bluuebunny/crossref_metadata_2025 huggingface dataset:
2244. What Happened? Antibiotic Resistance During the First Two Years of the SARS-CoV-2 (COVID-19) Pandemic
Authors: Crotty Matthew P , Henderson Joel , Hohulin Jacqueline , Wright Jennifer , Cui Mingyang , Alexander Julie , Hunter Leigh , Hupert Mark , Dominguez Edward A
Published: November 2023

Background

Increased antibiotic utilization and resistance have previously been demonstrated in the initial wave and surges of the COVID-19 pandemic but there are few evaluations of long-term impact. We sought to assess the utilization of antibiotics and incidence of resistant pathogens prior to and during the first two years of the COVID-19 pandemic.

Methods

Patients age ≥ 18 years admitted between March 2019 – February 2022 were eligible for inclusion. The study timeframe was divided into three phases: pre-pandemic (PRE, March 2019-February 2020), pandemic year 1 (PAN1, March 2020-February 2021), and pandemic year 2 (PAN2, March 2021-February 2022). Antimicrobial utilization (administration) data was summarized as days of therapy per 1,000 patient days (DOT/1000PD). Antibiotic resistance data was summarized as incidence per 100 hospital admissions. Interrupted time-series analysis with linear regression was performed to assess trends in antibiotic utilization and resistance between study time periods.

Results

Significant increases in ceftriaxone (+20.4 DOT/1000PD, P=0.002), azithromycin (+13.3, P=0.002), and anti-pseudomonal β-lactams (APBL; +17.4, P=0.001) utilization were observed between PRE and PAN1 (Figure 1). Subsequently, these increases were followed by significant decreases in utilization from PAN1 to PAN2.

Non-significant increases in the incidence of third-generation cephalosporin resistant bacteria (Figure 2A; +0.71, P=0.171) and carbapenem-resistant bacteria (Figure 2C; +0.34, P=0.068) were observed between PRE and PAN1 (Figure 2).

A non-significant decrease in MRSA slope (P=0.148) was observed from PRE to PAN1 resulting in a reduction in the average monthly incidence of MRSA infections going from 1.09 per 100 admissions in PRE and PAN1 to 0.75 in PAN2 (Figure 3A). A non-significant decrease in vancomycin-resistant enterococci (VRE) incidence per 100 hospital admissions was also observed for VRE over the three year study period (Figure 3B).

Conclusion

Increased use of key inpatient antibiotics and gram-negative resistance were observed in the first year of the COVID-19 pandemic. Utilization and resistance in PAN2 was similar to that of PRE levels and may represent encouraging signs for the long-term impact on antibiotic resistance.

Disclosures

Matthew P. Crotty, PharmD, BCIDP, Paratek Pharmaceuticals Inc.: Grant/Research Support
2246. A comparison between empiric carbapenem and non-carbapenem use for patients admitted with urinary tract infections and sepsis in the Dominican Republic
Authors: De Luna David , Roque Yori A , Lora Alfredo Jose Mena , Morel Danay Perez , Caraballo Jonas Sthir , Vargas Francelis
Published: November 2023

Background

Septic shock causes major morbidity and mortality. Early resuscitation and empiric antimicrobial therapy is the cornerstone of therapy. Mortality can increase up to 5 times in patients with septic shock treated with an empiric regimen that does not cover the primary pathogen. Carbapenems have broad spectrum and are commonly used in sepsis. The balance of empiric use and antimicrobial stewardship can be difficult in low and middle income countries (LMIC) where multi-drug resistance (MDR) is common.

Methods

This is a prospective observational study from September 1 to November 30, 2020. Patients admitted with urinary tract infection (UTI) and sepsis criteria by SOFA score were included. Patients were categorized by antibiotic into a carbapenem or non-carabpenem cohort. Data was collected prospectively and length of stay, mortality and outcome was compared between groups.Graphic 1.Distribution of antibiotic schemesGraphic 2Distribution of Gram negative bacteria isolation

Results

We evaluated a total of 44 patients. Most of the cases had length of stay (LOS) > 7 days (72.2%). The antibiotic most frequently used were meropenem (36.4%) and cefepime (31.8%), alone or in combination with other drug (Figure 1). Table 2 shows that there was no increased LOS or death between the two study groups; however, medical complications were more common in the non-carbapenem cohort.Table 2.Outcome of studied population

Conclusion

Overall, there were no major significant differences between the groups. We did not find an significant increased risk of death or prolonged LOS between the carbapenem and non-carbapenem cohorts, however, the appearance of complication did have an impact depending on the type of antibiotic regimen. This may offer opportunities for empiric treatment guidelines and a target for antimicrobial stewardship.

Disclosures

All Authors: No reported disclosures
2247. Improvements in Antibiotic Stewardship for Patients Who Use Injection Drugs: Subgroup Analysis of Patients with Bacteremia
Authors: Duffield Olivia , Patel Kaya , Schultz Sara K , Spivack Stephanie
Published: November 2023

Background

Infectious complications are common in patients who inject drugs (PWID). In this population, infections include acute bacterial skin and skin structure, bacteremia, endocarditis, and osteomyelitis. Despite low rates of gram-negative (GN) infections, coverage for these organisms is often initiated on presentation. Herein, we describe the microbiological and clinical characteristics of PWID admitted to our large academic medical center in Philadelphia with a focus on GN bacteremia.

Methods

We queried Epic for admissions with patients that had documented opioid use disorder with injection behavior and positive blood cultures from September of 2021 to March of 2022. We conducted a retrospective chart review of these encounters and collected data regarding their hospital course and treatment.

Results

During the six-month study period, we reviewed 159 encounters of PWID with bacteremia on admission. Of these encounters, 156 (98%) patients had gram-positive (GP) organisms in their blood culture, 12 (7.5%) patients had GN organisms. Of the GP organisms, MRSA (65, 41%), MSSA (27,17%) and Group A streptococcus (53, 33%) were the dominant organisms. Of the patient encounters with GN bacteremia, 4 (33%) encounters were found non-attributable to injection behavior (2 in the setting of gastrointestinal infection, and 2 attributed to pneumonia without presence of septic pulmonary emboli). Three (20%) were found to be secondary to necrotizing soft tissue infections. Five (41%) patients with GN bacteremia left the hospital prior to identification of source. In addition to the 159 encounters for bacteremia, there were an additional 78 (33%) encounters with positive blood cultures later determined to be a contaminant. 61 of 78 encounters (78.2%) had timely discontinuation of antibiotics upon speciation of contaminant blood culture.

Figure 1

Characteristics of Positive Blood Cultures

Conclusion

Although PWID frequently present with infectious symptoms with bacteremia, GN bacteremia occurs in a minority of infections, challenging the notion that patients require empiric GN coverage. Furthermore, a notable percentage of GN bacteremia is secondary to a source non-attributable to injection behavior. We are continuing to explore why this population may have a high rate of contaminant blood cultures.

Disclosures

Sara K. Schultz, MD FACP FIDSA, AbbVie: Advisor/Consultant
2251. Evaluating the Financial Implications of Antimicrobial Therapy in Clinical Settings: A Prospective Observational Study
Authors: Gnanamani James , Dorairajan Suresh Kumar , Magesh Poojadharshini , Rajakumar Ratheesh
Published: November 2023

Background

Unnecessary antimicrobial use is a significant public health concern that can lead to antimicrobial resistance in hospitalised patients. The WHO defines the rational use of drugs as prescribing the right drug at an adequate dose for an appropriate duration based on the clinical needs of the patient and at the lowest cost possible. Inappropriate use of antimicrobials can lead to drug resistance, medication therapy problems and an increase in drug costs. The aim of this study is to assess the irrational use of antibiotics and to analyse the cost effectiveness of antibiotic prescriptions for patients

Methods

This prospective observational study was conducted in a tertiary care hospital in India for a period of three months. Data on patient demographics and antimicrobial usage were collected including any escalation, de-escalation, discontinuation or other changes to therapy recommended by the hospital's infectious disease specialist (ID) opinion in response to specific patient cases. Follow-up was performed to determine whether the ID opinion recommendations were followed. Financial implications, such as increase in drug costs were documented when the ID opinion was not followed. The necessity of antimicrobial usage and its cost effectiveness were analysed using basic statistical method.

Results

A total of 538 prescriptions for antimicrobial therapy were included in this study. Of these 349 prescriptions (64.8%) were in accordance with ID opinion, while 189 prescriptions (35.2%) were not in accordance with ID opinion. The data was analysed and correlated based on the cost of antimicrobial medication (Table 1)

Conclusion

The study found that the average expenditure for a person/day increases by ₹2469 ($30.20) for prescriptions that did not follow ID opinion. This highlights the unnecessary increase in drug expenditure and the risk of antimicrobial resistance. Moreover, these patients had a longer hospital stay on average, leading to additional healthcare costs. Implementing strategies such as antimicrobial stewardship programs and promoting rational use of antibiotics can help reduce unnecessary spending and improve patient outcomes. Further studies are needed to assess the cost-effectiveness of antimicrobial therapy in different clinical settings.

Disclosures

All Authors: No reported disclosures
2253. Hospitalist Antibiotic Prescribing Patterns by Hour and Weekday
Authors: Gray Joshua H , Wahid Lana , Moehring Rebekah W , Yarrington Michael E
Published: November 2023

Background

Hospital medicine physicians providing coverage during evening and night shifts are often responsible for higher patient volumes during these busy shifts. Data on decisions to start or broaden antibiotic therapy by covering physicians are limited.

Methods

We evaluated antibiotic administration data from Duke University Health System between July 1, 2021 and March 31, 2023 to identify antibiotic “starts” and “escalations” attributed to hospitalists. Starts were defined as the first administration per patient encounter without antibiotics on the preceding calendar day. Escalations were defined as an increase in cumulative spectrum score (using a previously validated antibiotic spectrum index) in the 48 hours following administration compared to the score in the 48 hours prior. Shifts from intravenous to only oral antibiotics were not counted as an escalation. We visualized these data as a heat map based on weekday-hour combinations and then compared the median number of starts and escalations between daytime shifts (weekdays 7AM to 5PM, weekends 7AM to 2PM), evening, “cross cover,” coverage shifts (weekdays 5PM to 10PM, weekends 2PM to 10PM), and overnight shifts (remaining times), using the Mann-Whitney U nonparametric test with daytime shifts as the comparator group.

Results

The analysis included 7,045 antibiotic starts and 4,879 escalations across 78,845 unique patient admissions. Heat maps (Figure 1A and B) revealed specific practice patterns. Median starts for night shift were significantly lower than day shift starts, but cross cover starts were significantly higher (p = 0.011 and p < 0.001, respectively, Figure 2A). Night shift escalations were significantly lower than day shift while cross coverage showed no difference (p< 0.001 and p = 0.51, respectively, Figure 2B).

Antibiotic starts and escalations by hour and day of week

Heat maps of counts of antibiotic (A) starts and (B) escalations by hour and day of week

Hourly starts and escalations of antibiotics by hospitalist shift

Box-and-whisker plots of counts of antibiotic (A) starts and (B) escalations per hour by hospitalist shift.

Conclusion

Antibiotic escalations differed across work shifts; visualization of these patterns aids in antimicrobial prescribing pattern recognition and may assist in finding opportunities for supportive antimicrobial stewardship strategies.

Disclosures

Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties
2258. "Identification of Respiratory Viral Pathogens Using Real-Time PCR Was Not Associated with Reduced Antibiotic Use During the COVID-19 Pandemic, but Displayed Viral-Viral Interactions"
Authors: Khan Asif , Marti Ojeda Daynha P , Murphy Richard A , Elzweig Joel , Lacasse Victoria W , Rovelsky Suzette
Published: November 2023

Background

We aimed to investigate the relationship between SARS-CoV-2 and other circulating respiratory pathogens. A secondary objective was to assess the correlation between respiratory pathogen detection and antibiotic use at a single medical center during the COVID-19 pandemic.Table 1.Negative and positive interactions among viruses at population scale (n=883)

Significant unadjusted correlations from bivariate cross-correlation analysis applying Spearman’s rank method to monthly viral infection prevalence are shown in gray, with negative and positive correlations indicated by − and +, respectively, and noncorrelated virus pairs in white.

Methods

For viral-viral interaction analysis, data were collected from infection control surveillance reports on all positive respiratory viral pathogen tests (e.g., antigen, PCR) conducted between October 2018 and February 2022. Real-time PCR respiratory panel (RT-PRP) results (negative or positive) were extracted from the VA Corporate Data Warehouse for inpatients and outpatients. A random subset of patients (15-20%) was selected for chart review. Baseline characteristics, signs and symptoms, laboratory results, imaging interpretation, and admission and discharge diagnoses were collected. Spearman's rank correlation was employed to identify viral-viral interactions. Chart review data were analyzed using Wilcoxon-rank sum tests and Fisher's exact test.Table 2.Correlations between results of RT-PRP result and antibiotics prescribed.

Results

A total of 883 positive surveillance tests were analyzed for viral-viral interactions. A significant negative relationship was identified between SARS-CoV-2 and the prevalence of 43% of other respiratory pathogen types. Among 1,002 RT-PRP results, 168 patients with an RT-PRP result were chart reviewed. Although numerically a smaller proportion of patients with positive RT-PRP – compared to negative RT-PRP – received antibiotics this difference did not reach statistical significance.

Conclusion

This project highlights the diverse influence of SARS-CoV-2 on the prevalence of other respiratory pathogens. No significant impact was detected on antibiotic use of a positive RT-PRP result. A positive RT-PRP result represents only one factor leading to the utilization of antibiotics, with other factors including clinician experience, symptom duration and severity, immunocompetency, and imaging. Based on these findings, we aim to enhance the integration of viral pathogen identification into antibiotic stewardship efforts.

Disclosures

All Authors: No reported disclosures
2263. Amoxicillin Use for Common Acute Respiratory Infections During a National Shortage: Results from the SHARPS-OP Benchmarking Collaborative
Authors: Lee Brian R , Poole Nicole M , Herigon Joshua C , Kronman Matthew , Olivero Rosemary M , Patel Sameer , Smith Michael J , Wattles Bethany A , Wirtz Ann , El Feghaly Rana E
Published: November 2023

Background

Amoxicillin is a first-line agent for most pediatric acute respiratory infections (ARIs). In Fall 2022, a nationwide amoxicillin shortage occurred. This study sought to provide precise estimates in outpatient amoxicillin usage during the shortage, using a nationally representative sample of institutions providing pediatric care.

Methods

Twenty-two institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship Outpatient (SHARPS-OP) Collaborative provided aggregate quarterly data from Jan 2019 - Dec 2022. Data included total counts of encounters with an ARI ICD-10 code and proportions of ARIs treated with any oral antibiotic, amoxicillin, and azithromycin. Data were stratified by location type (Emergency Department [ED], Urgent Care [UC], and primary care clinics [PCC]). We compared ARI prescribing (ARI encounters resulting in any antibiotic prescription) and the amoxicillin and azithromycin indices (ARI encounters resulting in amoxicillin or azithromycin prescription out of ARI encounters resulting in any antibiotic prescription) between pre-shortage (Jan 2019 - Sep 2022) and shortage (Oct 2022 - Dec 2022) time periods by location type.

Results

A total 4.89 million ARI encounters (4.24 million during pre-shortage and 0.65 million during the shortage) were reported across 22 institutions. Overall antibiotic prescribing for ARI encounters changed slightly from pre-shortage to shortage period for ED (28.7% to 22.6%; delta: -6.1 [-6.4, -5.8]), UC (41.1% to 39.6%; delta: -1.6 [-1.8, -1.3]) and PCC (38.1% to 38.1%; delta: 0.03 [0.001, -0.003]). Substantial declines in the amoxicillin index were observed for ED (76.1% to 60.9%; delta: -15.1 [-15.8, -14.5]), UC (71.9% to 60.1%; delta: -11.7 [-12.1, -11.3]) and PCC (63.9% to 53.3%; delta: -10.6 [-14.2, -9.6] with considerable variation within and between SHARPS-OP institutions (Figure 1). Azithromycin use among ARI encounters decreased slightly during the amoxicillin shortage (-0.3% [-0.38%, -0.20%]).Figure 1:Amoxicillin indices for pre-shortage and amoxicillin shortage time periods for included SHARPS-OP institutions, stratified by location type.Location types: Emergency Department [ED]; Urgent Care [UC]; Primary Care Clinic [Primary]

Conclusion

Amoxicillin utilization disproportionately decreased compared to overall antibiotic prescribing for ARIs during the shortage. Providers may have prescribed alternative antibiotics rather than no therapy for ARIs.

Disclosures

Michael J. Smith, M.D., M.S.C.E, Merck: Grant/Research Support|Pfizer: Grant/Research Support Bethany A. Wattles, PharmD, MHA, Merck: Grant/Research Support
2269. Inpatient Antibiotic Prescribing for Symptomatic COVID-19 Patients in a Large US Sample, 2020-2022
Authors: Pulia Michael , Griffin Meggie , Hekman Daniel J , Schwei Rebecca , Pop-Vicas Aurora E , Schulz Lucas , Shieh Meng-Shiou , Pekow Penelope , Lindenauer Peter
Published: November 2023

Background

Significant concerns have been raised regarding antibiotic exposure in patients with COVID-19 and the impact of the pandemic on antimicrobial stewardship in the acute care setting. Therefore, we assessed trends in inpatient antibiotic prescribing practices for symptomatic COVID-19 patients and patients with non-COVID-19 respiratory tract infections (RTIs).

Methods

We identified non-elective, inpatient and observation admissions from March 2020 – December 2022 for COVID-19 and non-COVID-19 RTIs at 765 hospitals in the Premier Healthcare Database using an ICD-10 code algorithm. We described antibiotic usage as the % of encounters with at least one antibiotic dose and by highest level of care (general care, intermediate care (IMC), intensive care unit (ICU)) and antibiotic appropriateness (inappropriate, appropriate) which was characterized as the cooccurrence of ICD-10 code(s) indicating a bacterial infection, as defined by the CDC. We used chi-squared tests to compare antibiotic usage by level of care and by year for 2020 v. 2021 and 2021 v. 2022.

Results

Our sample included 1,198,687 symptomatic COVID-19 cases and 1,713,714 non-COVID-19 RTIs. Antibiotic prescribing for COVID-19 declined from 75.6% in 2020 to 65.2% in 2021 (p < 0.001) and remained at 65.0% in 2022 (p = 0.093) (Fig. 1a). Non-COVID-19 RTIs had a significant decrease in antibiotic prescribing from 90.9% in 2020 to 88.1% in 2021 (p < 0.001) and 85.4% in 2022 (p < 0.001) (Fig. 1a). Inappropriate antibiotic prescribing for COVID-19 declined from 31.2% in 2020 to 27.4% in 2021 (p < 0.001) and 18.1% in 2022 (p < 0.001) (Fig. 1b). Antibiotic usage was significantly different for ICU, IMC, and general care for both COVID-19 (p < 0.001) (Fig. 1c) and non-COVID-19 RTIs (p < 0.001) (Fig. 1d).

Figure 1. Monthly antibiotic prescribing trends for COVID-19 and non-COVID-19 RTI hospital encounters

Conclusion

Despite downward trends in antibiotic prescribing, a majority of COVID-19 patients are prescribed an antibiotic at some point during their admission. Our analysis suggests most of these patients have a co-occurring appropriate indication for antibiotics, yet nearly 1 in 5 COVID-19 patients still receive non-indicated antibiotics. Future work should identify drivers of inappropriate antibiotic prescribing in COVID-19 patients.

Disclosures

All Authors: No reported disclosures
2275. No "One-Size-Fits All": Chronic "Carryover" Diagnoses Dilute Antibiotic Prescribing Metrics in Primary Care
Authors: Smith Mary , Hawkens Marten , Laikijrung Chananid , Mui Emily , Leung Thomas , Zimmet Alex , Ha David R , Holubar Marisa
Published: November 2023

Background

International Classification of Diseases, Tenth Revision (ICD-10) encounter coding is used to identify sub-optimal outpatient antibiotic use, but the utility of a popular billing data based metric, antibiotic prescribing rate (APR), for diagnoses which antibiotics are situationally indicated remain unexplored. We assessed the impact of different ICD-10 groupings on outpatient sinusitis APR to characterize its use.

Methods

We included all adult telemedicine and office encounters from January 2021 to March 2022 with an acute or chronic sinusitis ICD-10 from two academic urgent care and eight academic primary care clinics. We calculated an APR (encounters with antibiotics/all encounters) by sinusitis ICD10 code, ICD10 group (acute vs. chronic) and clinic type (Table 1). We then reviewed 100 urgent and 182 randomly selected primary care sinusitis encounters conducted in 2021 to assess symptom documentation and guideline adherence (Table 2). This quality improvement project was deemed non-human subjects research.

Results

We included 987 sinusitis encounters of 821 unique patients with an overall APR of 56.5% (Table 3). The APR for acute sinusitis encounters was higher than chronic (72.7% vs 22.0%), with a larger difference in primary care (65.5% vs 10.4%) compared to urgent care (76.9% vs 54.2%). Upon chart review, 42.3% (77/182) of primary care sinusitis encounters had no active symptoms (60/77) or did not address sinusitis (17/77); the majority used chronic sinusitis ICD-10s (66/77) (Table 4). Antibiotic prescriptions were guideline adherent for 32.8% of primary care (23/70) compared to 58.0% (40/69) of urgent care encounters (Figure 1).

Conclusion

Combining acute and chronic sinusitis ICD10 codes yielded lower APR than acute sinusitis ICD10s alone, predominately in primary care, suggesting a dilution effect. Compared to urgent care, lack of documentation of active symptoms for chronic sinusitis encounters was common in primary care, hindering the assessment of antibiotic appropriateness. Until there is improved ICD10 utilization with methods to control for ‘carryover’ ICD-10s in primary care, acute and chronic sinusitis ICD-10 categories should likely be analyzed separately to increase the usefulness of sinusitis APR as a metric.

Disclosures

All Authors: No reported disclosures
2277. Variability in Changes in Physician Outpatient Antibiotic Prescribing from 2019 to 2021 during the COVID-19 Pandemic in Ontario, Canada
Authors: Tandon Pranav , Brown Kevin , Daneman Nick , Langford Bradley J , Leung Valerie , Friedman Lindsay , Schwartz Kevin
Published: November 2023

Background

Outpatient antibiotic prescribing decreased during the COVID-19 pandemic. Understanding how antibiotic prescribing habits changed differentially based on physician and practice characteristics presents an opportunity to inform antibiotic stewardship. Our objective was to evaluate inter-physician variability and predictors of changes in antibiotic prescribing before (2019) and during (2020/2021) the COVID-19 pandemic.

Methods

We conducted a retrospective cohort analysis of physicians in Ontario, Canada prescribing oral antibiotics in the outpatient setting between 1 January 2019 and 31 December 2021 using the IQVIA Xponent dataset. The primary outcome was the change in the number of antibiotic prescriptions between the pre-pandemic and pandemic period. Secondary outcomes were changes in the selection of broad-spectrum agents and long-duration ( >7 days) antibiotic use. We used multivariable linear regression models to evaluate physician- and practice-level predictors of change.

Results

There were 17,288 physicians included in the study with substantial inter-physician variability in changes in antibiotic prescribing (median change of -43.5 antibiotics per physician, IQR -136.5 to -5.0). In the multivariable model, later career stage (adjusted mean difference [aMD] -45.3, 95% confidence interval [CI] -52.9 to -37.8, p< .001), family medicine (aMD -46.0, 95% CI -62.5 to -29.4, p< .001), male patient sex (aMD -52.4, 95% CI -71.1 to -33.7, p< .001), low patient comorbidity (aMD -42.5, 95% CI -50.3 to -34.8, p< .001), and high prescribing to new patients (aMD -216.5, 95% CI -223.5 to -209.5, p< .001) were associated with decreases in antibiotic initiation. Family medicine and high prescribing to new patients were associated with significant decreases in selection of broad-spectrum agents and prolonged antibiotic use.

Conclusion

Antibiotic prescribing changed throughout the COVID-19 pandemic with overall decreases in antibiotic initiation, broad-spectrum agents, and prolonged antibiotic courses with inter-physician variability. These findings present opportunities for targeted community antibiotic stewardship interventions.

Disclosures

All Authors: No reported disclosures
2951. Nursing home clinician characteristics associated with simulated urinary tract infection treatment decision-making
Authors: Taylor Lindsay , Wilson Brigid , Jolles Sally , Bej Taissa A , Kowal Corinne , Hicks Oteshia , Jump Robin , Crnich Christopher J
Published: November 2023

Background

Antibiotic overuse and misuse are common in nursing homes (NHs). Urinary tract infection (UTI) is the most common indication for antibiotics in NHs. We conducted a clinical vignette experiment to identify clinician-level characteristics associated with suboptimal UTI treatment decision-making among a sample of NH clinicians.

Methods

Six clinical vignettes, two designed to assess clinicians’ treatment threshold and four designed to assess antibiotic choice decision-making, were created through an iterative process. NH clinicians were recruited nationally via professional organizations from December 2021 to April 2022. Clinical vignettes were shared using a web-based survey tool (Qualtrics) during which participants were asked if they would initiate antibiotics and which one. Participants provided demographic information, including degree, specialty training and NH experience. A multivariable logistic regression model with the decision to initiate antibiotic therapy (Yes/No) as the dependent variable and a multivariable ordinal regression model with number of vignettes for which a fluoroquinolone (FQ) was empirically chosen as the dependent variable were constructed in R.

Results

A total of 298 NH clinicians, whose characteristics are detailed in Table 1, responded to the survey. Despite national guidelines not recommending treatment for asymptomatic bacteriuiria (ASB), 10.4% of participants chose to initiate antibiotics when presented with the ASB vignette. Physicians (vs. APPs) and clinicians with ≥ 10 years NH experience were less likely to initiate antibiotics for ASB (Table 2). Empiric treatment was withheld for simple cystitis by 38.9% of clinicians, with APPs more likely to withhold antibiotics than physicians (Table 2). Across the four cases assessing empiric antibiotic choice, 38.3% of clinicians chose a FQ in at least one clinical case (Table 1). Clinicians with more years of NH-practice experience were more likely to prescribe a FQ (aOR 2.41, 95% CI 1.47-3.95, p< 0.01, Table 2).

Respondent Characteristics

Abbreviations: Advanced Practice Provider (APP); Asymptomatic bacteriuria (ASB); Fluoroquinolone (FQ), Nursing Home (NH).

Effect of clinician credentials, training, and experience on antibiotic prescribing for urinary tract infection

Abbreviations: * reference; Adjusted odds ratio (aOR); Confidence interval (CI); Asymptomatic bacteriuria (ASB); Advanced practitioner (APP)

Conclusion

Our results indicate that specific clinician characteristics are associated with suboptimal antibiotic prescribing. This suggests that tailoring stewardship interventions to clinician-specific factors may augment ongoing efforts to improve antibiotic use in NHs.

Disclosures

Lindsay Taylor, MD, MS, Merck: Grant/Research Support Robin Jump, MD, PhD, Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support
2287. Goal! Goal! Goal! Detection of SARS-CoV-2 Variants in Travelers During the FIFA World Cup, Qatar 2022 — CDC Traveler-Based Genomic Surveillance Program, November 2022–January 2023
Authors: Byrd Katrina M , Bart Stephen , Smith Teresa C , Loh Samantha M , Guagliardo Sarah Anne J , Rome Benjamin , Aichele Thomas , Ernst Ezra T , Morfino Robert C , Cetron Martin S , Friedman Cindy R , Walker Allison T
Published: November 2023

Background

Over 1 million people traveled to Qatar and surrounding countries during the World Cup 2022 soccer tournament, a mass gathering that could enhance transmission of SARS-CoV-2 variants. Minimal information about circulating variants in World Health Organization (WHO) Eastern-Mediterranean region (EMRO) which includes Qatar, United Arab Emirates, and Saudi Arabia were available from global data bases (GISAID). The Traveler-based Genomic Surveillance (TGS) program samples arriving international travelers to detect new variants and fill surveillance gaps. Monitoring of flights from EMRO was increased during the tournament.

Methods

Travelers at six US airports volunteered to provide nasal swabs that were pooled by flight origin and sent to laboratories for SARS-CoV-2 reverse transcription polymerase chain reaction. Positives underwent whole genome sequencing. Pool positivity and variant frequencies were compared for travelers from EMRO vs. other regions. Chi-square tests were used to determine statistical significance.

Results

During November 20, 2022–January 2, 2023, 2050 sample pools from 16,595 travelers were collected. Of these, 100 pools (703 travelers) were from EMRO and 1950 pools (15,892 travelers) were from other regions. Pool positivity from EMRO was 28% (28/100) vs. 25% (489/1950) in other regions (p=0.51). Regionally detected variant proportions were: EMRO (n=25) XBB (40%), BQ.1 (20%), BQ.1.1 (20%); Europe (n=166) BQ.1.1 (48%), BQ.1 (20%), XBB (9%); Western Pacific (n=51) BA.5 (24%), BN.1 (22%), XBB (18%); South-East Asia (n=21) BQ.1.1 (33%), XBB (29%), BA.2 (10%), BA.5 (10%), XBB.1.5 (10%); and Africa (n=15) BQ.1.1 (53%), BA.5 (27%), XBB (20%). The proportion of XBB in EMRO was significantly higher than Europe and Western Pacific regions (p< 0.05).

Conclusion

During World Cup 2022, SARS-CoV-2 positivity was similar for travelers from EMRO compared to all other regions. Variant proportions differed among regions, with EMRO having the highest proportion of XBB, a recombinant lineage associated with higher transmissibility. TGS fills gaps in SARS-CoV-2 surveillance and can be surged during mass gathering events.

Disclosures

Benjamin Rome, MBA, Ginkgo Bioworks, Inc.: Employee|Ginkgo Bioworks, Inc.: Stocks/Bonds Robert C. Morfino, MBA, Ginkgo Bioworks Inc.: I am an employee|Ginkgo Bioworks Inc.: Stocks/Bonds
2952. Impacts of an evidence-based, pre-populated order panel on antimicrobial prescribing trends in ambulatory patients with community-acquired pneumonia
Authors: Stevens Ryan W W , Arensman Hannan Kellie , Schanz Caitlin C , Vergidis Paschalis , Anderson Benjamin , Dierkhising Ross , Kooda Kirstin , Virk Abinash , Jensen Kelsey L
Published: November 2023

Background

Optimizing antimicrobial regimens for outpatients with community-acquired pneumonia (CAP) represents an area of opportunity for ambulatory antimicrobial stewardship programs. A pre-populated, antibiotic order panel for outpatient respiratory syndromes was implemented in the Mayo Clinic Enterprise on 1/4/2021. For CAP, it provides national guideline adherent regimens (i.e., selection, dosing, and durations) by patient comorbidity and beta-lactam allergy status. We aimed to assess impacts of panel use on antibiotic prescribing in outpatients with CAP.

Methods

This retrospective review included Mayo Clinic outpatient encounters from Minnesota in 2021 and 2022. Eligible encounters used a CAP-related primary ICD-10 code, conveyed intention to treat CAP in encounter notes, and were performed by primary care, emergency department, or urgent care clinicians who managed ≥1 CAP patient with the panel and ≥1 without the panel during the study period. Encounters were excluded if patients were already receiving antibiotics at the time of encounter. The primary outcome was adherence (drug and duration) to guideline recommendations. Secondary outcomes included utilization rate by agent and therapy duration. Outcomes were analyzed with Kruskal-Wallis rank sum and Pearson’s chi-squared tests (α level = 0.05).

Results

352 encounters (134 panel vs. 218 non-panel) were included. Prescribing was guideline adherent in 61.9% and 29.4% (p< 0.01) of panel and non-panel encounters, respectively. The most common reason for guideline non-adherence during panel use was inappropriate drug selection (n = 45/51, 88.2%). This was predominantly driven by use of the incorrect section of the treatment panel based on patient comorbidity status (n = 30/45, 66.7%). Individual antibiotic utilization rates differed between panel and non-panel cohorts (Table 1), with higher rates of amoxicillin and amoxicillin/clavulanate use and lower rates of azithromycin and doxycycline use in the panel cohort. Durations >5 days were more common in the non-panel as compared to the panel cohort (34.4% vs. 7.5%, p < 0.01).

Conclusion

Use of a pre-populated antimicrobial order panel in outpatients with CAP resulted in greater adherence to national guideline recommendations.

Disclosures

Paschalis Vergidis, MD, MSc, AbbVie: Advisor/Consultant|Ansun: Grant/Research Support|Cidara: Grant/Research Support|Scynexis: Grant/Research Support
2288. Short and Longer-Term All-Cause Mortality among SARS CoV-2-Infected Persons and the Pull-Forward Phenomenon in Qatar
Authors: Chemaitelly Hiam , Faust Jeremy Samuel , Krumholz Harlan M , Ayoub Houssein H , Abu-Raddad Laith J
Published: November 2023

Background

Risk of short- and long-term all-cause mortality after a primary SARS-CoV-2 infection is inadequately understood.

Methods

A national, matched, retrospective cohort study was conducted in Qatar to assess the risk of all-cause mortality in the national cohort of people infected with SARS-CoV-2 compared with a reference national control cohort of uninfected persons. Associations were estimated using Cox proportional-hazards regression models.

Results

Among unvaccinated persons, within 90 days after primary infection, adjusted hazard ratio (aHR) comparing incidence of death in the primary-infection cohort with the infection-naïve cohort was 1.19 (95% CI: 1.02-1.39). The aHR was 1.34 (95% CI: 1.11-1.63) in persons more clinically vulnerable to severe COVID-19 and 0.94 (95% CI: 0.72-1.24) in those less clinically vulnerable to severe COVID-19. In subsequent follow-up, the aHR was 0.50 (95% CI: 0.37-0.68). The aHR was 0.41 (95% CI: 0.28-0.58) in months 3-7 after the primary infection and 0.76 (95% CI: 0.46-1.26) in subsequent months. The aHR was 0.37 (95% CI: 0.25-0.54) in persons more clinically vulnerable to severe COVID-19 and 0.77 (95% CI: 0.48-1.24) in those less clinically vulnerable to severe COVID-19. Among vaccinated persons, no evidence was found for differences in incidence of death in the primary-infection versus infection-naïve cohorts, even among persons more clinically vulnerable to severe COVID-19.

Conclusion

COVID-19 mortality in Qatar appears primarily driven by forward displacement of deaths of individuals with relatively short life expectancy and more clinically vulnerable to severe COVID-19. Vaccination negated the mortality displacement by preventing early deaths.

Disclosures

All Authors: No reported disclosures
2289. Accuracy of the National Early Warning Score 2 (NEWS2) in predicting Mortality and ICU Admission among COVID-19 patients in the Emergency Department of a Tertiary Private Hospital in the Philippines
Authors: Cruz Bernice Ong-dela , Cledera Darlene Mae E
Published: November 2023

Background

The objective of this study is to evaluate the prognostic value of NEWS2, assessed upon arrival at the emergency department, for predicting in-hospital mortality and ICU admission in COVID-19 patients.

Methods

In this retrospective cohort study, the medical records of patients with confirmed COVID-19 infection between June 2021 to November 2021 were reviewed. The study evaluated the predictive accuracy of NEWS2 for ICU admission and in-hospital mortality based on the patients' baseline scores at the emergency department. Sensitivity, specificity, and the area under the curve were calculated for NEWS2 score of ≥ 5.

Results

A total of 382 COVID-19 patients were analyzed. The median age was 63 years, of whom 59% were male. The overall mortality rate was 23.5%, and 28.5% of patients were admitted to the ICU. The median NEWS2 score was 7 with more than half of the patients considered high risk.The sensitivity and specificity of a NEWS2 score of 5 or higher in predicting ICU admission were 93.58% and 40.66%, respectively, with an area under the curve of 0.67 (95% CI: 0.63-0.71). The sensitivity and specificity of a NEWS2 score of 5 or higher in predicting mortality were 87.78% and 36.64%, respectively, with an area under the curve of 0.62 (95% CI: 0.58-0.67). Age, respiratory rate, oxygen saturation, hypertension, diabetes mellitus, and cardiac disease were found to be associated with an increased risk of ICU admission and mortality.

Conclusion

NEWS2 has good sensitivity and is a reliable predictor of ICU admission and in-hospital mortality in COVID-19 patients

Disclosures

All Authors: No reported disclosures
2301. Viral Kinetics of Sequential SARS-CoV-2 Infections
Authors: Kissler Stephen , Hay James , Fauver Joseph , Mack Christina , Tai Caroline , Anderson Deverick , Ho David D , Grubaugh Nathan , Grad Yonatan H
Published: November 2023

Background

An estimated 65% of the US population had at least two SARS-CoV-2 infections by November 2022, but the impact of prior infection on disease course in subsequent infections has been debated. Population-level studies can yield conflicting results due to biases that arise from differences in differences in infection history, vaccination status, and patient characteristics. Examining the dynamics of SARS-CoV-2 infections at the individual level can help adjust for these biases.

Methods

Using a convenience sample of 94,812 longitudinal RT-qPCR measurements from samples each taken from a combined anterior nares/oropharyngeal swab, we compared the SARS-CoV-2 viral kinetics of first vs. second infections, adjusting for viral variant, vaccination status, and age. We characterized the kinetics of these infections by fitting a hierarchical Bayesian piecewise linear model to the viral concentration measurements.

Results

Relative to first infections, second infections usually featured a faster clearance time (5.1 days, 95% CI (4.7, 5.7) vs. 8.8 days (7.8, 9.8) in first infections), especially in individuals who received a vaccine dose between their first and second infection. Furthermore, a person’s relative (rank-order) viral clearance time, compared to others infected with the same variant, was similar across first and second infections (Spearman correlation: 0.475, p < 0.0001); that is, individuals who had a relatively fast clearance time in their first infection tended to also have a relatively fast clearance time in their second infection.

Conclusion

Like vaccination, immunity from a prior SARS-CoV-2 infection shortens the duration of subsequent acute SARS-CoV-2 infections principally by reducing viral clearance time. Additionally, there appears to be an inherent element of the immune response, or some other host factor, that shapes a person’s relative ability to clear SARS-CoV-2 infection that persists across sequential infections.

Disclosures

Stephen Kissler, PhD, ModernaTx: Advisor/Consultant Christina Mack, PhD, IQVIA: Full time employee of IQVIA which is in paid contractual relationship with bio pharma companies. Caroline Tai, PhD, Evidation Health: Stocks/Bonds|IQVIA: Employee Yonatan H. Grad, MD, PhD, Day Zero Diagnostics: Board Member|GSK: Advisor/Consultant
2315. Hidden in Plain Sight: Latent Class Analysis of Respiratory Infection Symptoms based on COVID-19 Testing and Vaccination History
Authors: Sun Xiaowu , Lupton Laura L , Henriette Coetzer , DeShazo Jonathan , Berk Alexandra , Anatale-Tardiff Laura
Published: November 2023

Background

During XBB variant dominance, there is still a lack of evidence describing phenotypes of acute respiratory infection (ARI) symptoms present at COVID testing and how clusters of symptoms are associated with COVID test positivity, COVID vaccination status, and vaccination timing.

Methods

This observational cohort included 88,147 adult symptomatic individuals presenting for COVID testing at CVS Pharmacy® locations across the US during March and April of 2023. Individuals self-reported ARI symptoms, comorbid conditions, vaccination status, vaccination timing, and demographics when making an appointment for COVID testing. Latent class analysis (LCA) is a statistically robust method of cluster analysis and was adopted to examine patterns of ARI symptoms. COVID testing positivity was tabulated for each pattern by time from last dose of vaccine.

Results

Patients were 43.3 (SD: 16.6) years old on average and 37% male. The cohort was composed of 43% White or Caucasian, 21% Hispanic, 16% Black, 11% Asian, and 9% other race and/or ethnicities. About 20% of patients self-reported at least one comorbid condition. PCR and antigen tests were chosen by 79% and 21% of patients, respectively. Overall, 33% of patients tested positive for COVID. Of 87% vaccinated, 4% had been vaccinated within three months of testing, 21% within 4-6 months, 17% within 7-12 months, and 45% had been vaccinated over one year prior to testing.

The number of months since vaccination was associated with an increased number of reported symptoms, presenting a marked uptick of symptoms at 6-months following the last vaccination dose (Figure 1). LCA identified four distinct phenotype groups of ARI symptoms described with prevalence (%) (Figure 2). Phenotype group positivity rates were also associated with time since last dose of vaccines, and yet unlike individual symptoms, appeared to stabilize six months post-vaccination.

Conclusion

Four ARI symptom phenotypes having distinct responses to vaccine and COVID positivity were identified. Some phenotypes (such as P3 and P4) may present with symptom patterns consistent with seasonal influenza or RSV. More research is needed to validate these findings and understand the implications of possible COVID phenotypes.

Disclosures

Xiaowu Sun, PhD, CVS Health: Employee|CVS Health: Stocks/Bonds Laura L. Lupton, MD, MHSA, CVS Health: employee|CVS Health: Stocks/Bonds Coetzer Henriette, MD, Astra Zeneca: Stocks/Bonds|CVS Health: Employee|GSK: Stocks/Bonds Alexandra Berk, PhD, CVS Health: employee|CVS Health: Stocks/Bonds Laura Anatale-Tardiff, MPH, CVS Health: employee|CVS Health: Stocks/Bonds
2955. The Impact of the Healthcare Environment on the Nasal Microbiome in Children with Cancer
Authors: McNeil Jonathon C , Sommer Lauren M , Joseph Marritta , Runge Jessica , Murugesan Marudhu , Brackett Julienne , Mitchell Amya , Wilber Matthew , Ann Luna Ruth
Published: November 2023

Background

Children with cancer are at risk for healthcare associated infections (HAIs) given their immunosuppression as well as frequent hospitalizations and antibiotic and antiseptic exposure. The degree to which the healthcare environment impacts the flora of children with cancer and its subsequent role in infection is uncertain. We prospectively evaluated the nasal microbiome in children with malignancy relative to healthy children.

Methods

Subjects were enrolled into two cohorts. The high risk cohort included children with a new diagnosis of malignancy recruited from the Texas Children’s Hospital Cancer Center. Children in the low risk cohort were otherwise healthy and enrolled from two Houston area general pediatrics clinics. Subjects had anterior nares swab samples obtained at 3-month intervals for one year. Genomic material was extracted from samples and the 16S rRNA V4 region was amplified and sequenced. Microbiome analysis was performed using QIIME 2, and comparisons in both bacterial diversity (alpha diversity via Shannon index) and composition (genus-level) were made based on cohort and time point. We present early data from the time of subject enrollment and first follow-up.

Results

272 subjects were enrolled. Cohorts were similar in terms of demographics. No subjects were neutropenic at time of sample collection. High-risk subjects were significantly more likely to have received antibiotics (96.4% vs. 17.5%, p< 0.01) and/or chlorhexidine gluconate containing products (91.6% vs. 0%, p< 0.01) in the 90 days prior to enrollment. Within the high-risk cohort, 98.8% had received antineoplastic chemotherapy. Alpha diversity (Shannon index) was lower in the high risk cohort compared to the low risk cohort. In the high-risk cohort, the genera Staphylococcus and Corynebacterium were disproportionately represented relative to the low-risk cohort in which Moraxella predominated (Figure 1). Nasal microbiota were similar across cancer diagnoses.

Conclusion

There are significant changes in the nasal microbiota of children with cancer relative to healthy children. These findings suggest a high impact of healthcare exposure and specifically antibiotics and antiseptics on colonizing flora. Further work is needed to understand how these microbiome perturbations modify risk for HAI.

Disclosures

Jonathon C. McNeil, MD, Allergan: Grant/Research Support|Nabriva Therapeutics: Grant/Research Support