bluuebunny/crossref_metadata_2025 huggingface dataset:
1741. Antibiotic Prescribing Practices in Pediatric Acute Respiratory Illnesses in Northern Vietnam
Authors: Nguyen-Tran Hai D , Nguyen Nam , Ngo Long N , Nguyen Trang , Do Nga , Olson Daniel , Lewycka Sonia
Published: December 2022

Background

Antimicrobial resistance (AMR) is a global challenge and influenced by several factors including antibiotic overprescribing. Antibiotics are frequently prescribed in Vietnam, especially in pediatric acute respiratory illnesses (ARIs). Understanding prescribing practices for pediatric ARIs is important to help identify areas for improved practices to prevent overprescribing and AMR.

Methods

We performed a retrospective review of pediatric patients aged 0-15 years with an ARI diagnosis based on ICD-10 codes from January 1-December 31, 2019 in 112 primary care centers in Northern Vietnam. Variables collected included age, sex, district, antibiotic prescribed, World Health Organization access, watch, reserve classification (WHO AWaRe), symptomatic agents prescribed, and signs and symptoms. Data was analyzed using descriptive statistical analysis.

Results

A total of 35,679 encounters were reviewed. Of all encounters, 34,018 (95.3%) received antibiotics, and 1,650 (4.9%) of these received >1 antibiotic (Table 1). According to WHO AWaRe classification, 19.3% of children 0 to < 5 years received a watch antibiotic compared to 10.4% in those 5 to15 years. The most frequent diagnosis was acute pharyngitis (21,270 encounters, 59.6%) and 20,496 (96.4%) of those encounters received antibiotics. Common signs and symptoms reported included cough (76.3%), fever (40.9%), and erythematous pharynx (33.1%). Though acute pharyngitis was the most common diagnosis, only 168 (0.5%) and 59 (0.2%) of encounters described lymphadenopathy and exudate, respectively.

Conclusion

Antibiotics are frequently prescribed for pediatric ARIs in Northern Vietnam. Most antibiotics prescribed were WHO AWaRe access antibiotics; however, 14% were watch antibiotics or not recommended. Though acute pharyngitis was the most common diagnosis, only a few of the encounters reported signs or symptoms that would be more suggestive of acute bacterial pharyngitis warranting antibiotics. Further investigation of the appropriateness of antibiotic prescriptions are needed to help identify targeted areas of improvement in prescribing practices and help decrease the burden of AMR.

Disclosures

Daniel Olson, MD, Pfizer: Grant/Research Support|Roche: Grant/Research Support.
1744. Association Between Antibiotic Prescribing for Urinary Tract Infection (UTI) and UTI Severity of Illness Upon Admission to Hospitals in New York State
Authors: Nero Alexa , Weber Mckayla , Carreno Joseph
Published: December 2022

Background

It has been previously demonstrated that county-level antibiotic prescribing (CP) and resistance (AR) influence urinary tract infection (UTI) severity of illness upon hospital presentation in New York State (NYS, Grillo et al. IDWEEK 2021). However, previous investigations were geographically limited to the most densely populated regions of NYS. This study builds on the previous study by evaluating additional NYS regions and outcomes.

Methods

Retrospective, cross-sectional study, combining data from NYS Statewide Planning and Research Cooperative System (SPARCS) and previously published data on CP for UTI in female Medicare beneficiaries. Eligibility criteria: female patients admitted to a NYS inpatient setting in 2017, UTI (CCS 159), Medicare insurance. New York county (Manhattan) county was excluded. CP was the primary exposure. “Low” or “high” CP was based on the statewide median. Severe infection (All-patient refined severity of illness on admission ≥ 3, SI) was the primary outcome. Association between CP and SI, hospitalization costs, were evaluated using chi-square, logistic regression, Mann-Whitney U test. Log-rank test assessed time to discharge, censoring those that went to hospice or died inpatient.

Results

13,173 patients were included, 4,250 (32.3%) low CP, 8,923 (67.7%) high CP. Baseline demographics (Figure 1) that differed between groups included age, race, ethnicity, and emergency admission (P < 0.001, χ2 test). In the multivariable logistic regression analysis low CP was associated with increased odds for severe urinary tract infection after adjusting for potential confounders (aOR: 1.08 [1.003 – 1.163]). Additional factors associated with severe infection are presented in Figure 2. Median (IQR) hospital costs were similar but statistically significantly lower in the low CP group (Figure 3), median (IQR) time to hospital discharge was 4 days in each group (P < 0.001). Figure 1.Adjusted Odds Ratios for Severe Urinary Tract InfectionFigure 2.Hospital Costs

Conclusion

Low CP may be a risk factor for severe initial presentation to the hospital in UTI. Further research is needed to examine the effects of prescribing patterns and additional factors that may influence severity of infection in this setting.

Disclosures

Joseph Carreno, PharmD, MPH, Accelerate Diagnostics: Advisor/Consultant|IDbyDNA: Advisor/Consultant.
1754. Implementation of a targeted antimicrobial stewardship clinical decision support system on outpatient fluoroquinolone prescribing
Authors: Smith Savanna , Weihs Sayo , Fanizza Teri
Published: December 2022

Background

Fluoroquinolones are broad spectrum antibiotics with several Food and Drug Administration (FDA)-issued black box warnings. Due to these risks, the FDA recommends reserving fluoroquinolones for situations with no alternatives. Beginning in 2020, the Joint Commission required outpatient antimicrobial stewardship activities due to overprescribing and growing resistance to antimicrobials. The role of this study was to implement a clinical decision support system (CDSS) targeting inappropriate outpatient fluoroquinolone prescribing.

Methods

This was a single center, quasi-experimental study evaluating patients prescribed oral fluoroquinolones in an outpatient ambulatory care setting between December 1, 2020-February 28, 2021 and December 1, 2021-February 28, 2022. Patients included in this study were divided into Pre-CDSS and Post-CDSS groups if they received oral antibiotics for pre-determined indications (see table 2 for the list of indications). The primary outcome was overall reduction in outpatient fluoroquinolone prescribing. Secondary objectives were reduction in outpatient fluoroquinolone prescribing by indication, orders by provider type, appropriate fluoroquinolone dosing per renal function and incidence of an emergency department (ED) visit or hospitalization within 90 days consistent with a fluoroquinolone adverse drug reaction.

Results

A total of 2,447 (1,105 in Pre-CDSS vs. 1,342 in Post-CDSS) were included for analysis. Fluoroquinolone prescribing significantly decreased in Post-CDSS group compared to Pre-CDSS group (4.9% vs. 3.4%; p = 0.03). There was a significant reduction in fluoroquinolone prescribing in abscess (8.5% vs. 4.9%; p = 0.003), dental abscess (4.4% vs. 0%; p < 0.00001), sinusitis (2.4% vs. 0.2%; p < 0.00001) and soft skin tissue infections (5.3% vs. 0.8%; p < 0.00001). In the fluoroquinolone subgroups, prescribing per provider type and appropriate dosing per renal function were similar, and there were no adverse events leading to an ED visit or hospitalization within 90 days.

Conclusion

Implementation of a CDSS resulted in a reduction of overall and targeted indication inappropriate fluoroquinolone prescribing.

Disclosures

Teri Fanizza, Pharm.D., BCPS, BCIDP, Merck & co inc: Stocks/Bonds|Pfizer Inc: Stocks/Bonds.
1757. Regional distribution of Escherichia coli antibiotic resistance among outpatients in Washington state, 2013-2019
Authors: Fenelon Hannah T , Rabinowitz Peter M , Salm Ann , Kapoor Hema , Hawes Stephen E , Radcliff Jeff
Published: December 2022

Background

Escherichia coli is the predominant pathogen of urinary tract infections in the United States. Understanding regional patterns of uropathogenic E. coli antimicrobial resistance (AMR) may help further the practice of antibiotic stewardship through the creation of region-specific antibiograms. In this study, we analyzed regional patterns of uropathogenic E. coli AMR among outpatients in Washington state.

Methods

Deidentified results from antibiotic susceptibility tests performed by Quest Diagnostics on Washington state outpatient isolates from 2013 through 2019 were analyzed. Only the first E. coli isolate from each patient was included in the analyses. We conducted separate relative risk regressions with robust standard errors for five antibiotics (ampicillin [AMP], ciprofloxacin [CIP], ceftriaxone [CRO], gentamicin [GEN], and trimethoprim/sulfamethoxazole), classified as “susceptible” or “non-susceptible.” The state is divided into nine Public Health Emergency Preparedness Regions (PHEPRs), which served as the exposures for the analysis, with adjustment for sex, year of isolate collection, and age group (0-18, 19-50, > 50).

Results

We included 40,865 isolates in the study (93% female, mean age 47 years). Compared to the Central PHEPR (containing Seattle), most other regions had significantly lower adjusted relative risks (aRR) of AMR; no regions had significantly higher aRR of resistance for any of the five antibiotics. Differences in resistance between Central and other regions varied by antibiotic. Regional AMR differences were largest for CRO (low aRRs compared to Central) and smallest for AMP. Other patterns observed include a lower aRR of AMR for females compared to males for AMP, CIP, CRO, and GEN; higher aRR of AMR for CRO for recent years (2015-2019) compared to 2013; and higher AMR with age for CIP and CRO.

Conclusion

Given the differences in resistance across Washington’s PHEPRs, antibiograms should be tailored to provide the most regionally accurate information to prescribers. The emergent situation surrounding AMR calls for more specific outpatient antibiograms to enable healthcare providers to improve health outcomes and mitigate emerging resistance to antibiotics among outpatients.

Disclosures

Ann Salm, PhD, Quest Diagnostics Inc.: Employed and own stock in Quest Diagnostics Inc.|Quest Diagnostics Inc.: Stocks/Bonds Hema Kapoor, MD, D(ABMM), Quest Diagnsotics: Stocks/Bonds Stephen E. Hawes, PhD, InBios International: Advisor/Consultant Jeff Radcliff, B.S., Quest Diagnostics: Employee|Quest Diagnostics: Stocks/Bonds.
2301. Neurodevelopment in Infants with Antenatal or Early Neonatal Exposure to SARS-CoV-2
Authors: Mulkey Sarah B , Williams Meagan E , Jadeed Nadia , Zhang Anqing , Israel Smitha , DeBiasi Roberta L
Published: December 2022

Background

Antenatal and neonatal viral exposure may put the developing brain at risk for abnormal neurodevelopment. A clinical follow-up program was created in the Congenital Infection Program at Children’s National Hospital to follow infants with in utero or early life exposure to SARS-CoV-2. The aim of this study was to determine if infants with early SARS-CoV-2 exposure have abnormal neurodevelopment in infancy.

Methods

We performed a retrospective review of all infants evaluated in the follow-up program between 3/2020 – 11/2021. Demographic details, SARS-CoV-2 infection/testing data, pregnancy/birth data, and specialty consult and NICU records were extracted from infants’ medical charts. Infants were divided into 3 SARS-CoV-2 exposure groups: 1) antenatal exposure to symptomatic mother, 2) antenatal exposure to asymptomatic mother, 3) neonatal infection.

All infants received a neurologic exam and developmental screening with the Ages and Stages Questionnaire (ASQ) in 5 domains (Communication, Gross Motor, Fine Motor, Problem Solving, Personal-Social) during their evaluation. The ASQ accounts for prematurity.

Outcomes of interest were an abnormal neurologic exam or ASQ scores close to or below suggested cut-offs. Multivariate analysis was used to study correlations between exposure group and neurodevelopmental outcomes.

Results

Thirty-five infants were seen for up to 3 outpatient visits. Most infants (83%) were exposed in utero – 16 to symptomatic mothers (Group 1) and 12 to asymptomatic mothers (Group 2); 1 chart did not have symptom data. Six were exposed only as a neonate (Group 3).

Group 1 had abnormal neurologic exams at mean (SD) age 112 (24) days (Table 1) and ASQ scores close to or below cut-offs for all domains (Fig. 1) more frequently than Groups 2 or 3.

Group 1 was more likely to score below any ASQ cutoff compared to Group 2 (P=.04); of the 5 domains, differences were significant for Fine Motor (P=.01) and Personal-Social (P=.02).

Conclusion

Early SARS-CoV-2 exposure may impact infant development, especially among those exposed in utero to a symptomatic mother. Vaccination and other precautions to reduce spread and symptoms may protect against early neurodevelopmental delays. Future work should prioritize longitudinal follow-up of children with early SARS-CoV-2 exposure.

Disclosures

All Authors: No reported disclosures.
1762. A Review of Antibiotic Outcomes Data Utilizing the Multidisciplinary OPTIONS-DC Conference for PWUD
Authors: Douglass Alyse H , Mayer Heather , Young Kathleen , Streifel Amber C , Franklin Heather , Strnad Luke , Makadia Jina T , Sikka Monica K
Published: December 2022

Background

Persons who use drugs (PWUD) admitted for serious infections face many challenges when long courses of intravenous (IV) antibiotics are recommended. OPTIONS-DC is a structured multidisciplinary care conference used to navigate some of these challenges with harm reduction principles to consider patient preferences, decrease length of stay when safe, and support successful completion of antibiotics1. We aimed to describe antibiotic course outcomes 4 years after implementation of OPTIONS-DC.

Methods

We conducted a retrospective review of patients who had an OPTIONS-DC from February 2018 to February 2022. Any PWUD diagnosed with a serious infection requiring > 2 weeks of IV antibiotic treatment were eligible for an OPTIONS-DC. Data was collected via a REDCap database. R version 3.3.2 (R Core Team, 2016) was used for statistical analysis.

Results

144 conferences were included, for 129 unique patients. The mean age was 39.4 with 56.3% being male. The most common infections were bacteremia (52.8%) endocarditis (36.1%), and osteomyelitis (47.9%) with a mean recommended treatment duration of 5.62 weeks (Table 1). 87 (60.4%) patients with any substance use initiated medication assisted therapy (MAT) during admission including 74.5% (79/106) of those with opioid use disorder. 112 (77.8%) antibiotic courses were completed with 71 (63.4%) completed outpatient. Of those who initiated or continued MAT during admission, 83 (74.1%) completed antibiotic therapy. Course completion was similar for those discharged home at 84% (21/25) or to a Skilled Nursing Facility (SNF) 81.8% (9/11). All 18 patients who received antibiotics via home infusion vendor and 17 (81%) via infusion center completed their course. 39 (39.8%) patients received long acting IV antibiotics and 23 (23.5%) received oral antibiotics to complete their course. Average out of hospital antibiotic days for those who completed their course were 30.5. Table 1.OPTIONS-DC Table 1Table 1.OPTIONS-DC Table 1 continued

Conclusion

The OPTIONS-DC model continues to be a useful tool by incorporating harm reduction principles and patient preferences for PWUD at our hospital. Our completion rate of 77.8% and outpatient completion rate of 63.4% are higher while the patient directed discharge rate of 8.3% is lower than what is generally reported in literature for this population2-5.

Disclosures

Monica K. Sikka, MD, F2G: Site research investigator.
2308. A Nationwide Surveillance of the Clinical Presentation and Genomic Characteristics of Listeria monocytogenes Infections in Japan; Preliminary data
Authors: Shinohara Koh , Tsuchido Yasuhiro , Yukawa Satomi , Noguchi Taro , Yamamoto Masaki , Matsumura Yasufumi , Nagao Miki
Published: December 2022

Background

Listeria monocytogenes is the cause of listeriosis and is associated with foodborne outbreak and severe diseases in immunocompromised persons. However, the clinical and genomic characteristics of listeriosis remains unclear in Japan. We describe preliminary findings from a nationwide surveillance of patients and isolates of listeriosis in Japan over 11-year period.

Methods

We conducted a nationwide, multi-center retrospective study of consecutive cases with a confirmed diagnosis of listeriosis between 2011 and 2021. 25 hospitals participated in this study. Clinical characteristics, treatment and outcome were retrieved from the medical records. The preserved L. monocytogenes isolates were investigated with molecular analysis using whole genome sequencing.

Results

As of April 2022, a total of 113 cases from 16 hospitals and 26 isolates from 7 hospitals were included in this study. Sixty-one (54%) were male and median age was 74.0 (interquartile range: 64.0 – 82.0). Ten (9%) perinatal infections, 66 (58%) cases of bacteremia, 29 (26%) cases of neurolisteriosis, and eight (7%) other infections were included. In eight episodes with ten perinatal cases, four (50%) episodes experienced fetal loss or neonatal deaths. In 103 non-perinatal cases, 56 (54%) cases received immunosuppressive therapy and in-hospital mortality rate was 17.0%. In 29 neurolisteriosis cases, 13 (45%) cases were associated with poor outcome (mortality or neurological sequelae). In 26 isolates, from two perinatal infections, 13 bacteremia, 9 neurolisteriosis and two other infections, clonal complex (CC) 1, CC2 and CC3 were predominant and accounted for 18 (69%) isolates (Figure). CC1 (5/8 isolates) and CC3 (2/6 isolates) were predominantly found in neurolisteriosis. Variations of the presence of several virulence factors associated with adherence, invasion, and exotoxin were observed. CC1 and CC2 lacked ActA and Ami, whereas Listeriolysin S (LLS) were seen in CC1, CC3 and CC4.

Conclusion

In Japan, most cases of listeriosis are sporadically seen in elderly patients with co-morbidities, instead of foodborne outbreak. Outcomes of neurolisteriosis and perinatal listeriosis were poor. CC1 and CC3, which harbored LLS, were associated with neurolisteriosis.

Disclosures

All Authors: No reported disclosures.
1774. Impact of Dalbavancin as Step-Down or Salvage Therapy on Duration of Hospitalization Among People Who Inject Drugs
Authors: O’Rourke Emerald , Maguire Christina , Torgersen Jessie , Torgersen Jessie , Talati Naasha J , Binkley Amanda
Published: December 2022

Background

A well-known clinical dilemma complicating the management of infections in people who inject drugs (PWID) is the restriction of outpatient parenteral antimicrobial therapy. As a result, PWID experience prolonged hospitalizations to complete parenteral antimicrobial courses inpatient. This strategy is also associated with increased rates of patient-directed discharge (PDD). Dalbavancin, a long-acting lipoglycopeptide, serves two unique roles in this population: step-down therapy to decrease inpatient length of stay once clinically stable and salvage therapy in the setting of imminent PDD.

Methods

This retrospective review of PWID from November 2019 through October 2021 identified patients in which on- or off-label dalbavancin could be considered. Day of hypothetical dalbavancin administration was determined when both ≥7 days of therapy and ≥48 hours of clinical stability (non-critical unit, afebrile, resolved leukocytosis, and source control or negative blood cultures) were completed. Included patients had ≥7 days of therapy remaining at time of hypothetical dalbavancin administration. A one-time dalbavancin dose was considered to provide up to 14 days of antimicrobial coverage. Patients were included in either the step-down cohort (completed entire parenteral antimicrobial course inpatient) or salvage therapy cohort (PDD prior to completing course). The number of potentially preventable inpatient days with dalbavancin and readmissions due to infection progression were assessed in each cohort, respectively.

Results

Nineteen patients were identified as potential dalbavancin candidates. In the step-down cohort (n=11) a one-time dalbavancin dose prevented a maximum of 146 inpatient days. In the salvage cohort (n=8), hypothetical dalbavancin administration at time of PDD could have prevented six readmissions due to infection progression, associated with 36 additional inpatient days.

Conclusion

Inpatient administration of dalbavancin may bridge treatment disparities experienced by PWID by reducing unnecessary inpatient days for parenteral antibiotic administration and by preventing hospital readmissions attributable to inadequate antimicrobial course.

Disclosures

All Authors: No reported disclosures.
1775. Interns and Residents’ Knowledge and Perspective on Appropriate Use of Antibiotics for Urinary Tract Infections and Skin and Soft Tissue Infections in the Hospital Setting
Authors: Motoa Gabriel , Borick Joseph , Bhatia Monisha , Bjork Lauren , Lichtenberger Paola
Published: December 2022

Background

Antibiotic resistance is recognized as a significant threat to public health worldwide. The rate of inappropriate use of antibiotics in hospitals has been reported as high as 50%. Exposure to suboptimal antibiotic therapy is associated with higher risk of infections with multidrug-resistant organisms and worse clinical outcomes. In academic hospitals, interns and residents are frontline worker who diagnose and treat infectious diseases (ID). The treatment of urinary tract infections (UTIs) and skin and soft tissue infections (SSTIs) is a common clinical scenario managed by these trainees.

Methods

A structured, anonymous questionnaire was sent via institutional email to internal medicine interns and residents rotating in three academic hospitals in Miami, FL. The 23-item questionnaire included knowledge questions on rational use of antibiotics and duration of therapy for complicated and uncomplicated UTIs, SSTIs, correct renal dosing of frequently used antibiotics and antivirals, and perception of confidence in antibiotic prescription. Data were entered to Microsoft Excel spreadsheet, then analyzed using JMP Pro software.

Results

A total of 36 preliminary and categorical interns, and 38 second-and third-year residents completed the initial questionnaire. The mean correct knowledge score on the treatment of UTIs was 52.8% (19/36) for interns and 76.3% (29/38) for residents, respectively. For SSTIs, the scores were 38.9% (14/36) and 65.8% (25/38); and for correct renal dosing of antibiotics, the scores were 47.2% (17/36) vs. 73.7% (28/38). Most of the interns (58.3%, 21/36) did not feel confident prescribing antibiotics for these conditions compared with 18.4% (7/38) of the residents.

Conclusion

In this cross-sectional study, interns had lower correct knowledge scores and confidence when prescribing antibiotics for UTIs and SSTIs compared to residents. There is room for improvement in advanced years of training. Further studies are necessary to assess the impact of implementing educational strategies to promote the appropriate use of antibiotics. We plan to address this through a pre-/post implementation We will compare antibiotic prescribing patterns and patient outcomes for these indications at one of our three clinical training sites.

Disclosures

All Authors: No reported disclosures.
2309. Ceftaroline for Central Nervous System and Ocular Infections
Authors: Siegrist Emily A , Sassine Joseph
Published: December 2022

Background

Ceftaroline is increasingly used in combination therapy for methicillin resistant Staphylococcus aureus (MRSA) bacteremia. Animal models suggest ceftaroline penetrates the central nervous system (CNS) and vitreous humor; however, there are limited data which describe outcomes of patients treated with ceftaroline for infections with CNS or ocular involvement.

Methods

This was a single-center, retrospective study at an academic medical center. The primary objective was to describe outcomes in patients treated with ceftaroline for CNS or ocular infections. Patients who received ceftaroline from January 2015 to February 2022 were identified. Patients > 18 years who received > 48 hours of ceftaroline and had evidence of CNS or ocular involvement were included. Descriptive statistics were used.

Results

Ten patients met the inclusion criteria: six with CNS and four with ocular infections. The cohort was predominantly white (90%) and male (70%). The most common comorbidities were hypertension (70%) and diabetes (40%) (Table 1). Nine patients were treated for MRSA and one patient was treated for methicillin resistant Staphylococcus epidermidis (Table 2). Ceftaroline was salvage therapy in nine patients (90%), often following vancomycin and used as part of combination therapy (Table 3).

Of the four patients with ocular infections, all had MRSA bacteremia. Two patients (50%) had positive vitreal cultures and received intra-vitreal injections (Table 2). Most of these patients (75%) died during admission (Table 4). Of the six patients with CNS infections, injection drug use was more common than in patients with ocular involvement (33% vs 0%), as was immunocompromise (50% vs 0%) and the presence of endocarditis (33% vs 0%). Of the patients with CNS involvement, three had abnormal lumbar punctures and the remainder were diagnosed by CNS imaging (Table 2). Four patients with CNS involvement survived hospital stay (67%), and one of these had recurrence of CNS infection within 90 days (Table 4).

Conclusion

Although patients with CNS or ocular involvement represent a severely ill subset of staphylococcal infections, ceftaroline is a promising agent in combination therapy. Comparative data is needed to validate these findings.

Disclosures

All Authors: No reported disclosures.
1780. Analysis of Appropriate Outpatient Prescriptions based on Diagnosis Codes, Tennessee, 2020
Authors: Ouedraogo Youssoufou , Evans Christopher D , Wilson Christopher , Staub Milner B , Katz Sophie E
Published: December 2022

Background

In the US, approximately 60% of antimicrobial prescriptions (Rx) are written in the outpatient setting, and roughly 30% of those are unnecessary. The Tennessee Department of Health (TDH) previously described outpatient antimicrobial use in 2016 and 2018. TDH acquired additional data from the IQVIA Longitudinal Prescription and Medical Claims datasets. We sought to link antimicrobial Rx to diagnosis claims from preceding outpatient office visits to measure appropriateness of statewide antimicrobial Rx.

Methods

IQVIA medical claims data and antimicrobial Rx data for calendar year 2020 were used in this study. A unique patient ID was used to track antimicrobial Rx over time. Prescriptions filled within 7 days after a patient’s medical visit were included. Diagnoses codes from the medical visits were categorized as Tier 1 (diagnoses that always require antimicrobial therapy) and Tier 3 (diagnoses that never require antimicrobial therapy). Tier 2 diagnoses were excluded. We compared Tier 1 prescriptions versus Tier 3 Rx volume.

Results

We identified 2.3 million Rx linked to a preceding outpatient office visit within 7 days; 70.5% were filled within 3 days of the corresponding office visit, 14.1% within 4–5 days, and 15.4% within 6–7 days. Of all included Rx, 16.4% were prescribed following a pure Tier 1 diagnosis, and 83.6% were prescribed following a pure Tier 3 diagnosis. Diagnoses for respiratory conditions accounted for 38.4% of the pure Tier 3 visits, urinary tract conditions for 17.7%, gastrointestinal conditions for 16.2%, and skin and soft tissue conditions for 15.8%. For the respiratory conditions, viral upper respiratory infection accounted for the highest percent of antimicrobials prescribed (27.1%), followed by asthma/allergy indications (17%), and bronchitis (8.9%).

Conclusion

A significant number of antimicrobials prescribed in Tennessee in 2020 were able to be linked to office visit diagnosis codes. Most Rx were prescribed for indications that do not require antimicrobial therapy. Respiratory conditions accounted for the highest percentage of visits resulting in antimicrobial therapy that did not require treatment. Continued educational efforts and provider feedback of these data are planned to combat unnecessary overprescribing in Tennessee.

Disclosures

Milner B. Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds.
1784. Appropriateness of Intravenous Vancomycin in a Canadian Acute Care Hospital
Authors: Glassman Heather , Ismail Arif , Smith Stephanie W , Stewart Jackson J , Lau Cecilia , Kabbani Dima , Chen Justin Z
Published: December 2022

Background

Intravenous (IV) vancomycin is a commonly prescribed antimicrobial. However, there is limited literature assessing IV vancomycin appropriateness. The objective of the study was to assess the appropriateness of IV vancomycin prescriptions in a Canadian acute care hospital.

Methods

Prospective audit and feedback (PAF) was conducted on all new IV vancomycin prescriptions in hospitalized adults (age ≥ 18 years) at the University of Alberta Hospital from January 17 to February 11, 2022. Appropriateness was assessed against institutional prescribing guidelines (Bugs & Drugs® and Alberta Health Services Formulary Prescribing Guidelines). Verbal and written feedback were provided to the attending teams.

Results

A total of 109 prescriptions were audited. Median age was 57 (IQR 43-72) years and 42% were female. 65 (60%) were admitted to Medicine, 18 (17%) to Surgery, and 26 (24%) to Intensive Care units. MRSA colonization was present in 32 (29%) patients, β-lactam allergy recorded in 21 (19%), and acute kidney injury (AKI) in 21 (19%). Infectious Diseases consultation (IDC) occurred in 29 (27%). The top indications were skin and soft tissue, pulmonary, and bloodstream infections (Table 1); 70% of prescriptions were empiric in nature.

Overall, 43 (39%) prescriptions were assessed to be suboptimal. Antimicrobial Stewardship program (ASP) recommendations were made in 56 prescriptions, totaling 63 unique recommendations. Vancomycin was recommended to be discontinued in 24 (43%) cases or changed to a different agent in 15 (27%). Regimen optimization (duration or frequency change) was recommended in 4 (7%). ASP recommended investigations in 8 cases and IDC in 12. Full or partial acceptance was achieved in 49 cases (88%).

IDC was associated with greater appropriateness (83% vs 53%, p=0.004) as was MRSA colonization (75% vs 55%, p=0.047), but AKI was not (62% vs 60%, p=0.888). Adjusting for age, AKI, and MRSA colonization, IDC remained a significant predictor of vancomycin appropriateness (OR=4.27, [95%CI 1.44-12.70]; p=0.009).

Conclusion

IV vancomycin prescriptions were suboptimal in 39% of cases. IDC was associated with increased appropriateness. This pilot informs the need for antimicrobial stewardship intervention and the importance of IDC at our center.

Disclosures

Dima Kabbani, MD, MSc, AVIR Pharma: Grant/Research Support|AVIR Pharma: Honoraria|GSK: Honoraria|Merck: Grant/Research Support.
1789. Current Antibiotic Prescription Practices in Hospitalized Patients with Acute Myeloid Leukemia (AML) and Febrile Neutropenia of Unknown Origin (FN-FUO): Data from a Large Tertiary Community Hospital
Authors: Portales-Castillo Carlos , Laguio-Vila Maryrose R
Published: December 2022

Background

Optimal duration of empiric antibiotic therapy in hospitalized patients with febrile neutropenia of unknown origin (FN-FUO) remains controversial. Emerging evidence suggests that early discontinuation of antibiotics at 48-72 hours of apyrexia is safe regardless of neutrophil count. However, in the U.S., the adoption of this and other antibiotic use practices in these patients remains unstandardized and understudied, particularly in community hospitals. In this pilot study, we sought to evaluate current antibiotic prescription practices in our large community hospital in admitted patients with AML and FN-FUO.

Methods

We conducted a retrospective cohort study from January 1st, 2020 to December 16th, 2021. All patients admitted with a diagnosis of AML and febrile neutropenia (FN) were screened and those with FN-FUO, defined as no microbiological growth on blood, respiratory or urine cultures at 48 hours of first fever were included. Data on initial antibiotic choices, use of vancomycin and its congruence with IDSA guidelines, mean days of therapy (DOT), mean days of “excess” therapy (DOET), defined by days of antibiotics after >72 hours of apyrexia and total DOET were obtained by medical record review and descriptive analysis was performed.

Results

A total of 65 patients with FN were screened. After screening, 27 patients met criteria for inclusion and data from their hospital stay was obtained (Table 1). Cefepime was the preferred choice of initial intravenous β-lactam in 85% of cases and piperacillin-tazobactam was used in the remainder of cases. Vancomycin was used initially in 55% of cases out of which its use was considered to be incongruent with IDSA guidelines in 25% of cases. The most common reason for IDSA incongruent use of vancomycin was lack of documentation for its use. Mean DOT was 10 and mean DOET was 3 (Table 2). In total, we identified 87 excess days of antibiotic therapy in this cohort.

Conclusion

Little is known about antibiotic prescription practices in high risk FN-FUO patients in community hospitals. Our findings highlight potential concrete antibiotic stewardship targets and shortening this knowledge gap may help guide the development of interventions that have been previously shown to improve clinical outcomes in this overall underrepresented population.

Disclosures

All Authors: No reported disclosures.
1790. Dethroning Vancomycin: A Multifaceted Stewardship Approach to Reduce Vancomycin in an Academic Medical Center
Authors: Lusardi Katherine , Bailey Brett , Rico Crescencio Juan Carlos , Awad Ramez , Jenkins Mitchell , Dare Ryan K
Published: December 2022

Background

Vancomycin is a broadly used antimicrobial, and from 2014-2022 represented the most used antibiotic at our academic medical center. Since 2015, the stewardship program has introduced several measures to optimize vancomycin use including pharmacy consultation, addition of MRSA nares PCR testing, embedding MRSA nares PCR order into vancomycin order panel, and introducing an electronic medical record (EMR) best practice alert to assist providers in identifying patients eligible for vancomycin discontinuation. The impact of each of these interventions are described.

Methods

This is a retrospective, single academic center, comparison of vancomycin utilization over time, following the introduction of various stewardship measures. Each intervention remained in place during subsequent periods. Wilcoxon rank sum was used for analysis. Period 1 (P1): 4/2015-12/2016 vancomycin pharmacy consultPeriod 2 (P2): 1/2017-6/2019 pharmacists authorized to order Nasal MRSA PCRPeriod 3 (P3): 7/2019-2/2020 embed nasal MRSA PCR into consult panelPeriod 4 (P4): 2/2020-3/2022 addition of automated EMR time-out

Results

Each period of vancomycin optimization was associated with a statistically significant decrease in vancomycin length of therapy (LOT) in days, when compared to the period before it (P1 vs P2, p< 0.0001; P2 vs P3, p< 0.0001; P3 vs P4, p< 0.0001). Overall institution vancomycin consumption, expressed as monthly days of therapy (DOT)/1000 patient days (PD) also decreased over time, starting with period 3 (P1 vs P2, p=0.4812; P2 vs P3, p=0.0003; P3 vs P4, p=0.0019) (Table 1). Table 1Vancomycin utilization trends over 4 periods of stewardship intervention.

Conclusion

Decreasing vancomycin at an academic medical center is challenging and takes a multifaceted approach with continued efforts over time to maintain a steady downward trend for utilization. These combined efforts have led to vancomycin no longer being the most commonly prescribed antibiotic at our institution.

Disclosures

All Authors: No reported disclosures.
1793. Evaluation of Ambulatory Antibiotic Use in Children and Adult Patients of a Healthcare System in Bolivia Using the AWaRe Classification
Authors: Quiros Rodolfo E , Escobar Elvio D , Tapia Juan Carlos , Cosgrove Sara E , Fabre Valeria
Published: December 2022

Background

The World Health Organization (WHO) has established the AWaRe (Access, Watch and Reserve) classification based on the impact of different antibiotics on antimicrobial resistance. For ambulatory patients, WHO recommends Access antibiotics to represent >60% of all prescriptions, and an Access to Watch (AW) index of ≥1.5. The use of Access and Watch antibiotics has not been evaluated in ambulatory patients in Latin America. The aim of this study was to describe antibiotic use among members of two health plans within a private health insurance in Bolivia.

Methods

We retrospectively evaluated antibiotic use among 8,405 members of a private healthcare system in Santa Cruz de la Sierra, Bolivia, between Jan-2017 and Dec-2018. Antibiotic use was calculated as defined daily doses (DDD) per 1,000 member-days, and compared between two plans, one a Health Maintenance Organization (HMO) (2,419 members) and the other a Preferred Provider Organization (PPO) (5,986 members). In the HMO plan, members have a general practitioner (GP) as the primary point of care, whereas in the PPO plan, members can access specialists directly without a referral from the GP. Differences between groups were calculated using Byar test with 95% confidence intervals (CI).

Results

Antibiotic use in DDD/1,000 member-days for the study period was 8.31 in ambulatory, 10.7 in the Emergency Department, and 0.72 in the hospital. Ambulatory antibiotic use in the HMO plan was lower than the PPO plan (6.95 vs. 8.89 DDD/1,000 member-days; diff. –1.94, 95%CI –2.15 to –1.72) (Table). Of all ambulatory antibiotics, 55% were Access and 45% were Watch (AW index: 1.24). By patient group, 52% of pediatric and 58% of adult prescriptions were Access; diff. –6%; p< 0.001 (AW index: 1.07 and 1.39, respectively). By health plan, 62% of HMO and 53% of PPO antibiotics were Access; diff. 9%; p< 0.001 (AW index: 1.13 and 1.67, respectively).

Conclusion

Ambulatory antibiotic use in this cohort was high. Overall use of Access antibiotics was lower than the recommended by WHO; however, we found less broad-spectrum antibiotic use in the HMO plan compared to the PPO plan. These findings highlight the urgent need for antibiotic stewardship in the ambulatory setting, and the important role of GPs in appropriate antibiotic prescribing.

Disclosures

Sara E. Cosgrove, MD, Basilea: Member of Infection Adjudication Committee.
1804. Quality Improvement Project to improve empiric antibiotic therapy for skin and soft tissue infections using the nasal MRSA PCR
Authors: Kasule Sabirah N , Gupta Simran , Klyver John , Chan Lynn , Seville Teresa
Published: December 2022

Background

Large cohort studies from the Veteran’s Administration support the negative predictive value of the methicillin resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) swabs for skin and soft tissue infection (SSTI). We investigated the use of the nasal MRSA PCR swab to reduce the inappropriate empiric use of vancomycin and piperacillin-tazobactam for SSTI at our institution.

Methods

Between July and August 2021, we educated Hospital Internal Medicine (HIM) and Internal Medicine Residents (IMR) on the basics of SSTI management and the utility of a negative nasal MRSA PCR swab. Data on empiric use of vancomycin and piperacillin-tazobactam for SSTIs were collected 3/1/2021 to 7/1/2021 (pre-intervention) and 8/30/2021 to 12/29/2021 (post-intervention). We excluded patients who didn’t have an SSTI, weren’t managed by IMR or HIM, and whose empiric antibiotics were for another indication. To account for antibiotics started in the emergency department (ED), a patient was regarded as having received appropriate empiric antibiotics if they were de-escalated in the first 24 hours of being admitted to IMR or HIM.

Example of education material. These fliers were distributed to resident rooms following a series of noon conferences

Results

Pre-intervention there were 106 patient encounters. In 56 of these (52.8%), patients were placed on inappropriate empiric antibiotics. Post-intervention, there were 72 patient encounters. In 23of these (31.9%), patients were placed on inappropriate empiric antibiotic for an absolute risk reduction (ARR) of 20.9% with a statistically significant 95% CI (6.522 - 35.249) and a number needed to treat (NNT) of 4.78. Nasal MRSA PCR testing increased from 40.6% to 56.9%. The ARR among the HIM teams was 21.3% and was statistically significant with a 95% CI (4.24 - 38.394). Their proportion of MRSA testing increased from 41.5% to 50%. The IMR teams had an ARR of 14.8%, which was not statistically significant (95% CI, -11.339 to 40.884). Their MRSA nasal PCR testing increased from 37.5% to 72%.

Conclusion

Education on SSTI treatment coupled with use of the MRSA nares PCR appeared to improve empiric antibiotic choices. Residents stated that the nasal MRSA PCR facilitated empiric antibiotic choice. Positive ARR was seen in whole and sub-group analyses of physician teams. We theorize that the lack of statistical significance in the IMR group was related to a small sample size.

Disclosures

All Authors: No reported disclosures.
1806. The gap in the amount of monthly antimicrobial use according to the data source: Electronic Health Record Data vs. National Health Insurance Claim Data in Korea
Authors: Kim Bongyoung , Chae Jung Mi , Kim Dong-Sook , Woo Hyunki , Kim Changhui , Bin Kim Hong , Kim Hyung-Sook , Park Sun Hee , Jeong Su Jin , Uh Young , Ahn Song Vogue , Park Yoon Soo , Choi Jun Yong
Published: December 2022

Background

Korea has single health insurance system and insurance claim information on almost all medical practices in Korean hospitals is collected and processed by the Health Insurance Review and Assessment Service (HIRA). Since information about prescription of almost all hospitals is available in National Health Insurance (NHI) claim data, recently established the Korea National Antimicrobial Use Analysis System (KONAS) has been using NHI claim data as data source. The purpose of this study is to validate the accuracy of NHI claim data.

Methods

Data on all antimicrobial agents prescribed in four tertiary-care hospitals in Korea between January 2019 and December 2019 were obtained using NHI claim data extracted by HIRA and data extracted by common data model based on electronic health record (EHR) in each hospital. Antibiotics and antifungal agents according to the Anatomical Therapeutic Chemical class J01 and J02 were included while antiviral, antitubercular, antiparasitic, and topical antimicrobial agents were excluded. Antimicrobial consumption was measured as days of therapy (DOT) and standardized to per 1,000 patient-days. The ratio of monthly antimicrobial consumption calculated using the NHI claim data compared to that calculated using the common data model was demonstrated (HIRA/EHR ratio).

Results

The monthly HIRA/EHR ratio of broad-spectrum antibiotics predominantly used for hospital-onset infections was 1.08-1.12 and that of broad-spectrum antibiotics predominantly used for community-acquired infections was 1.11-1.21. The monthly HIRA/EHR ratio of other antimicrobial classes are as follows: antibacterial agents predominantly used for resistant gram-positive infections 1.15-1.31, narrow-spectrum beta-lactam agents 1.00-1.05, antifungal agents predominantly used for invasive candidiasis 1.00-1.27, and antibacterial agents predominantly used for extensive antibiotic-resistant gram-negative bacteria 0.70-1.09.

Conclusion

The monthly antimicrobial consumption calculated using NHI claim data differs from that calculated using EHR data by up to 30%. It would be desirable to establish a system that can analyze and monitor antimicrobial consumption using EHR data in each hospital in Korea in the future.

Disclosures

Hyunki Woo, BS, Evidnet Inc.: Employee changhui Kim, BS, Evidnet Inc.: Employee.
1808. Treatment Adherence and Outcomes Associated with Partial Oral Therapy vs. Intravenous Therapy in Patients with Serious Staphylococcus aureus Infections: A Comparative Effectiveness Study
Authors: Craig Alexandra , Shihadeh Katherine C , Miller Whitney , Young Heather , Knepper Bryan , Aragon Deborah , Jenkins Timothy C
Published: December 2022

Background

Randomized trials found oral step-down therapy to be as effective as intravenous (IV) therapy for infective endocarditis and bone and joint infections. However, the comparative effectiveness of IV versus oral step-down therapy for deep seated Staphylococcus aureus infections outside of the clinical trial setting is unknown. The objectives of this study were to compare treatment adherence and clinical outcomes between these two approaches in clinical practice.

Methods

This was a retrospective comparative effectiveness study involving adults hospitalized at an academic, safety net hospital between January 2019 to June 2021 with bacteremia, endocarditis, osteomyelitis, or septic arthritis due to S. aureus. Based on initial treatment plans, patients were categorized and analyzed in two groups: all IV or IV followed by oral step-down therapy. The co-primary outcomes were antibiotic adherence (percent of planned course received) and the proportion who completed therapy. The key secondary outcome of clinical failure was a composite of all-cause mortality, recurrent or new metastatic site of S. aureus infection, or requirement of an unplanned source control procedure.

Results

Of 249 patients included, 101 were in the all IV and 148 were in the oral step-down groups. Indications for treatment were osteomyelitis (72%), complicated bacteremia (25%), endocarditis (22%), septic arthritis (11%), and uncomplicated bacteremia (8%). Active substance abuse was observed in 43% of the IV group and 55% in the oral group. Between the all IV and oral step-down groups, antibiotic adherence rates did not differ significantly (Table); antibiotic therapy was completed by 93% vs 87% of patients (p = 0.13), respectively. Clinical failure occurred in 25% of the all IV group and 26% of the oral step-down group (p = 0.87). The frequency of other secondary outcomes was similar between groups; however, hospital length of stay was significantly longer in the IV group (Table). Table 1

Note: data presented as n (%) unless otherwise specified

*within 6 months of hospital admission date for index infection

Conclusion

In clinical practice, oral step-down therapy for serious S. aureus infections was associated with similar rates of treatment adherence and completion, clinical outcomes and less health care resource utilization compared with IV therapy. Our findings support use of oral step-down therapy as an effective alternative to IV therapy.

Disclosures

All Authors: No reported disclosures.