes. Review of the literature identified 93 children with purulent pericarditis. The median age of the cohort is 4 years old. In 68.8% of children the etiology was identified from culture of pericardial fluid. The most common organism detected was S. aureus (38.7%) and a concurrent infection was seen in 49.4% -pneumonia (36.5%), osteomyelitis (17.2%), soft tissue (7.5%), and meningitis (2.1%). In North America specifically, methicillin-resistant S. aureus was most common 35% (7/20) and associated infection was seen in 80% (16/20). Clinical course was complicated by pericardial tamponade in 68.5% (37/54) of patients, 48.6% (18/37) of those children with tamponade also had pneumonia. Pericardiocentesis is the most frequent initial intervention, performed in 77.4% of cases. The mortality rate was 4.3%.

Conclusion

In pediatric purulent pericarditis, Gram-positive organisms account for 81.2% of all children with positive pericardial fluid culture, and 75% of infections in North America. A bacterial pathogen can be isolated from the pericardial fluid in a majority of patients with purulent pericarditis. There is a high rate of concurrent infection, most notably pneumonia, and there is a strikingly high percentage of tamponade in those cases.

Disclosures

All Authors: No reported disclosures
1376. Oral Vancomycin as Secondary Prophylaxis Against Clostridioides difficile Infection in Pediatric Patients
Authors: Bao Hongkai , Dubrovskaya Yanina , Papadopoulos John , Siegfried Justin , Merchan Cristian , Lighter Jennifer , Jen Shin-Pung
Published: January 2021

Background

Secondary oral vancomycin prophylaxis (OVP) has been utilized in adults with a history of Clostridioides difficile infection (CDI) while receiving systemic antibiotics to prevent CDI recurrence. However, this practice is poorly described in pediatric patients. Rates of CDI recurrence in pediatric patients range from 10-40% and is associated with morbidity and mortality. This study assessed the efficacy and safety of secondary OVP in pediatric patients with subsequent antibiotic exposure.

Methods

This retrospective study evaluated pediatric patients ≤18 years with any history of clinical CDI and receiving systemic antibiotics in a subsequent encounter during the time period of 2013-2019. Patients who received OVP 10 mg/kg (up to 125 mg per dose) every 12 hours during concomitant antibiotics were compared to those who did not. The primary outcome was CDI recurrence within 8 weeks following antibiotic exposure. Secondary outcomes included time to recurrence, severity of recurrence, and isolation of vancomycin-resistant enterococci (VRE) from any site. Risk factors for CDI recurrence were assessed using logistic regression.

Results

A total of 153 patients were screened for inclusion, of which 32 and 47 patients were assigned to the OVP and no OVP group, respectively. Median age was 8.6 years and the most common comorbidities were malignancy (47%) and immunosuppression (46%). Median time since last CDI to study inclusion was 64.5 days in the OVP group and 90 days in the no OVP group, P=0.320. Compared to the no OVP group, OVP patients had longer hospital stays (5 vs 14 days, P=0.001) and more concomitant antibiotic exposure (8 vs 12.5 days, P=0.001). Median duration of OVP was 12 days. CDI recurrence occurred in 12 patients and was significantly lower in the OVP vs no OVP group (3.1% vs 23.4%; odds ratio, 0.106; 95% confidence interval, 0.013-0.864; P=0.022). VRE was not isolated in any patients. After adjustment in a multivariate analysis, only secondary OVP remained as a protective factor against recurrence (odds ratio, 0.082; 95% confidence interval, 0.009-0.748; P=0.027).

Conclusion

Secondary OVP effectively reduces the risk of recurrent CDI in pediatric patients with a history of CDI while receiving systemic antibiotics. Future prospective studies should validate these findings.

Disclosures

Cristian Merchan, PharMD, BCCCP, abbive (Speaker’s Bureau)
1380. Current status of the legal landscape regarding Rotavirus Vaccination in the United States
Authors: Bhatti Alexandra , Carias Cristina , Chen Ya-Ting
Published: January 2021

Background

In the US, the Advisory Committee on Immunization Practices recommended routine rotavirus vaccination for all infants in 2006. Since then, rotavirus (RV) vaccination coverage (VC) has increased; however, RV VC is still below that of other routine childhood vaccines. All states require children to be vaccinated against certain communicable diseases as a condition for childcare attendance; other states require that children with diarrhea are excluded from childcare. Given the potential impact of these policies on VC, we sought to understand the legal landscape affecting rotavirus (RV) vaccination.

Methods

Legal epidemiological methods using Westlaw NEXT database were used to complete a systematic assessment of RV vaccination requirements for childcare entry and evaluate the ease at which non-medical exemptions are attained. These methods were also used to evaluate state diarrhea childcare exclusion policies.

Results

Six states require RV vaccination for childcare attendance: Wyoming (2018); Ohio and Rhode Island (2015); Idaho (2011); North Dakota (2008); and Pennsylvania (2002) (Figure 1). All 6 states permit non-medical exemption that allow children to be exempt from vaccination. Ohio, North Dakota, and Pennsylvania are the most lenient, only requiring parental signature to withdraw from vaccination; while Wyoming is the least lenient, requiring a signed notarized official document. Childcare diarrhea exclusion policies were found in 28 states.

Rotavirus Vaccination Requirements for Childcare Entry by State as of 2019.

Conclusion

To date, a minority of states have implemented RV vaccination policies while more states have diarrhea exclusion policies. However, vaccination policies may play a role in increasing VC and consequently lower acute gastroenteritis and diarrhea burden. In 2017, the VC for the full series of RV vaccination was 73.2%. Four of the states that have RV state vaccination policies had higher state-wide vaccination coverages than the national average. Given the concern in reducing diarrhea transmission, as evidenced by the large number of diarrhea exclusion policies, and the potential impact of policies on higher VC which may result in greater protection and reduction in RV disease, considerations should be given to implementing such policies in more states.

Disclosures

Alexandra Bhatti, JD, MPH, Merck (Employee) Cristina Carias, PhD, Merck (Employee, Shareholder) Ya-Ting Chen, PhD, Merck & Co., Inc. (Employee, Shareholder)
1382. Varicella Burden Disease in Argentina: 4 Years after National Vaccination Strategy
Authors: Neyro Silvina , Juarez Maria del Valle , Pasinovich Marina , Rancaño Carolina , Katz Nathalia , Elbert Gabriela , Yunes Marcela López , Stecher Daniel , Lucconi Verónica , Saralegui Martín , Mykietiuk Analía , Vizzotti Carla
Published: January 2021

Background

In Argentina, around 150,000-180,000 total Varicella (VZV) cases per year (c/y) are registered; however, underreport exists and some 400,000 cases are estimated to occur annually. Varicella vaccine (VV) was included in the National Immunization Schedule (NIS) in 2015, with a 1-dose schedule administered at 15 months-of-age. We aimed to describe and to compare the epidemiological situation of VZV infections in Argentina in two periods: pre (2010-2014) and post (2016-2018) vaccine introduction in NIS.

Global Incidence rates and vaccine coverages

Incidence rates (age groups)

Methods

Before-and-after study comparing cases and incidence rates (100,000) of varicella reported to the National Health Surveillance System between pre-vaccination period (Pre-VV) and post-vaccination (Post-VV), excluding year of intervention (2015) since it was considered a transition year. Epi Info 7 was used for data analysis.

Results

Vaccination coverage (VC) for 2015 was 44.7%; 74.4% in 2016; 76.8% in 2017 and 81% in 2018 (Figure 1). 728,392 cases of VZV were notified (R=363.1) in Pre-VV period and 222,305 cases in Post-VV (R=180.7), with a global incidence rate reduction of 49% (95%CI= 40.9-56.2; p< 0.001). Both 12-24 months of age and 2-4 years old groups (Pre-VV R=2,253 and Post-VV R=900; Pre-VV R=2,399 and Post-VV R=875, respectively) showed the greatest reductions in incidence rates (-59.3% [95%CI 58.7-60] p< 0.001 and -61.7% [95%CI 61.3-62] p< 0.001). Age groups not affected by vaccination (< 1 year, 5-9 years and 10-14 years) presented minor but significant reductions (-56.4% [95%CI 55.6-57.3] p< 0.001; -35% [95%CI 34.5-35.4] p< 0.001; and -28.6% [95%IC 27.6-29.7] p< 0.001 respectively) (Figure 2).

Conclusion

A decreasing trend in VZV number of cases and incidence rates was observed, especially in children less than 5 years old, despite suboptimal VC. The reduction of VZV cases in non-vaccinated age groups could be related to a decline in the transmission risk. Improving VC will likely reflect a greater impact on the burden of disease.

Disclosures

All Authors: No reported disclosures
1383. Characterizing Real-world Patterns of Early Childhood Vaccination
Authors: Butler Anne M , Newland Jason , Sahrmann John , O’Neil Caroline , Sayood Sena , McGrath Leah
Published: January 2021

Background

Vaccine hesitancy is increasingly common, but more information is needed on patterns of childhood vaccination. We characterized patterns of vaccine delay among commercially-insured children in the U.S.

Methods

Using the IBM MarketScan Commercial Database, we identified infants who received a timely first dose of diphtheria-tetanus-acellular pertussis (DTaP) vaccine from October 2009 to June 2017. We used CPT codes to collect vaccine administration history on antigen, formulation, dose, and date. We ascertained injectable and oral vaccine antigens (DTaP, polio, pneumococcal conjugate, rotavirus, Haemophilus influenza type b (Hib), measles, mumps, rubella, varicella). Timely receipt was defined as concomitant administration of the CDC-recommended number of antigens during the following time windows: 2, 4, 6, and 12-15 months of age (grace period: -7, +21 days). We generated heat maps to illustrate age distributions at receipt of specific antigens and doses. We created Sankey diagrams to illustrate the number of antigens received concomitantly during each time window and depict transitions to different states over time (e.g., no vaccine delay to vaccine delay). For each antigen and dose, we estimated the cumulative incidence of receipt.

Results

Among 1,066,216 eligible infants, the majority (84%) concomitantly received all 5 CDC-recommended antigens at 2 months of age while others only received 1 (1%), 2 (2%), 3 (4%) or 4 (9%) antigens. Many vaccinations were delayed – 30% and 39% of children did not receive all recommended antigens concomitantly at 4 and 6 months, respectively. The heat map shows wide variation in age at vaccination. For several antigens including Hib, measles, mumps, rotavirus, rubella, and varicella, the cumulative incidence increased steeply at ≥2 time points, suggesting vaccine delay for some infants (e.g., the first dose of Hib was administered to 85% of infants by 2 months of age, with subsequent small but distinct increases at 4, 6, 12, and 15 months of age).

Conclusion

Using real-world data to study early childhood vaccination patterns, we observed evidence of substantial deviation from the CDC-recommended schedule. These results expand current knowledge on the magnitude and timing of antigen- and dose-specific vaccine delay on a population level.

Disclosures

Jason Newland, MD, MEd, FPIDS, Merck (Grant/Research Support)Pfizer (Other Financial or Material Support, Industry funded clinical trial) Leah McGrath, PhD, NoviSci, Inc. (Employee)
1388. DTaP-containing combination vaccines use and adherence to the recommended infant-toddler vaccination series among privately insured children in the US
Authors: Loiacono Matthew M , Pool Vitali , Van Aalst Robertus
Published: January 2021

Background

Despite universal recommendation of the 3 + 1 diphtheria, tetanus, and pertussis (DTaP) vaccine series in infants and toddlers, adherence (i.e. coverage and timeliness) remain suboptimal in the US. DTaP-containing combination vaccines are presumed to improve vaccine coverage rates and timeliness, but research on this topic is limited. The purpose of this study was to compare adherence to the recommended infant-toddler vaccination series between recipients of DTaP-containing combination vaccines (i.e. quadrivalent/pentavalent) and stand-alone vaccines (i.e. trivalent).

Methods

We used the Optum de-identified Clinformatics Data Mart database to create a cohort of children born between 2009 and 2016 with > 24 months of continuous enrollment from birth, and records of > 1 DTaP vaccine receipt. Patients were classified by DTaP-containing vaccine receipt: combination vaccines only, stand-alone vaccines only, or a mixture of both. The primary adherence outcome was completion of the 4-dose series within 20 months of life. We adjusted outcomes for gender, birth year, race, and socioeconomic status via a logistic regression model.

Results

The cohort contained 200,568 female (48.6%) and 211,882 male (51.4%) children. Of these children, 167,091 received combination vaccines only (40.5%), 61,342 received stand-alone vaccines only (14.9%), and 184,017 received a mixture of both (44.6%). Completion of the 4-dose series was highest among children who received combination vaccines only (75.5%), followed by those who received a mixture of vaccines (72.7%) and those who received stand-alone vaccines only (54.5%). Relative to those who received stand-alone vaccines only, adjusted odds of completion were approximately 2.9 times higher among combination vaccine recipients (odds ratio, OR = 2.93 [95% CI: 2.87, 2.98]) and 2.5 times higher among those who received a mixture of vaccines (OR = 2.54 [2.49, 2.59]).

Conclusion

DTaP-containing combination vaccine use was associated with significantly greater adherence. Although these results warrant further investigation to better understand the determinants of infant vaccination adherence, such evidence may further support preferential recommendations for combination vaccine use.

Disclosures

Matthew M. Loiacono, MSc, Sanofi Pasteur (Employee) Vitali Pool, MD, Sanofi Pasteur (Employee) Robertus Van Aalst, MSc, Sanofi Pasteur (Employee)
1394. Impact of 7-Valent and 13-Valent Pneumococcal Conjugate Vaccines in the United States: A Systematic Literature Review
Authors: Kistler Kristin , Gomez-Espinosa Evelyn F , Sutton Kelly , Chapman Ruth , Dillon-Murphy Desmond , Wasserman Matthew
Published: January 2021

Background

The availability of 7-valent (PCV7) and 13-valent (PCV13) pneumococcal conjugate vaccines (PCVs) in the United States (US) since 2000 and 2010, respectively, has substantially reduced the occurrence, morbidity and mortality of pneumococcal disease. This systematic literature review aimed to assess the impact of the PCVs in reducing the pneumococcal disease burden since their introduction.

Methods

We searched Embase and Medline and disease-surveillance websites for observational studies of US participants < 19 years, published 1999–2019 and reporting incidence or prevalence of acute otitis media, invasive pneumococcal disease, meningitis, or pneumococcal disease-related morbidity, mortality, healthcare resource utilization (HCRU) or costs.

Results

Of 499 citations identified from the databases and other sources, 125 met inclusion criteria (Figure), all indicating clear reductions in multiple manifestations of pneumococcal disease with PCV7 and PCV13 use. However, variations across studies in outcomes reported, study years, and age strata, confounded assessment of vaccine impact on specific pneumococcal disease outcomes and key burden indicators, such as tympanostomy tube placement and antibiotic prescriptions.

Conclusion

PCVs have greatly decreased multiple manifestations of pneumococcal disease in the US. However, granular data on the frequency and morbidity associated with specific pneumococcal diseases and on associated HCRU are needed to quantify the public-health impact of these vaccines.

Disclosures

Kristin Kistler, PhD, Evidera, Inc. (Employee, Evidera, Inc. received the funding to conduct this study.) Evelyn F. Gomez-Espinosa, BSc, PhD, Evidera Inc (Employee, Scientific Research Study Investigator)Pfizer Inc (Consultant, Scientific Research Study Investigator) Kelly Sutton, PhD, Evidera (Other Financial or Material Support, Evidera, Inc. received the funding to conduct this study.) Ruth Chapman, MSc, PhD, Evidera, Inc, (Evidera, Inc. received the funding to conduct this study.) (Consultant) Desmond Dillon-Murphy, MSc, PhD, Evidera, Inc. (Evidera, Inc. received the funding to conduct this study.) (Consultant) Matthew Wasserman, MSc., Pfizer Inc. (Employee)
113. Impact of Urinalysis with Reflex to Culture on Antimicrobial Prescribing Patterns for Patients with a Positive Urine Culture
Authors: Diehl Nicolette , Yu Daohai , Gallagher Jason C , Sullivan Kaede V , Mueller Daniel , Lu Xiaoning , Cavaretta Marissa
Published: January 2021

Background

Temple University Hospital recently implemented a protocol in which a urinalysis will reflex to culture only in the presence of pyuria. The purpose of this study is to compare appropriate antimicrobial use for patients with positive urine cultures before and after implementation of the urinalysis with reflex to culture protocol.

Methods

This is a single center, observational chart review. Adult internal medicine patients with a urinalysis and positive urine culture before and after the intervention were included in the pre- and post-intervention groups. Patients in the intensive care unit, undergoing urologic or surgical procedures, with leukopenia, being treated for another infection, who were discharged within 72 hours of the urine culture order, or pregnant were excluded. The primary endpoint was the percentage of patients with appropriate antimicrobial management of the positive urine culture before and after implementation of the protocol. Appropriate management was defined as antimicrobial treatment for a symptomatic urinary tract infection or no antimicrobial treatment for asymptomatic bacteriuria. Duration of therapy was also assessed. A sample size of 334 cultures was needed to detect a 15% difference in initiation of antibiotics between groups. Comparisons of categorical variables were analyzed by Chi-Square/Fisher exact test while continuous variables were analyzed by Wilcoxon test.

Results

Patient characteristics and outcomes are listed in the tables below.

Table 1: Patient Characteristics

Table 2: Outcomes

Conclusion

The urinalysis with reflex to culture intervention appeared to have minimal impact on the management of patients with a positive urine culture, with a possible increase in inappropriate management. Duration of therapy was significantly reduced by approximately one day with the intervention. Additional interventions to improve appropriate management of bacteriuria should be explored.

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)
1403. The Pediatric Emergency Room as a Promising Setting for Receiving the Flu Shot
Authors: Miller Christine M , McMahon Erin , Parrillo Marissa , Sobelman Celia , Golenia Peter , Kirchner Rory , Hermos Christina , Mathews Bonnie
Published: January 2021

Background

Children are the most likely population to get influenza, and are two times more likely compared to adults aged 65 and greater (attack rate by age group: 0-17 yo 9.3%, 18-74 yo 8.8%, 65 + 3.9%). Additionally, children are at high risk of suffering complications from influenza. According to the CDC, the overall effectiveness of the 2018-2019 flu vaccine for both strains A and B was 48% in children aged 6m-8 years and 7% in children aged 9- 17 years. Currently our Pediatric Emergency Department (PED) does not routinely offer influenza vaccine to unvaccinated patients. Our project goals are to identify barriers to the administration of influenza vaccine in the PED and to offer and administer influenza vaccine to eligible patients.

Methods

After performing root cause analysis with key stakeholders, the first countermeasure implemented in a Plan-Do-Study Act (PDSA) cycle was the development of a screening form including eligibility criteria, history of influenza vaccine, consent for vaccine or reason for declining vaccine. The screening form was administered by resident physicians in our PED from October to November who then went on to order the vaccine for eligible patients who consented. Primary outcome measures included number of patients screened per month, percent of patients who desired the vaccine, and the percent of patients who received the vaccine in the ED during their visit. Secondary outcome measures included length of PED stay.

Results

Preliminary results show that 75% (42/56,CI: 62%-86%) of children screened in the PED between October and November were eligible for the influenza vaccine. Of those eligible, 59% (29/42, CI: 43%-74%) received the vaccine. The average length of stay was comparable between those that received influenza vaccine and those that did not (p value 0.4756).

Conclusion

A subset of eligible patients are now being offered and receiving the flu shot in our PED. Over half of eligible patients received the influenza vaccine, demonstrating that a resident administered screening form has been a successful countermeasure for increasing vaccine rates. Future PDSA cycles will focus on further increasing the number of patients screened and capturing patients who consented but did not receive vaccine.

Disclosures

All Authors: No reported disclosures
114. Implementation of an Empiric Organism Specific Guidelines for Gram-negative Bacteremia in conjunction with Rapid Diagnostic Testing
Authors: Bernice Fidelia , Avdic Edina , Dzintars Kathryn , Cruz Aliyah
Published: January 2021

Background

The objective of this study was to confirm the validity of institution specific treatment recommendations targeting organisms identified by GenMark Dx® ePlex® blood cultures identification (BCID) Gram-negative panel prior to susceptibility results.

Methods

We developed and implemented institution specific guidelines for empiric antibiotic therapy for Gram-negative organisms targeted by GenMark Dx® ePlex® BCID. We utilized blood culture antibiograms, existing evidence for the most optimal agent for each pathogen, probable resistance mechanisms and patient clinical status to create these guidelines. From December 16, 2019 through May 31, 2020, infectious diseases pharmacists reviewed all positive blood cultures; assessed compliance with guidelines and intervened as needed. The primary objective was to determine how frequently guideline recommend agents would be ineffective against targeted pathogens based on susceptibilities. Secondary objectives were compliance with guidelines and frequency of therapy escalation or de-escalation.

Results

GenMark® testing was completed on 222 cultures positive for Gram-negative rods with target organisms identification in 195 (88%) blood cultures. Two hundred and five organisms were identified; most commonly E. coli (40%) and K. pneumoniae (21%).Resistance markers were detected in 30 aerobic blood cultures; 28 CTX-M, and 2 KPC. Our institutional guideline provided appropriate empiric coverage in 93% of bacteremia episodes. The most common reason for ineffective therapy was the presence of resistance mechanisms not detected by GenMark® test (e.g. non-CTX-M extended spectrum beta-lactamases). The compliance rate with the guidelines was 55%; the most common reason for non-compliance was the use of an anti-pseudmonal beta-lactams in neutropenic patients.. The system failed to identify panel organisms in only 5 (2%) of blood cultures.

Conclusion

The institution-specific guidelines providing empiric coverage for each organism identified by rapid diagnostic tests can aid antimicrobial stewardship efforts to de-escalate therapy while still providing effective coverage in >90% of cases.

Disclosures

All Authors: No reported disclosures.