bluuebunny/crossref_metadata_2025 huggingface dataset:
1170. Follow-up of vaccine preventable disease hospitalisations in the ageing population: Loss of Independence
Authors: Salem Ahmed , Hartmann Maximilian , Servotte Nathalie , Aris Emmanuel , Doherty T Mark , Beck Ekkehard
Published: November 2023

Background

Influenza, pneumococcal infection, herpes zoster and pertussis are vaccine preventable diseases (VPDs) that cause significant burden for older adults (50+ years old). Downstream effects beyond the acute phase such as loss of independence have not been well characterised.

Methods

Using Optum’s de-identified Clinformatics® Data Mart Database, a retrospective claims database study was conducted to assess the impact of a VPD hospitalisation on subsequent loss of independence over 365 days of follow-up during the epidemiological years 2016–2018. Loss of independence is a composite endpoint defined as either a change in residence status from “living at home” to “long-term care facility” or the need of home health/home care (HHHC) which was not needed at baseline. Both were assessed over 365 days of follow-up after a VPD-hospitalisation. The VPD-hospitalised cohort were subjects hospitalised due to VPD as primary or secondary diagnosis or both. Controls were matched at baseline on variables like demographics, insurance, comorbidities, and Charlson Comorbidity Index (CCI) score. Results were stratified by age and CCI category at baseline and reported as mean difference between cohorts (with 95% confidence interval, CI).

Results

Subjects hospitalised for a VPD would experience at least 20% (18.9–21.5%, p< 0.001) more LoI versus their matched counterparts over 365 days (Figure 1). Furthermore, at least 12% (10.0–13.2%, p< 0.001) more subjects in the VPD-hospitalised cohort experienced a worsening in their residence status (Figure 2) at 365 days of follow-up. Finally, the need for HHHC was more pronounced for subjects hospitalised for a VPD where a mean difference of at least 9% (8.1–9.3%, p< 0.001) and a maximum of 27% (25.0–28.7%, p< 0.001) was observed compared to controls (Figure 3).Figure 1:Loss of inpendanceFigure 2:Proportion with worsening in residence statusFigure 3:Experiencing worsening in HHHC Status

Conclusion

Individuals hospitalized for a VPD were more likely to experience a loss of independence as defined by change in residence status and the need for home health care compared to matched controls. These findings highlight the potential burden of VPDs beyond the acute disease phase and can provide important motivation to improving preventive programs including vaccination.

Disclosures

Ahmed Salem, MSc, GSK: employee|GSK: Stocks/Bonds Maximilian Hartmann, PhD, GSK: Grant/Research Support Nathalie Servotte, PhD, GSK: employee|GSK: Stocks/Bonds Emmanuel Aris, PhD, GSK: employee|GSK: Stocks/Bonds T. Mark Doherty, PhD, GSK: employee|GSK: Stocks/Bonds Ekkehard Beck, PhD, GSK: employee|GSK: Stocks/Bonds
1171. Follow-up of vaccine preventable disease hospitalisations in the ageing population: onset of chronic comorbidities
Authors: Salem Ahmed , Hartmann Maximilian , Servotte Nathalie , Aris Emmanuel , Doherty T Mark , Beck Ekkehard
Published: November 2023

Background

Vaccine preventable diseases (VPD) such as influenza, pneumococcal infection, herpes zoster and pertussis pose a significant burden for adults 50 years and older. The disease burden beyond the acute phase (downstream effects) where a VPD can trigger or exacerbate comorbidities is less studied.

Methods

Using Optum’s de-identified Clinformatics Data Mart Database, a retrospective claims database study was conducted to assess the diagnosis of new comorbidities in older adults (50+) up to 365 days following an index hospitalisation with a VPD during the epidemiological years 2016 – 2018. A subset of outcomes is reported here, focusing on the new onset of myocardial infarction (MI) and congestive heart failure (CHF). Subjects hospitalised with a VPD were compared to matched controls without a VPD hospitalisation. Matching was conducted on the day of VPD hospitalisation based on baseline variables like demographics, insurance, comorbidities, and Charlson-Comorbidity Index (CCI) score. The study analysed the new onset of MI and CHF over 365 days following a VPD index hospitalisation stratified by age category and CCI score at baseline. Results are reported as mean change (95% confidence interval (CI)).

Results

At 365 days, there was a significant higher risk for a new MI observed in the VPD-hospitalised cohort compared to their matched controls (Figure 1) across all age groups and CCI categories. In particular, individuals without any comorbidity at baseline (CCI = 0) experienced an increased probability for a new MI diagnosis between 6% (4.9–7.4%, p< 0.001) and 13% (11.6% - 14.3%, p< 0.001). Furthermore, the VPD-hospitalised cohort also showed a significant higher risk for a new CHF diagnosis versus their non-VPD matched controls (Figure 2). Those without any comorbidity at baseline (CCI = 0) showed an increased proportion of new CHF diagnosis over 365 days between 12% (10–14%, p< 0.001) and 25% (24–27%, p< 0.001).

Conclusion

Results suggest that individuals hospitalised for a VPD were more likely to experience a new MI or CHF compared to their matched controls. Limitations exist around direct associations between the VPD hospitalisation and the onset of a new MI or CHF diagnosis, but the findings support the hypothesis that downstream effects of VPDs could trigger or exacerbate a comorbidity.

Disclosures

Ahmed Salem, MSc, GSK: employee|GSK: Stocks/Bonds Maximilian Hartmann, PhD, GSK: Grant/Research Support Nathalie Servotte, PhD, GSK: employee|GSK: Stocks/Bonds Emmanuel Aris, PhD, GSK: employee|GSK: Stocks/Bonds T. Mark Doherty, PhD, GSK: employee|GSK: Stocks/Bonds Ekkehard Beck, PhD, GSK: employee|GSK: Stocks/Bonds
1180. Empiric treatment of uncomplicated intraabdominal infection with cefazolin with or without metronidazole
Authors: Borkowski Jaime , Polisetty Radhika S , Shah Rishita , Liu Jay , Manrique Luis , Grohmann Stephen , Johnson Nicholas
Published: November 2023

Background

Treatment guidelines for management of intra-abdominal infection (IAI) differ on whether cefazolin should be used first line to treat uncomplicated infection. In an effort to reduce unnecessary fluoroquinolone and piperacillin/tazobactam use, protocols were implemented with which recommendations were made to narrow to cefazolin ± metronidazole for uncomplicated IAI. The purpose of this study was to determine if there is a difference in outcomes with cefazolin +/- metronidazole versus broader-spectrum antibiotics for treatment of uncomplicated IAI.

Methods

This was a retrospective cohort study that reviewed inpatients at three acute-care community teaching hospitals from January 1, 2017, through December 31, 2021. Treatment groups were patients treated with cefazolin +/- metronidazole (study group) compared to those treated with piperacillin/tazobactam or ceftriaxone, ciprofloxacin, or cefepime each +/- metronidazole (control group). Inclusion criteria were age ≥ 18 years old; admission diagnosis of uncomplicated cholecystitis, diverticulitis, or appendicitis; and received as empiric inpatient treatment either cefazolin ± metronidazole, piperacillin/tazobactam, or ceftriaxone, ciprofloxacin, or cefepime ± metronidazole for at least 24 hours. Exclusion criteria were presence of perforation or abscess for cholecystitis or diverticulitis, cholangitis or pregnancy. The primary outcome measure was all-cause 30-day readmission rate.

Results

A total of 779 patients were included in the cefazolin group and 2269 patients were included in the broader-spectrum group. All-cause 30-day readmission rate was 5.8% in the cefazolin +/- metronidazole compared to 12.1% in the broader-spectrum group (OR 0.38, 95% CI 0.27-0.53, p < 0.001). Average length of stay was 3.6 days for the cefazolin group vs. 4.4 days for the broader-spectrum group (cefazolin group range 1 to 35 days, broader-spectrum group range 1 to 59 days, p < 0.0001).

Conclusion

Empiric treatment of uncomplicated intra-abdominal infection with cefazolin +/- metronidazole did not result in an increase in 30-day readmissions compared to broader-spectrum empiric antibiotics.

Disclosures

All Authors: No reported disclosures
1182. Impact of Penicillin Allergy Focused Antimicrobial Stewardship Interventions on Antimicrobial Use and Allergy Documentation - Optimizing Allergy Prescribing Alerts and Pharmacy Allergy Assessments
Authors: Stephens Emily , Riney Jennifer , Burnett Yvonne J
Published: November 2023

Background

The discrepancy between true prevalence and reported penicillin (PCN) allergies results in suboptimal antimicrobial use, which is associated with increased adverse drug reactions, antimicrobial resistance, increased hospital length of stay, and poor outcomes. Many patients with mild-moderate reactions tolerate other beta-lactams, but allergy records are often inaccurate or missing information. In 2021, our institution began suppressing prescriber-facing PCN allergy alerts when ordering cephalosporins for patients with mild-moderate PCN reactions. More recently, a pharmacist-driven allergy assessment via chart review +/- patient interview was piloted to clarify PCN allergy documentation. This quasi-experimental study evaluated the effect of PCN allergy interventions on antimicrobial use.

Methods

Days of broad-spectrum antimicrobials in patients with PCN allergies was compared between groups [pre-intervention (G1, n=100), post-alert suppression (G2, n=100), and allergy assessment (G3, n=50)]. Patients were excluded for cephalosporin allergy, MRSA or ESBL history, surgical prophylaxis or UTI indication, or antibiotics within 48 hours of mechanical ventilation. Groups were matched 2:2:1 based on length of stay and antibiotic indication. Additional outcomes included cephalosporin use, allergy clarifications, and time spent per allergy assessment.

Results

The most common antibiotic indications were pneumonia (54%) and intra-abdominal infection (28%). No differences were noted in median duration of broad-spectrum therapy (2 vs 1 vs 1 days, p=0.52) or cephalosporin therapy (1 vs 2 vs 3 days, p=0.39). However, more patients received cephalosporins as initial therapy post-alert suppression, G1 40 (40%) vs G2 57 (57%), p=0.02 vs G3 26 (52%). A pharmacist completed 50 allergy assessments (50 chart review with 19 interviews) and clarified 43 (86%) records to include previous beta-lactam tolerance. Average time of chart review and interview was 4 minutes each.

Conclusion

PCN allergy alert suppression significantly increased initial cephalosporin use and decreased broad-spectrum use. Pharmacist allergy assessment improved allergy documentation accuracy, but future study is required to assess the clinical impact on antimicrobial use.

Disclosures

All Authors: No reported disclosures
1185. Evaluation of Antimicrobial Stewardship Practices at a Veterans Affairs Health Care System Community Living Center
Authors: Ampuero Andrea , Melville Brittany , Guest Bailey , Creel Joseph
Published: November 2023

Background

Antimicrobial stewardship programs (ASP) have demonstrated improvement in patient outcomes, reduction of antimicrobial adverse drug events (ADE) and a decrease in antimicrobial resistance in hospitals. Antimicrobials maintain the second highest rate of ADEs in long-term care facilities. Prescribed antimicrobials in nursing homes may be unnecessary or inappropriate in upwards of 75% of cases. There is limited evidence available quantifying the impact of pharmacist-led ASP interventions in long-term care facilities. The purpose of this project is to evaluate the effectiveness of antimicrobial stewardship interventions completed at the Salisbury Veterans Affairs Health Care System Community Living Center (SVAHCS CLC).

Methods

This is a retrospective quality improvement project. Eligible subjects included Veterans residing in the SVAHCS CLC to which an ASP intervention documented in TheraDoc® was proposed from May 2018 to January 2021. The primary objective is to determine the effectiveness of ASP interventions in the CLC based on acceptance rate. Secondary objectives include to assess safety of select implemented CLC ASP interventions through reported ADEs within 30 days of performed CLC ASP intervention and determine potential cost savings of the implemented ASP interventions.

Results

A total of 379 interventions were included. Of these interventions, 370 were accepted (98%), 5 were accepted with modification (1%) and 4 were rejected (1%). The most common ASP interventions included lab monitoring, renal adjustment, pharmacokinetic consults and duration changes. The most common indications for many ASP interventions performed were osteomyelitis, influenza and bacteremia. Vancomycin, cefepime and ceftriaxone were the most common antimicrobials involved for which ASP interventions were performed. Of the 131 interventions assessed for safety, one Veteran experienced ADEs within 30 days of the intervention including nephrotoxicity and Clostridioides difficile infection. There was a total potential cost savings of $101,704.

Most Common Infections

ASP Intervention Acceptance Rate and ADEs within 30 Days of ASP Intervention

Conclusion

This study demonstrates that pharmacist-led ASP interventions proposed in the SVAHCS CLC were effective with a high rate of acceptance. These interventions resulted in a low rate of ADEs and potential cost savings for the facility.

Disclosures

All Authors: No reported disclosures
1188. Evaluation of Antimicrobial Stewardship Discontinuation of Antimicrobial Therapy for Misdiagnosed Urinary Tract Infections in Hospitalized Patients
Authors: Duke Jessica A , White Brittany N , White Cyle
Published: November 2023

Background

Urinary tract infections (UTIs) are often misdiagnosed resulting in unnecessary treatment of asymptomatic bacteriuria (ASB) and pyuria. This practice has been associated with the development of antimicrobial resistance and increased risk of antibiotic-related adverse events, including Clostridioides difficile infection (CDI).

Methods

This single-center, retrospective, observational review assessed the effect of a unique antimicrobial stewardship initiative to reduce inappropriate antibiotic use in patients with misdiagnosed UTIs. In July 2018, Erlanger Health System revised the antimicrobial stewardship policy to include automatic discontinuation of antibiotics for patients with misdiagnosed UTIs. Adult patients admitted from November 2017 to November 2022 who received an antibiotic order for ASB or pyuria were included. Presence of UTI symptoms was evaluated via comprehensive chart review. The intervention group consisted of patients with ASB in which antibiotics were discontinued by the antimicrobial stewardship team. Patients with altered mental status (AMS) were included. The primary endpoint was days of antimicrobial therapy. Secondary outcomes included 30-day hospital readmission, hospital mortality, incidence of CDI, hospital length of stay (LOS), and growth of multidrug-resistant organisms in subsequent urine cultures.

Results

A total of 306 patients were included in this study. After propensity score matching, 70 patients were included in each group. The median age was 74 ± 10 years, 85.7% were female, and 55% presented with AMS. Patients in the intervention group received a median of 2 days of antibiotics compared to 6 days in the pre-intervention control (p< 0.0001). Hospital LOS was longer in the intervention group (6 vs 4 days, p< 0.0001). There were no significant differences in other secondary outcomes. Antibiotics were reinitiated in 7% of patients.

Conclusion

This antimicrobial stewardship initiative was associated with a reduction in inappropriate antibiotics days for misdiagnosed UTIs. This intervention is novel as most interventions described are passive and rely on recommendations to providers. The findings of this evaluation highlight the effectiveness of active interventions on reducing inappropriate antimicrobial use.

Disclosures

All Authors: No reported disclosures
1193. Impact of Removing Extended-spectrum Beta Lactamase Status Labeling from Culture Reports on Carbapenem Use for Non-bacteremic Patients With Urinary Tract Infections: A Multi-hospital Assessment
Authors: Alvarado Lourdes R Menendez , Landayan Alice Margulis , Williams Kelsey N , Frederick Corey M , Murillo Jorge , Gauthier Timothy P
Published: November 2023

Background

Reporting extended-spectrum beta lactamase (ESBL) status on microbiology results for Enterobacterales is not required by laboratory, infection prevention, or antimicrobial stewardship guidelines. Ceftriaxone (CRO) resistance may be utilized as a proxy for ESBL production. Current practice guidelines recognize select non-carbapenems as acceptable treatment options for ESBL-producing uncomplicated urinary tract infections (UTI). This project aimed to evaluate carbapenem prescribing for CRO-resistant UTIs caused by Enterobacterales before and after removal of ESBL status from microbiology laboratory results at seven sites across a large health system.

Methods

This was a retrospective cohort study of adult patients treated for at least 48 hours for an ESBL-producing/CRO-resistant Enterobacterales UTI. Patients were excluded if they had a concomitant infection outside the urinary tract, a polymicrobial infection, or if treatment was started outside the hospital. The primary endpoint was the rate of carbapenem prescribing for initial definitive treatment of UTIs. Secondary endpoints included total days of therapy for initial definitive therapy with carbapenems, clinical cure rates, time to transition to oral antibiotic therapy for initial definitive therapy, rate of guideline-compliant therapy, 30-day readmission rate, rate of relapsed infection within 30 days, and 30-day all cause in-hospital mortality. This study was approved by the Institutional Review Board.

Results

Of 3055 patients screened, 199 were included in the pre-group and 153 were included in the post-group. Demographics are displayed in Table 1. The rate of carbapenem prescribing for initial definitive treatment was 156 patients (78%) in the pre group, compared to 93 patients (61%) in the post group (p=< 0.01). The rate of non-carbapenem prescribing was 43 patients (22%) in the pre-group, compared to 60 patients (39%) in the post-group (p=< 0.01). There was a 40% reduction in total days of therapy for initial definitive therapy with carbapenems (620 vs. 372, p=< 0.01). Other secondary outcomes are listed in Table 2.

Conclusion

Removal of ESBL status labels from laboratory reports may substantially reduce carbapenem use for initial definitive treatment of UTIs without impacting clinical outcomes.

Disclosures

Jorge Murillo, MD, FIDSA, FACP, Insmed: Advisor/Consultant|Melinta Therapeutics: Advisor/Consultant|Merck: Advisor/Consultant Timothy P. Gauthier, PharmD, BCPS, BCIDP, Ferring: Advisor/Consultant|Firstline: Advisor/Consultant|Firstline: Writing|GSK: Advisor/Consultant|LearnAntibiotics.com & IDstewardship.com: Owner|Melinta: Advisor/Consultant|Pattern Biosciences: Advisor/Consultant|Pfizer: Advisor/Consultant
1209. Let’s take a time-out: Implementing a standardized process to assess the clinical use of vancomycin for pharmacists
Authors: Oderinde Jennifer , Chiang Anthony , Juska Alicia , ADEYEMI O L U W A D A M I L O L A A
Published: November 2023

Background

Vancomycin is often started empirically for its reliability with gram-positive pathogens, particularly Methicillin Resistant Staph aureus (MRSA). Consequently, it is often over-prescribed. Antimicrobial stewardship programs (ASP) have used time-outs to ensure therapies are tailored to the patient with proper indication and coverage. This study aims to evaluate the impact of a standardized vancomycin time-out to optimize utilization and safety.

Methods

This is a pre-/post-implementation study conducted at a community teaching hospital. The study was separated into a pre-implementation phase (July-September 2022), implementation/teaching phase (October 2022), and post-implementation phase (November 2022-February 2023). Study subjects included inpatient adults on vancomycin for longer than 48 hours. Patients who are immunocompromised, hospice, or on a vancomycin regimen prior to admission were excluded.

Primary outcomes include (1) percent appropriate vancomycin continued after time-out, (2) percent inappropriate vancomycin discontinued during time-out, and (3) time to de-escalation. Additional outcomes include vancomycin days of therapy (DOT) per 1000 patient days, hospital length of stay, and acute kidney injury (AKI) incidence rate.

This study looked at 182 patients in the retrospective arm and 214 patients in the prospective arm. Preliminary data was initially presented at the Illinois Pharmacy Residency Conference when only 195 total patients had been reviewed.

Results

There was a statistically significant difference seen in percent appropriate vancomycin continued after time-out, with 57% and 40.2% seen in the prospective and retrospective arm respectively. The percent inappropriate vancomycin discontinued during time-out was also statistically significant with 69.9% and 38.8% respectively. With a time-out, average days to discontinuation for continued inappropriate regimens, and overall vancomycin DOT were decreased. There was no significant difference seen in safety outcomes including AKI incidence rates.

Conclusion

Pharmacy driven time-outs are useful for promoting antimicrobial stewardship and can contribute to decreased vancomycin use,

Disclosures

All Authors: No reported disclosures
1212. Impact of Infectious Diseases Fellow Collaboration in the Medical Intensive Care Unit and Medical Intermediate Unit on Antimicrobial Utilization in COVID-19 Patients
Authors: Rajput Smit , Mikell Franklin , Kipp Aaron , Emberger Jennifer
Published: November 2023

Background

During the COVID-19 pandemic, historic gains made in antibiotic stewardship were challenged as antibiotic utilization for patients with COVID-19 increased despite low co-infection rates, as evidenced by a 15% increase in resistant infections 2019 - 2020. Studies demonstrate that input of an infectious diseases (ID) specialist can improve appropriate antibiotic use without increasing length of stay or mortality. But, there is limited data on this among COVID-19 patients. We evaluated the impact of an ID fellow rounding in the Medical ICU (MICU) and medical intermediate unit (MIU) on antibiotic prescribing among COVID-19 patients admitted to a tertiary care center in eastern North Carolina.

Methods

An ID fellow rounded with the MICU and MIU teams twice weekly to provide antibiotic guidance from 3/21-6/21. The intervention group comprised patients admitted with COVID-19, prescribed antibiotics, and receiving antibiotic guidance. Concurrent (3/21 - 6/21) and retrospective (11/20 – 1/21) controls met the same criteria but without ID fellow antibiotic guidance. Antibiotic and other data were obtained from chart review. Prescribing rates (antibiotic days per 1000 hospital days) were calculated and compared using Poisson regression to estimate rate ratios while controlling for covariates.

Results

Analysis included 48 intervention patients, and 38 concurrent and 64 retrospective controls. The intervention group had higher BMI, longer hospital stay, and more frequent ICU stay than either control group (Table 1). The median prescribing rate in the intervention group (788.9 antibiotic days per 1000 hospital days) was lower than the retrospective controls but higher than the concurrent controls (Figure 1). Upon adjusting for covariates, the intervention group had a 32% lower antibiotic prescribing rate than retrospective controls (rate ratio: 0.68; 95% CI: 0.50 – 0.77). A similar result was seen when compared to the concurrent controls (Table 2).

Table 1

Demographic, clinical, and hospital stay characteristics, by intervention group, among those prescribed any antibiotics

Figure 1

Median antibiotic days per 1,000 hospital days, by intervention group

Table 2

Adjusted analysis of antibiotic prescribing rate (per hospital stay) 1: Adjusted for age, BMI, and spending time in the ICU (Yes/No) 2: Restricted to only the Concurrent Control and Intervention group, Adjusted for age, BMI, and spending time in the ICU (Yes/No)

Conclusion

We found a significant reduction in antibiotic prescribing among COVID-19 patients when an ID fellow provided antibiotic guidance. Our study contributes to the growing body of data that ID providers are critical to the fight against antimicrobial resistance and are valuable resources in determining the need for antimicrobials.

Disclosures

All Authors: No reported disclosures
1219. Utility of Plasma Microbial Cell-Free DNA Testing for Therapeutic Management and Antimicrobial Stewardship
Authors: Thompson Riley , Donnelley Monica , Thompson George R , Desai Angel
Published: November 2023

Background

Microbial cell-free DNA (mcfDNA) sequencing is a promising potential tool in the detection of infectious pathogens when traditional methods fail to identify the causative agent. It may be particularly helpful in identifying pathogens that are present at low levels or that do not grow well in standard culture. The aim of this study was to determine whether plasma mcfDNA sequencing resulted in a change in therapeutic management.

Methods

A retrospective cohort at UC Davis Medical Center was reviewed. All patients, both pediatric and adult, that underwent plasma mcfDNA (Karius) sequencing between December 11th, 2019, and January 4th, 2023, were included. Patient demographics, comorbid conditions, immunocompromised status, indication for testing, pre and post antimicrobial therapies from when the sample was collected, pathogen identified, ID consultation status, and ordering service at the time of testing were recorded. Each patient was analyzed by two independent reviewers for clinically significant microbial findings, treatment, and reviewer concordance with therapeutic management. If discordance between reviewers was present, a third reviewer analyzed the data.

Results

A total of 127 Karius tests were reviewed from 71 patients. Baseline characteristics included 62 (48%) pediatric and 65 (51%) adult tests. 25 (33%) tests were from female patients, and 37 tests (50%) were obtained from immunocompromised patients. The most frequent adult ordering services included the Medical Intensive Care Unit and Bone Marrow Transplant Unit. The most frequent pediatric ordering services included the Pediatric Intensive Care Unit followed by General Pediatrics. 69 (95%) of tests had a formal Infectious Diseases consultation associated with testing. 22 (30%) tests resulted in a change in antimicrobial therapy, and 35 (47%) of tests resulted in a clinically significant organism.

Conclusion

In this retrospective cohort study conducted at a single center, Karius testing resulted in clinically significant pathogens in less than half of all tests conducted, and most test results did not lead to a change in therapeutic management. Testing in certain clinical scenarios or high-risk settings may be warranted, however further studies are needed.

Disclosures

George R. Thompson, III, MD, Astellas: Advisor/Consultant|Astellas: Grant/Research Support|Cidara: Advisor/Consultant|Cidara: Grant/Research Support|F2G: Advisor/Consultant|F2G: Grant/Research Support|Mayne: Advisor/Consultant|Mayne: Grant/Research Support|Melinta: Advisor/Consultant|Melinta: Grant/Research Support|Mundipharma: Advisor/Consultant|Mundipharma: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support
1952. Second Time’s the Charm? Low Yield of 3 AFB Smears among Inpatients Evaluated for Pulmonary Tuberculosis
Authors: Dugdale Caitlin , Zachary Kimon C , McEvoy Dustin S , Courtney Amy , Craig Rebecca L , Germaine Lindsay , Green Chloe V , Hooper David C , Hyle Emily P , Paras Molly L , Shenoy Erica S
Published: November 2023

Background

Among inpatients with suspected tuberculosis (TB), CDC and IDSA guidelines recommend collecting three respiratory specimens 8-24 hours apart for acid-fast bacilli (AFB) smear and mycobacterial culture. However, data supporting this approach are limited, particularly in the era of Xpert MTB/RIF PCR assays (Xpert). Our objective was to estimate the sensitivity of 1, 2, or 3 AFB smears +/- Xpert to detect pulmonary TB in a low incidence setting.

Methods

We conducted a retrospective study of inpatients at a large U.S. academic medical center with mycobacterial culture performed on one or more respiratory specimens July 2016 – December 2022. AFB smear microscopy, Xpert, or both, were performed on each specimen. We evaluated percent positivity on serial AFB smears and on Xpert among patients with confirmed TB, as well as the yield of a third AFB smear among all patients tested.

Results

A total of 7,445 inpatients underwent 15,710 mycobacterial cultures on respiratory specimens, of whom 52 (0.7%) were diagnosed with culture-positive pulmonary TB (Figure 1). Among patients with TB, the first AFB smear was positive in 22/52 (42%) cases and a second AFB smear was positive in 5/24 (21%) cases; there were no cases in which a third AFB smear was positive after two initial negative smears (Table 1). Among 1,523 instances in which a third specimen was obtained among patients with and without TB, the third sample yielded a diagnosis of TB by culture in 1 case. Overall sensitivity to detect a positive AFB smear or Xpert result among patients with TB was equivalent between 2 and 3 AFB smear pathways at 52%. Overall sensitivity to detect TB prior to culture positivity was highest with addition of an Xpert to 2 or 3 AFB smears at 67% (Table 2).

Conclusion

In a low incidence setting, TB screening with 2 AFB smears offers the same diagnostic yield as with 3 AFB smears while potentially reducing laboratory burden and duration of patient isolation. Xpert demonstrated high sensitivity for detection of TB, and it increased sensitivity to detect TB when added to AFB smear-based screening alone. However, a quarter of patients with TB diagnosed by mycobacterial culture were not detected by AFB smear or PCR, highlighting the importance of using clinical judgement when discontinuing isolation.

Disclosures

Emily P. Hyle, MD MSc, UpToDate.com: Royalties Molly L. Paras, MD, Angiodynamics: Honoraria|Angiodynamics: Honoraria
1226. Differences in diagnosis and procedure codes used among 5 Veterans Affairs telehealth antibiotic stewardship services
Authors: Abdelrahim Sara A , Wilson Brigid , Vivo Amanda , Walkner Tammy , Ewers Tola M , Livorsi Daniel J , Crnich Christopher J , Sabzwari Rabeeya , Webster Andrew S , Epstein Lauren H , Milner Amelia , Jump Robin L , Evans Charlesnika T , Bej Taissa A
Published: November 2023

Background

Telehealth offers an opportunity for rural healthcare settings to connect with infectious disease (ID) experts to augment clinical care of people with suspected infections and to support antimicrobial stewardship efforts. We are currently disseminating a project that uses Veterans Affairs (VA) telehealth systems to connect multidisciplinary teams from rural VA medical centers with ID experts at geographically distant locations to form Videoconference Antimicrobial Stewardship Teams (VASTs). Here, we used diagnosis and procedure codes to describe preliminary outcomes from 5 VASTs, assessing the time used for each consult as well as the infectious and other clinical syndromes discussed.

Methods

We extracted Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Revision (ICD-10) codes associated with clinical encounters from January 2022 – April 2023 for 5 VASTs. CPT codes indicated the time spent by the ID expert. ICD-10 codes were summarized into the following broad categories: infections, pathogens, other clinical diagnoses, signs and symptoms, treatments, and administrative codes.

Results

A total of 315 cases were discussed across all 5 sites, with most cases taking < 30 minutes to complete (210; 67%; Figure 1). The cases yielded 600 ICD-10 codes, of which 219 (36%) described an infection and 165 (27%) described other medical diagnoses (Figure 2). The number of ICD-10 codes per consult ranged from 1.0 (Sites A and C) to 3.5 (Site D). Overall, the most common infections discussed pertained to the respiratory tract (57/219, 26%) and skin and soft tissue (53/219, 24%); the most common pathogen code was for Enterococcus spp. (10/59, 17%) (Figure 3).Figure 1:Length of Time per ConsultFigure 2:Types of ICD-10 CodesFigure 3:ICD-10 Codes for Infections

Conclusion

Our results reveal notable differences in the diagnosis and procedure codes used across the 5 VASTs. In general, the VASTs address a similar array of infectious disease syndromes, suggesting that the observed differences may relate to how the ID experts approached coding. Further evaluations will assess the patients discussed and may consider further evaluation of coding practices used for telehealth.

Disclosures

Daniel J. Livorsi, MD, Merck: Grant/Research Support Robin L. Jump, MD, PhD, Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support
1227. Analysis of Prescriber Interaction with an Electronic Antibiotic Time-out Best Practice Alert
Authors: Ackley Tyler , Bilinskaya Anastasia , Kuti Joseph L , Linder Kristin E , Dempsey Casey J
Published: November 2023

Background

The impact of antibiotic time-outs (ATOs) on antibiotic use relies heavily on prescriber interaction, which may be reduced due to workflow disruption or alert fatigue. In August 2022, Hartford HealthCare implemented a 72-hour ATO best practice alert. Herein, we evaluated prescriber behavior when interacting with the ATO alert to assess the impact on prescriber stewardship workflow.

Methods

An ATO alert was designed to fire between 0700 and 1630. Upon firing, prescribers were prompted to assess for antibiotic modification – a composite including discontinuation, de-escalation, inclusion of stop-date, and transition to oral therapies. Additional responses were included to defer re-firing for patients deemed not to be a candidate for antibiotic modification. The primary endpoint was defined as the rate of ATO response aligning with antibiotic modification for the 10 most frequently utilized antibiotics and assessed from 10/1/22 – 12/31/22. A predefined subset of patients was evaluated for ATO appropriateness by prescriber specialty and role.

Results

A total of 15,383 ATO alerts were included for analysis, corresponding to 3,498 unique patients. The primary endpoint occurred in 21.4% of cases. The most commonly selected ATO response was a reminder in 10 minutes (48.2%). The median time viewing the ATO alert was 5 seconds (IQR 4 – 8s). In a subset of 400 patients, ATO selections were found to be appropriate in 56% of cases. When stratified by prescriber role, attending physicians were more likely to appropriately utilize the ATO compared to resident and advanced practice practitioners (62.7% vs 48.5% vs 46.2%, p = 0.007) and were more likely to select an ATO response aligning with antibiotic modification (39.5% vs 7.6% vs 12.3%, p < 0.001).

Conclusion

ATO selection corresponding to antibiotic modification was low regardless of prescriber role. Further work optimizing the ATO design will be required to improve integration into stewardship workflow.

Disclosures

Joseph L. Kuti, PharmD, bioMeriuex Inc.: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Merck & Co, Inc: Grant/Research Support|Shionogi Inc: Advisor/Consultant|Shionogi Inc: Grant/Research Support|Shionogi Inc: Honoraria
1229. Outpatient Penicillin and Sulfonamide Antibiotic Allergy E-Consult Service in Prospective Solid Organ Transplant Recipients
Authors: Bair Amanda M , Joshi Shyam , Anstey Karen , Streifel Amber C , Ham YoungYoon
Published: November 2023

Background

Solid organ transplant recipients (SOTr) are at increased risk for infections post-transplantation. A penicillin allergy incidence of 12% and sulfonamide antibiotic allergy incidence of 9% has been reported in transplant recipients. Documented penicillin and sulfonamide allergies lead to the unnecessary use of broad-spectrum antibiotics or suboptimal therapy leading to further adverse consequences. The purpose of this study is to improve the rates of antibiotic allergy delabeling in SOTr prior to transplantation through the implementation of an allergy testing pilot program.

Methods

From December 15, 2022 to April 28, 2023, prospective SOTr with a penicillin and/or sulfonamide allergy that was tested and delabeled at OHSU were included in this study. This process involves a clinical pharmacist contacting the patient and collecting a detailed allergy history via an e-consult. The e-consult is then routed to one of our allergists to determine patient testing eligibility. If the patient qualifies for testing, they are scheduled for a nurse visit at the clinic. After testing is completed, patients are notified of their results and the allergy is removed from their electronic health record with accompanying documentation.

Results

A total of 86 patients were evaluated for allergy testing (61% penicillin allergies and 39% sulfonamide allergies). Fourteen patients were successfully delabeled through the pilot program with one of the patients having both a penicillin and sulfonamide allergy delabeled. The primary reason for patients being excluded from this study was due to insurance not covering allergy testing done at OHSU as shown in Table 1. Although not included in the pilot program, 7 patients were successfully delabeled by obtaining a detailed allergy history and did not require allergy testing. Twenty-two patients have a future allergy testing appointment scheduled.Table 1:Patient Inclusion and Exclusion

Conclusion

The preliminary results of our study show the implementation of an e-consult service for antibiotic allergy testing in prospective SOTr prior to transplantation is an effective method for allergy delabeling. Allergy testing in this patient population has the potential to significantly improve the selection of antibiotics available for treatment as well as prophylaxis.

Disclosures

Shyam Joshi, MD, Cogent: Honoraria|Leo Pharma: Honoraria|Nectar Allergy: Advisor/Consultant|Nectar Allergy: Stocks/Bonds|Sanofi/Regeneron: Advisor/Consultant|Sanofi/Regeneron: Honoraria|Takeda: Honoraria
1237. Inpatients with a beta-lactam antibiotic allergy label (BAAL) and unrevealed tolerance: A prevalence study aimed to prioritize non-invasive delabeling for antimicrobial stewardship programs
Authors: Dickens Michael , Wang Sheila K , Weslander Erin , Qin Mingyu , Tran Hoang , Khankan Nour , Sutton Sarah , Peters Anju T , Watts Melissa M , Postelnick Mike
Published: November 2023

Background

This study aimed to use data analytics to retrospectively identify the prevalence of inpatients across a system of hospitals with a BAAL who received and tolerated the culprit or related beta-lactam (BL) without proper documentation in the allergy profile of the electronic medical record (EMR). Findings from this study could prioritize direct non-invasive delabeling opportunities as a feasible process measure for resource limited antimicrobial and diagnostic stewardship programs (ADSP).

Methods

Eligible patients were generated by a data analyst using the Northwestern Medicine (NM) Enterprise Data Warehouse. Patients eligible for inclusion: 1) adults > 18 years of age, 2) inpatients at a NM System Hospital (NMSH) with > 1 overnight stay between 8/1/2020 and 8/1/2022, 3) a BAAL in the allergy profile of the EMR, and 4) received > 1 dose of a BL during the study period. Patients who only received aztreonam were excluded. The primary objective of this study was to determine the prevalence of inpatients with a BAAL who received and tolerated the culprit BL antibiotic during the study period without proper documentation in the allergy profile of the EMR. The secondary objectives were 1) to determine the prevalence of inpatients with a BAAL who received and tolerated a related BL antibiotic during the study period without proper documentation in the allergy profile of the EMR and 2) to determine the prevalence of reported BL allergy reactions and severity risk.

Results

Results of our study identified up to 751 inpatient BAALs (9.7%), including 87 BAALs of high priority, as valuable targets for early direct non-invasive delabeling, requiring minimal effort and resources from ADSP.

Conclusion

Using data analytics to empirically assess digital allergy information could streamline the antimicrobial stewardship process, proactively identifying and prioritizing BAALs to cast a wider net and efficiently achieve process measure outcomes related to allergies compared to conventional methods of delabeling.

Disclosures

Anju T. Peters, MD MSCI, Astra Zeneca: Advisor/Consultant|Astra Zeneca: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support|Optinose: Advisor/Consultant|Sanofi Regeneron: Advisor/Consultant|Sanofi Regeneron: Grant/Research Support
1239. Early Lessons Learned: Implementation of a Statewide Mobile Application for Antimicrobial Stewardship in Colorado Using the PRISM Model
Authors: Dimo Joana , Weber Matthew J , MacBrayne Christine , Miller Matthew , Parker Sarah K , Bakel Leigh Anne
Published: November 2023

Background

Antimicrobial resistance, driven by improper antimicrobial use, is a global epidemic recognized as an urgent health threat by the Centers for Disease Control and Prevention (CDC). Previous collaborative work uncovered several self-identified barriers to antimicrobial stewardship in various Colorado hospitals (n=100), the most significant being lack of clinical guidelines, dosing knowledge in pediatric populations, and understanding stewardship methodologies.

Methods

The overarching goal was to mitigate the self-identified barriers from prior studies through implementation of a mobile application decision support system (Firstline). We used the Practical Implementation Sustainability Model (PRISM) and RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework for implementation. We describe barriers encountered by our team as lessons learned for others considering similar implementation.

PRISM Domains and RE-AIM Framework

We used the Practical Implementation Sustainability Model (PRISM) to identify contextual factors and the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework for implementation of a mobile application to improve antimicrobial stewardship in Colorado.

Results

Utilizing PRISM domains, we evaluated if Firstline aligned with our organization’s priorities and offered an acceptable balance of practice and efficiency. Several barriers were encountered including navigating differing strategic planning approaches, financial relationships, and contracural arrangements among potential institutional partners, and navigating data sharing and liability for outfacing content. The external environment factors we evaluated included compliance performance measures, policies, and regulations to incentivize continued use of the application. We used the PRISM domains identified to develop our RE-AIM outcomes. Effectiveness will be measured through distribution of in-application surveys and user feedback. Implementation will be assessed though tracking use of the application by users, general location, and content used. For rural and critical access hospitals, adoption of the application may aid Joint Commission antimicrobial stewardship compliance, and is anticipated to contribute to maintenance.

Conclusion

Use of PRISM helped elucidate and mitigate early implementation barriers including understanding institutional strategic planning, financial relationships, and legal significance of data sharing. Using RE-AIM, we will monitor our mobile application implementation success.

Disclosures

All Authors: No reported disclosures
1244. Antimicrobial Stewardship Knowledge, Attitudes, and Practices (KAP) Among Nurses
Authors: Hayes Jillian E , Perez Reinaldo , Winters Ali R , Moehring Rebekah W , Wrenn Rebekah
Published: November 2023

Background

Nurses are underutilized members of the antimicrobial stewardship (AS) team. Understanding knowledge, attitudes, and practices (KAP) is essential to designing effective AS initiatives. While KAP surveys have been performed among a variety of provider types, less is known about KAP among nurses. We describe KAP pertaining to AS among nurses at a large, academic hospital.

Methods

An electronic, 24-question KAP survey was designed by the AS team with relevant nursing and infection prevention champions. Nine knowledge-based questions about antimicrobials focused on 4 domains: beta-lactams first in sepsis, intravenous to oral transition, urinary tract infections, and penicillin allergies. Voluntary responses were collected via Qualtrics from January 9, 2023-March 31, 2023. Surveys were distributed by email link, with reminders to enhance survey response. Incentives included a chance to win a meal voucher.

Results

85 complete survey responses were received. The majority of respondents worked on dayshift (69%) in a staff nurse role (66%). Discrepancies were seen in perceptions of issues of stewardship nationally and locally. While nurses felt antimicrobial resistance and harm caused by antimicrobials are high nationally (92 and 69%, respectively), this was not as commonly felt to be true on a local level (35% and 26%). The majority (87%) agreed or strongly agreed that nurses’ responsibility includes promoting appropriate antimicrobial use. When assessing knowledge of AS domains, reported confidence in performance was discordant with actual performance and differed by domain (Figure 1). Respondents were largely unfamiliar with common AS reference resources (73-74%) and were more likely to consult an ID pharmacist (81%), ID physician (78%) or infection prevention team member (78%) with questions.

Conclusion

Nurses recognized AS as an important part of their professional responsibilities, but perceived AS opportunities to be a national rather than local need. Differing patterns in knowledge vs. confidence among topic domains provides key information to then design relevant, sustainable, nurse-driven antimicrobial stewardship initiatives.

Disclosures

Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties