bluuebunny/crossref_metadata_2025 huggingface dataset:
1737. Xeruborbactam (QPX) Potentiates the Activity of β-Lactam (BL) Antibiotics Against a Diverse Group of Highly Drug-Resistant Enterobacterales (ENT)
Authors: Newbrough Anthony , Fleres Giuseppe , Hao Binghua , Chen Liang , Shields Ryan K , Clancy Cornelius J , Nguyen Minh-Hong
Published: December 2022

Background

Antibiotic resistant ENT are a growing threat worldwide. QPX is an ultra-broad-spectrum β-lactamase inhibitor (BLI) with potent inhibition of classes A and D, and many metallo-β-lactamases, which has potential to fill the void of currently available BL-BLIs.

Methods

We evaluated QPX (fixed concentration of 8 µg/mL) in combination with meropenem (MEM), cefepime (FEP) and aztreonam (ATM) against a diverse group of ENT clinical isolates selected from a worldwide repository. Antibiotic resistance determinants were assessed by mining whole-genome sequencing data generated using Illumina MiSeq.

Results

Klebsiella spp, Enterobacter spp, and Escherichia coli were most common among the 90 isolates tested (Fig. 1). 71% (64) produced carbapenemases (Fig. 2): 3 isolates produced both class A and B carbapenemases. 11% of isolates harbored mutations in ompK 36/ompC genes. 57% (51) were resistant to MEM, 31% to imipenem-relebactam, 17% (15) to ceftazidime-avibactam (CZA), and 9% to MEM-vaborbactam (MVB). ENT-resistant to CZA were due to production of class B, D or KPC-3 variants, or ompC mutation in a K. aerogenes isolate. ENT-resistant to MVB were due to class B or D enzymes, or class A with ompK36 or ompC mutations. MIC distributions of BL with or without QPX against all isolates tested are presented in Fig. 3. Addition of QPX to MEM, FEP and AMT reduced MIC50s and MIC90s of these agents (Fig. 3; p< 0.0001). Of note, addition of QPX reduced MEM MICs more than did vaborbactam (median 533- versus 24-fold; p=0.0006). QPX reduced MICs of MEM, FEP and ATM to levels below respective breakpoints for non-susceptibility (Fig. 3). MIC distribution of ENT isolates stratified by the types of carbapenemases are presented in Fig. 4. QPX potentiated activity of MEM, FEP or ATM against ENT, regardless of whether they produced class A, B or D carbapenemases.

Conclusion

QPX enhanced activity of MEM, FEP and ATM against carbapenemase-producing or other carbapenem-resistant ENT (CRE), regardless of species or other resistance determinants. Most remarkably, QPX rendered each BL equally active against CRE. The expanded spectrum of QPX against class B and D carbapenemases addresses a major unmet need against CRE.

Disclosures

Cornelius J. Clancy, MD, receives research funding paid to his institution from Astellas and Merck: Grant/Research Support|serves as an advisory Board member for Astellas, Cidara, and Scynexis, served on the advisory board for Merck, Qpex Biopharma, and Shionogi: Advisor/Consultant|Venatorx and Needham & Associates: Advisor/Consultant.
1738. A Needs Assessment and Tailored Webinar Series to Extend Antimicrobial Stewardship Practices to a Skilled Nursing Facility Collaborative Network
Authors: Choudhury Rebecca L , Nori Priya , Stark Allison , DiPalo Katherine
Published: December 2022

Background

The CDC’s Core Elements (CDCCE) of Antimicrobial Stewardship outline best practices for antimicrobial stewardship programs (ASP) in skilled nursing facilities (SNFs). We conducted a needs assessment based on the CDCCE and applied the results to creating an educational webinar series.

Methods

A needs assessment based on the CDCCE Checklist was electronically distributed in 10/2021 to members of the Montefiore Health System SNF Collaborative: 33 Bronx and Hudson Valley facilities. A follow-up assessment was performed 2/2022. Responses were aggregated using Google Forms and Microsoft Excel. A 3-part webinar series addressing respiratory, urinary, and skin infections using AHRQ materials was then delivered via Zoom in 4/2022.

Results

Fifteen facilities responded to the initial assessment. Thirteen facilities reported the director or assistant director of nursing as an ASP leader, with 8 reporting the facility medical director as ASP leader, corresponding to the CDCCE of “Leadership Commitment” and “Accountability.” Fourteen facilities implemented policies to improve antibiotic use (AU), corresponding to “Action.” Corresponding to “Tracking,” all facilities used electronic medical records and monitored at least 1 AU metric, with 11 also monitoring at least 1 adverse outcome related to AU. Fourteen facilities shared AU data with staff, corresponding to “Reporting.” Eighteen facilities responded to the follow-up assessment. Facilities perceived “Action” (7 responses), “Reporting” (4), “Tracking” (2) and “Accountability” (2) as the main areas of weakness in their ASP, despite fulfilling these criteria per the CDCCE Checklist. Facilities expressed interest in education on best AU practices (9) and antibiotic stewardship education for nursing staff (7). Clinical syndromes of interest were pneumonia (5) and wound infections (5). There were 55 participants in the webinar series, from 22 of 33 facilities. Thirty were nurses, 17 were physicians, and 8 were administrators. Figure 1Responses from the follow up needs assessment in February 2022

Conclusion

Online communication platforms such as Zoom can be a useful tool for providing education about improving antibiotic use in SNFs. Further investigation is needed to determine best strategies to implement, evaluate, and improve ASP in SNFs, considering structural challenges unique to this setting.

Disclosures

All Authors: No reported disclosures.
1740. Antibiotic Allergy Delabeling in Pediatric Infectious Disease Clinic: Missed Stewardship Opportunities
Authors: Vermilye Katherine , Tesini Brenda L , Stern Jessica
Published: December 2022

Background

Reported beta lactam antibiotic allergies are common, with up to 10% of individuals carrying a penicillin [PCN] allergy label and approximately 1% carrying a cephalosporin allergy label. However, >90% of patients with a PCN allergy label can safely tolerate penicillins. Incorrect antibiotic allergy label can contribute to increases in antibiotic resistance and medication side effects. Appropriate medication allergy history taking is necessary and sometimes sufficient to effectively remove inappropriate allergy labels. We aimed to evaluate opportunities for addressing inappropriate PCN allergy labels in a pediatric infectious diseases clinic.

Methods

Electronic medical records (EMRs) for patients seen in an academic outpatient pediatric infectious diseases clinic from January 1, 2021 through April 30, 2021 were reviewed for presence of documented antibiotic allergy at time of visit, antibiotic class (PCN, cephalosporin [Ceph.], or non-beta lactam), reaction type, documentation of full reaction history needed to stratify for potential delabeling, and whether or not potential allergy delabeling was addressed during the visit.

Results

Antibiotic allergy labels were present in the EMR in 18% (n=16) of the 90 encounters reviewed, representing 19% (n=15) of patients seen. Beta lactam antibiotic reactions accounted for 69% (11/16) of documented allergies; 8 PCN class (73%), 2 Ceph. class (18%), 1 with both PCN and Ceph. class allergy (9%). Reactions included rash (6 visits; 54%), hives (3; 27%), nausea/vomiting (1; 9%), diarrhea (1; 9%), swelling (1; 9%), and none recorded (2; 18%). [Sum >100% due to multiple reactions listed]. No additional reaction history was obtained for any patient during the visits. Antibiotic allergy delabeling or assessment by an allergist was only addressed during 1 of the 16 visits with documented antibiotic allergy (6.3%).

Conclusion

Antibiotic allergy labels are common in pediatric infectious diseases clinic patients. However, appropriate medication allergy histories and the potential for allergy delabeling were not documented for the majority of patients with antibiotic allergy labels. This represents a significant missed opportunity for antibiotic allergy delabeling and a target for future antimicrobial stewardship opportunities.

Disclosures

All Authors: No reported disclosures.
1742. Antibiotic Use in the Podiatry Clinic: Antimicrobial Stewardship Setting Foot in Uncharted Territory
Authors: Oh Elizabeth , Bollam Rahul , Yadlapalli Mownika , Levin Joel , Arbulu Ricardo
Published: December 2022

Background

Podiatrists independently manage diabetic foot ulcers (DFU), often complicated by diabetic foot infections (DFIs). The prevalence of DFU is 40 - 60% and guidelines vary in their recommendations for DFI, creating a target for antimicrobial stewardship. However, the prevalence and appropriateness of antibiotics prescribed by podiatrists has not been reported. We describe both variables among patients with DFU in a podiatry clinic.

Methods

We conducted a retrospective chart review of all consecutive patients > 18 years of age with DFUs, infected or not, who had at least one visit to the UPMC Mercy Wound Clinic (Pittsburgh, PA) in 2020. We defined severity of infection using the PEDIS score and diagnosis of osteomyelitis (OM) (Figure 1). We collected data on antibiotics prescribed by podiatry in the clinic or by any provider during a hospitalization for DFI. Figure 2 shows our appropriateness criteria. Figure 1:Stratification of Severity of Diabetic Foot InfectionFigure 2:Criteria for Appropriateness of Antibiotic Use in Diabetic Foot Ulcers

Results

Of 72 patients with DFU, 32 (44.4%) received an antibiotic. Compared to those who did not receive antibiotics, patients who did were more likely male (86.2% vs. 63.6%), had a higher PEDIS score (2.03 vs. 1.49), and were more frequently diagnosed with OM (71.9% vs. 26.8%). (Table 1). Table 2 shows the most common antibiotics.

Among the five patients with no to mild infection, none received appropriate treatment (Table 3). Two patients in that category received IV antibiotics (when hospitalized for DFI), and neither received an Infectious Diseases (ID) consult. The other three were considered inappropriate due to durations > 7 days. The mean length of treatment for patients with mild infection was 12.6 (4.56). The two patients with moderate infection who received antibiotics had “inappropriate” courses; however, both had complicated Staphylococcus aureus bacteremia, and therefore 4-6 weeks courses were justified. All 12 inappropriate courses in severe infections were due to courses > 42 days.

Conclusion

Prescription of antibiotics among patients with DFU was common. Our findings suggest potential targets for antimicrobial stewardship: unnecessarily long courses an IV antibiotic use in patients with mild or no infection. Our criteria can be refined to recognize situations in which prolonged therapy may be justified, and larger studies are warranted.

Disclosures

All Authors: No reported disclosures.
1745. Drilling Down on Antibiotic Use in Dental Clinics
Authors: Son Andrea H , Boland Brendan P , Harsh Nicholas C , Hecker Michelle T
Published: December 2022

Background

Dentists are the third highest prescribers of antibiotics in outpatient settings in the US with reported suboptimal prescribing rates between 30 and 85%. The 2019 American Dental Association guidelines provide guidance for antibiotic use based on the presence of dental pain and/or swelling and whether definitive conservative dental treatment is immediately available. Our primary objective was to assess the appropriateness of systemic antibiotic use in our institution’s dental clinics based on these guidelines. Our secondary objectives were to describe antibiotic choice, duration of therapy, and use of non-first line antibiotics.

Methods

From January 2021 through December 2021 data on antibiotics prescribed during all patient encounters in our institution’s dental clinics were abstracted from the electronic medical record. Detailed review was performed on a randomly generated sample of 120 unique patient encounters (10 each month). First line antibiotics included penicillin, amoxicillin, and amoxicillin-clavulanate.

Results

Of 14,381 dental clinic encounters, 2,413 (16%) resulted in one or more antibiotic prescriptions (total of 2788 prescriptions). Non-first line antibiotics accounted for 402 (14%) of all antibiotic prescriptions (Table). Sixty-nine (17%) of non-first line antibiotics were prescribed for patients with no documented beta-lactam allergy. Of the 333 non-first line antibiotics prescribed for patients with a documented beta-lactam “allergy”, a first line antibiotic or cephalexin could have been used in 120 (36%). Of 120 patient encounters undergoing detailed review, antibiotics were prescribed for treatment (not prophylaxis) in 115 (96%). Antibiotics were indicated in only 16 of 108 (14%) evaluable patients. The mean duration of therapy was 7.2 days. Eleven percent of prescriptions were longer than 7 days.

Conclusion

At our institution most antibiotics prescribed from our dental clinics were for treatment, were commonly not indicated, and were usually prescribed for 7 days or more. First line antibiotics and cephalexin could have replaced nearly half of the non-first line antibiotics prescribed. Developing a clinical pathway incorporating updated guidelines and management of patients with beta-lactam “allergies” may improve patient care.

Disclosures

All Authors: No reported disclosures.
1747. Emergency Department Antimicrobial Stewardship Intervention Bundle to Optimize Antibiotic Prescribing in Urinary Tract Infections and Skin and Soft Tissue Infections
Authors: Ducas Stephanie R , Cubillos Ashley L , Chandler Elisabeth , Saunders Mary Beth
Published: December 2022

Background

Emerging literature has demonstrated a positive impact of emergency department (ED)-focused antimicrobial stewardship initiatives on antibiotic prescribing. To date, the majority of interventions focus on urinary tract infections (UTI) and few evaluate electronic medical record (EMR) integration.

Methods

This retrospective, quasi-experimental study was conducted at five EDs within a large-community health system. An antimicrobial stewardship intervention bundle was implemented in February 2022, consisting of ED-specific discharge antibiotic order sets for UTI and skin and soft tissue infections (SSTI) and education to ED prescribers and pharmacists. Adult patients receiving an ED discharge antibiotic prescription associated with a UTI or SSTI ICD10 code were included. The primary outcome was the percentage of prescriptions matching discharge order set antibiotic regimens for UTI and SSTI in the 2-month pre- and post-implementation periods. Secondary outcomes included evaluation of primary outcome indications (UTI or SSTI), use of recommended agents or durations of therapy, use of combination therapy (SSTI only), and rate of 30-day hospital admission.

Results

The implementation of this multi-intervention stewardship bundle was associated with a significant initial improvement in the percentage of prescriptions matching discharge order set recommendations for UTI and SSTI (30.9% vs. 35%, P = 0.04). There was a significant improvement in UTI prescribing (54.9% vs. 61.7%, P = 0.01), but the same benefit was not demonstrated for SSTI (6.2% vs. 3.6%, P = 0.04). A significant improvement was also observed in the use of recommended durations of therapy (34% vs. 38.5%, P = 0.023). No significant difference was observed in use of indication recommended agents (75.7% vs. 77.1%, P = 0.43), use of inappropriate combination therapy for SSTI (31.7% vs.26.3%, P = 0.07), or 30-day hospital admission (6% vs. 5%, P = 0.33).

Conclusion

This novel multi-intervention ED antimicrobial stewardship bundle was associated with overall immediate improvements in antibiotic prescribing for discharged patients. Future directions of research will include evaluation of methods to improve SSTI prescribing, implementation of prescriber data feedback, and expansion to additional indications.

Disclosures

All Authors: No reported disclosures.
1748. Epidemiology and resistance patterns of nursing home uropathogens in four states, 2018-2019
Authors: Taylor Lindsay , Irvine Jessica , Jolles Sally , Bej Taissa A , Kowal Corinne , Podzorski Raymond , Jump Robin L , Crnich Christopher J
Published: December 2022

Background

Urinary tract infections (UTIs) are the most common indication for antibiotic treatment in nursing homes (NHs) and are often treated empirically before culture results return. A previous study of uropathogens from NH residents in Georgia revealed high resistance to commonly used antibiotics, including ciprofloxacin. Here, we describe the distribution and key resistance patterns of uropathogens recovered from residents of NHs in Wisconsin, Ohio, Kentucky, and Indiana.

Methods

Results of urinary cultures from NH residents performed between 2018 and 2019 were obtained from contracting microbiology laboratories. Culture results were de-identified by an honest broker. Urine culture data was standardized across laboratories and years using key collision and nearest neighbor clustering methods. Non-pathogenic isolates were excluded. The 5 most common isolates were identified and mean susceptibilities to antibiotics commonly used for empiric treatment of UTIs were examined. Data standardization and analysis were performed in Open Refine and R.

Results

There were 11,007 urine cultures obtained from 5,642 NH residents living in 67 NHs. A total of 4,398 potentially uropathogens were identified (avg. per NH = 66; range = 2-279). Escherichia coli (43.1%), Klebsiella spp. (14.6%), Proteus spp. (14.3%), Enterococcus spp. (9.5%), and Pseudomonas spp. (4.6%) were the most commonly identified uropathogens. Resistance rates for the majority of evaluated bug-drug combinations (9/14) exceeded 20% (Figure 1). Nitrofurantoin was the only antibiotic with a resistance rate < 20% for E. coli isolates. When resistance was assessed cumulatively across the top 5 organism, 48.5% of isolates were resistant to ciprofloxacin and 21.3% of isolates were resistant to ceftriaxone (when excluding isolates with intrinsic resistance).

Percentage of common urinary isolates resistant to most common antibiotics

R denotes intrinsic resistance. Abbreviation: species pluralis = spp.

Conclusion

Consistent with a recent study conducted in Georgia NHs, high levels of resistance to commonly used antibiotics amongst uropathogens recovered from NH residents in four states were identified in the current study. These suggest a need for NH-specific UTI treatment guidelines and tools to support empiric antibiotic decision-making at the local facility level.

Disclosures

Robin L. Jump, MD, PhD, Merck: Grant/Research Support|Pfizer: Advisor/Consultant.
2300. Neonates born to mothers with SARS-CoV-2 infection in pregnancy: a follow-up and serological study
Authors: Marsico Concetta , Gabrielli Liliana , Arcuri Santo , Vocale Caterina , Borgatti Caterina , Lazzarotto Tiziana , Corvaglia Luigi , Capretti Maria Grazia
Published: December 2022

Background

To evaluate the early and late clinical outcomes of neonates born to mothers with SARS-CoV-2 infection in pregnancy, the dynamics of maternal IgG trans placental transfer and its persistence during the first month of life.

Methods

Prospective study enrolling neonates born to mothers with SARS-CoV-2 infection in pregnancy at IRCCS Azienda Ospedaliero Universitaria di Bologna, Italy, between April 2020 and September 2021. Neonates born to women with infection onset before 2 weeks prior to delivery were enrolled in a 12-month follow-up, including clinical and laboratory evaluations, cranial ultrasound, fundoscopy evaluation. Quantitative IgG to S1/S2 subunits of spike protein were assessed in mother-neonate dyads within 48 hours post-delivery and during follow-up until negative. Transplacental IgG transfer ratio was assessed in relation to the type and trimester of maternal infection.

Results

One hundred and forty-five neonates were included. the rate of preterm delivery was similar between women with and without SARS-CoV-2 infection (6.2% versus 8.7%, P=0.53). No clinical, laboratory, cerebral and fundoscopy abnormalities were detected at birth or during follow-up, through 11 months (range 8–12). MedianIgG level at birth was not different between neonates born to asymptomatic or symptomatic mothers (18.5 AU/mL, IQR 12–49, versus 31.5 AU/mL, IQR 15–71, P=0.07) nor in relation to the trimester of maternal infection (Table 1), even though mothers with third trimester infections had higher IgG level at birth. Transplacental transfer ratio was higher following second trimester maternal infections and was the lowest following third trimester infections (Table 1). Maternally derived IgG were rapidly weaned, with most infants (115/140, 82%) seronegative by 4 months of age.

Conclusion

Early and later outcomes of infants born to SARS-CoV-2 infected mothers were favorable. IgG trans placental transfer was higher following second trimester maternal infections, which could be relevant to inform studies on appropriate vaccination strategies aimed at neonatal protection. Maternally derived IgG are rapidly weaned in the first months of life.

Disclosures

All Authors: No reported disclosures.
1750. Evaluation of Antibiotic Allergy in the Ambulatory Setting
Authors: Yi Sarah M , Barsanti-Sekhar Mary C , Wozniak Amy W , Santarossa Maressa , Adams Jenna , Albarillo Fritzie S
Published: December 2022

Background

It is not uncommon for patients to have a labeled allergy to antibiotics without thorough investigation of their adverse reactions. The adverse reactions described by some patients are not immune-mediated and these patients are incorrectly labeled as having an antibiotic allergy. As clinical testing for antibiotic allergy is expensive and time intensive, recent initiatives have successfully used patient interviewing to differentiate non-immune mediated reactions from true antibiotic allergies. We investigated the prevalence of patients with non-immune mediated reactions to antibiotics among patients with documented antibiotic allergy by using a standardized questionnaire in the outpatient setting.

Methods

Patients with a documented antibiotic allergy were identified and recruited from 2 clinics located in the greater Chicagoland area. Subjects completed one standardized questionnaire regarding each of their previous adverse reaction to antibiotics. We then evaluated the questionnaire responses to extricate the non-immune-mediated adverse reactions. The full symptom classification can be found in Table 1 and Table 2.

Results

98 patients were recruited with a total of 159 antibiotic questionnaires completed. At the patient level, 18 individuals had no immune-mediated reactions despite antibiotic allergy labels: 18.37% (95% CI: 10.7%, 26.3%). At the antibiotic level, 35 labels had corresponding clinical histories that were likely non-immune mediated: 22.0% (95% CI: 14.7%, 29.4%). Macrolides (8/11, 72.7%), nitrofurantoin (1/2, 50%), and amoxicillin/clavulanate (2/8, 25%) were the antibiotics with the highest percentage of corresponding clinical histories that were likely non-immune mediated (Figure 1). Penicillin was the most prevalently listed antibiotic allergy (43/159, 27.0%), followed by sulfonamides (25/159, 15.7%) and fluoroquinolones (21/159, 13.2%).

Conclusion

This study demonstrated the feasibility of using a standardized questionnaire to discern true antibiotic allergies from non-immune mediated adverse reactions. The improved accuracy of documented allergies allows for better optimization of antibiotic prescribing.

Disclosures

All Authors: No reported disclosures.
1760. Selection of appropriate inpatients for outpatient parenteral antimicrobial therapy (OPAT) during the COVID pandemic
Authors: McKnight Angela Y , Liappis Angelike P , Adenew Ayne
Published: December 2022

Background

Providing a safe discharge in patients appropriate for outpatient parenteral antimicrobial therapy (OPAT) became an important focus of the inpatient to outpatient transition during the pandemic. Hospital beds were needed for ill patients with COVID; transfers in and out of facilities and interfacility infection became issues for long-term care (LTCF) and short-term nursing facilities (SNFs) in the US during the pandemic. We examine the traditional barriers, including age, and outcomes of patients selected for OPAT initiation during the pandemic period.

Methods

Washington DC VAMC (WDVAMC) is an urban medical center with 220 acute and LTC beds. At the start of the pandemic, a multidisciplinary OPAT program was initiated and led by ASP Nurse Practitioner (NP), supported by ASP Pharmacist and ASP/ID Physician. OPAT included care continued at home, SNF, LTC and hemodialysis locations; the OPAT program focus was on appropriate selection, post-discharge safety monitoring, outpatient follow-up at completion, tracking and outcome determination (30D, 90D readmissions). OPAT related readmissions related to drug or opat-indicated infections.

Results

Between April 2020-2022, 157 unique OPAT discharges (10.4 OPAT/1,000 admissions 2020 and 4.8 OPAT/1,000 admissions 2021); the majority were offered OPAT at home (47%). Mean duration OPAT 22±13days over that period; most frequent indication osteomyelitis and BSI. OPAT related readmissions were infrequent at 30D (7%) and 90D (1%). The mean age was 67±13y with 5% >90yrs, 21% >75yrs and 58% >65yrs. In the pandemic 92% completed OPAT; compared to younger group those >75y, rates of completion (93% vs 92%, P=NS) and mean duration of OPAT were similar however a modest increase in 90D OPAT-related readmission (1.2% vs 0%, P=0.04). The only two deaths prior to completion of OPAT occurred in those >75y.

Conclusion

Transitions to OPAT are required for serious infections in hospitalized patients of all ages, however transitions to SNF and LTC were limited at times during the pandemic. We found OPAT can be delivered safely, regardless of age during a pandemic state with careful coordination between stakeholders and a systematic process to monitor outcomes and track patients, particularly for the elderly.

Disclosures

All Authors: No reported disclosures.
1771. End-of-Life Use of Antibiotics in Pediatric Patients
Authors: LLoyd Patrick , Toia Jacquie , Lust Hannah , Shteynberg Emily , Newman Anders , Patel Sameer
Published: December 2022

Background

Antibiotic use at the end of life is common in adult patients but little is known about children. While important to treat and prevent infection in these vulnerable populations, unnecessary antibiotic exposure may result in adverse events and selection of antimicrobial resistant organisms. The purpose of this study was to describe clinical features of pediatric patients who receive antibiotic use at the end of life, quantify antibiotic utilization, and determine indications for antibiotic use.

Methods

We performed a retrospective review of antibiotic use in the last 30 days of life who had palliative care consultation at a tertiary care pediatric hospital from June 2012 to February 2020. Demographic characteristics, primary diagnosis, do not resuscitate (DNR) status, and hospice status were assessed. Days of antibiotic therapy were recorded.

Results

Of the 151 patients identified, 67 (44%) were female, and the median age at death was 3.5 years (IQR: 0.50-13.8 years). Of the causes of death, 133 (88%) had chronic progressive illness, 13 (8.7%) had a chronic static illness, 5 (3.3%) and had an acute illness. The most common primary diagnoses were oncologic (n=56, 37%), cardiac (n=32, 21%), genetic metabolic (n=19, 13%), and neurological (n=16, 11%). DNR status was recorded for 109 (72%) patients, and 11 (7.2%) had documented hospice status. Antimicrobial use was most common for a known organism (n=75, 50%), followed by no documented indication (n=33, 22.8%), empiric therapy (n=31, 20.5%), and prophylaxis only (n=2.7%). Of the 2126 total days of therapy of antibiotic use, the most common agents were vancomycin (n=379), meropenem (n=254), ceftazidime (n=171), and cefepime (n=143). The median number of unique antibiotics received in the last 30 days of life was 2 (IQR 0-5).

Conclusion

Antibiotic exposure was common in pediatric patients at the end of life, particularly for vancomycin and meropenem, even without documented infection. Opportunities for future interventions include better discussion of goals of care between providers and parents and risk of adverse events, particularly if suspicion of infection is low.

Disclosures

All Authors: No reported disclosures.
1772. Evaluating the Impact of a Pilot Structured Antimicrobial Stewardship Prospective Audit and Feedback Program in Emergency General Surgery in a Community Hospital
Authors: Nisenbaum Rosane , Tsang Melanie , Langford Bradley J , Wan Michael , Downing Mark , Chan April J
Published: December 2022

Background

The benefits of prospective audit and feedback (PAF) are established in critical care settings but not in the surgical population. We piloted once-weekly structured face-to-face PAF with the Acute Care Surgery (ACS) Service surgeon(s) and compared outcomes to usual care which comprised of ad-hoc PAF on targeted antimicrobials once or twice weekly with recommendations made to ACS surgeon(s) using written or verbal methods.

Methods

Interrupted time series segmented negative binomial regression analysis was used to evaluate the change in the primary outcome of antimicrobial usage measured in Days of Therapy/1000 patient days (DOT/1000-PD) for all systemic and targeted antimicrobials ordered by the ACS team. The structured PAF period was from August 1, 2017- April 30, 2019 while the ad-hoc PAF period was from May 1, 2019-January 31, 2021. Targeted antimicrobials included 3rd generation cephalosporins, piperacillin/tazobactam, carbapenems and clindamycin. Secondary outcomes included C. difficile infections, length of stay and readmission within 30 days. The first two secondary outcomes were analyzed using a logistic regression model while a negative binomial regression model was used to evaluate readmission within 30 days.

Results

There were 776 ACS patients in the structured PAF period with 783 patients in the ad-hoc PAF period. = No significant changes in level or trend of the primary outcome of DOT/1000-PD in both periods was found for all and targeted antimicrobials. However, there was a trend to small reduction in DOT/1000-PD of 0.9% per month (rate ratio 1.0, CI 0.99-1.02) for all antimicrobials and 0.3% per month (rate ratio 1.0, CI 0.98-1.03) for targeted antimicrobials in the ad-hoc PAF period. Similarly, there were no significant differences with respect to any of the secondary outcomes. There was a trend of 10% increase in length of stay (rate ratio 1.07, CI 0.98-1.17) and 13% reduction in 30-day readmission (OR 0.87, CI 0.56-1.35) in the ad-hoc PAF period.

Rates by Time Using Negative Binomial Models for All and Targeted Antimicrobials

Conclusion

Structured PAF showed similar clinical outcomes to ad-hoc PAF for the Acute Care Surgery Service at our institution. Other antimicrobial stewardship interventions can be explored to better support judicious antimicrobial use in General Surgery.

Disclosures

All Authors: No reported disclosures.
1778. Veterans’ Perceptions and Categorial Constructs Regarding Antibiotics for Upper Respiratory Tract Infections (URIs)
Authors: Reasoner Kaitlyn , Pellegrino Rachael , Gettler Erin , Johnson Morgan C , Hulgan Todd , Roumie Christianne L , Grijalva Carlos G , Dittus Robert S , Staub Milner B
Published: December 2022

Background

To reduce antibiotic prescribing, antimicrobial stewards must understand patient knowledge, attitudes, and perceptions (KAP) around antibiotics for URIs. Validated patient KAP surveys are scarce and for Veteran patients, nonexistent. We aimed to explore if published results of an exploratory factor analysis (EFA) of a KAP survey in emergency department (ED) patients and an online sample would approximate results in outpatient Veterans.

Methods

After cognitive testing in Veterans and healthcare providers, we omitted 13 of the 46 questions from the published KAP survey deemed confusing or with low factor loadings. We mailed the 33-item survey to Veterans seen for URI at 18 Veterans Affairs clinics from January 2018 to December 2019. We excluded Veterans not evaluated in-person, with documented dementia, or who died prior to study start. We excluded surveys with > 3 unanswered questions.

We used principal component factor analysis (PCFA) with orthogonal varimax rotation (Fig. 1) to assess Veteran responses and Cronbach’s alpha to assess each factor’s internal consistency. We removed questions to reach alpha of >0.7 (Fig. 2). We repeated PCFA and compared results to published EFA factors and loadings for the ED patients and online sample.

Results

Of 1329 eligible Veterans invited, 474 (36%) returned the survey; 407 met inclusion criteria (Table 1). PCFA of Veterans’ responses yielded 7 Factors (Fig 2). Like ED patients and the online sample, Veteran responses about side effects clustered together. Veteran responses about “antibiotics help” and “antibiotics don’t hurt” clustered together like ED patients. They grouped separately in the online sample. Veteran responses about safety and efficacy (Factors 3 & 5) and knowledge about viruses and bacteria, (Factors 4 & 5) clustered separately (Fig. 2). For ED patients and the online sample, safety and efficacy and virus and bacteria responses clustered together, respectively (Fig. 1).

Conclusion

While Veterans did share some KAPs around antibiotics for URIs with ED patients and the online sample, this study shows they also have distinct views. Further testing in Veteran and non-Veteran populations should validate and assess reliability of this survey as an antimicrobial stewardship tool.

Disclosures

Carlos G. Grijalva, MD, MPH, AHRQ: Grant/Research Support|Campbell Alliance/Syneos Health: Grant/Research Support|CDC: Grant/Research Support|FDA: Grant/Research Support|Merck: Advisor/Consultant|NIH: Grant/Research Support|Pfizer: Advisor/Consultant|Sanofi: Grant/Research Support|Sanofi-Pasteur: Advisor/Consultant Milner B. Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds.
1782. Antimicrobial Stewardship Opportunities in Gram-Negative Bacteremia Treatment at a Community Teaching Hospital
Authors: Ficinski Matthew , Laguio-Vila Maryrose R
Published: December 2022

Background

Gram Negative Bacteremia (GNB) is frequently encountered among hospitalized patients. In contrast to traditional 14-day lengths of treatment (LOT), recent literature supports a shorter (7-day) LOT for uncomplicated GNB with adequate source control, and the effectiveness of oral antibiotics. The goal of the following is to outline current practices of GNB treatment and identify opportunities for antibiotic stewardship (AS).

Methods

This study retrospectively reviewed all cases of uncomplicated GNB at a 528-bed community teaching hospital in Rochester, NY from January 2021 through March 2022. Demographic, laboratory, microbiologic, antibiotic therapy data, results of follow-up blood cultures (FUBC), hospital length of stay and 30-day readmission were collected. Exclusions were complicated or polymicrobial bacteremia, deaths during treatment, or prolonged hospitalization due to other medical factors. Influences of Infectious diseases (ID) or AS consult on treatment and outcomes were compared to cases with no consult. Continuous variables were analyzed using unpaired t-tests; categorical variables were analyzed using Fischer’s exact test and Chi-square as appropriate.

Results

133 cases met inclusion criteria. Demographic and laboratory data are in Table 1. The frequency of bacteria isolated and source of infection are in Figure 1 and Figure 2. ID was significantly more often consulted for central line infections (17% vs 3%, p=0.01), and significantly less frequently involved in urinary tract infections (39% vs 69%, p=0.009). While total LOT were similarly longer than current literature supports (11.7 vs 12.5 days, p=0.2644), cases without ID consultation received significantly more days of oral treatment (4.7 vs 7.1 days, p=0.0275). There were no significant differences between receipt and no receipt of AS recommendations.

Conclusion

GNB continued to receive longer LOTs than current literature recommends, with longer IV durations recommended by ID consultants compared to those without ID consult. Educational initiatives regarding the safety of shorter LOT for GNB, including the efficacy of oral antibiotics, are needed and should include ID specialists.

Disclosures

All Authors: No reported disclosures.
1786. Characterizing Antibiotic Use in Patients with Hematologic and Oncologic Malignancies Transitioned to Comfort Measures Only (CMO) During Hospital Admission
Authors: Chan Michelle , Pepe Dana , Mehrotra Preeti
Published: December 2022

Background

Antimicrobial treatment at the end of life is common. However, there is limited evidence on whether antimicrobial use during hospice care provides symptom palliation or contributes to discomfort. We sought to further investigate antimicrobial use at the transition to CMO in immunocompromised patients with active malignancies.

Methods

We conducted a retrospective cohort study of patients with active malignancies over 18 years of age admitted to Beth Israel Deaconess Medical Center from 3/1/2018 to 3/1/2021, who were transitioned to CMO. From hospital databases and from subsequent chart review, we examined: receipt of antimicrobials at any point in the admission; indication for antimicrobials; timing of CMO order; underlying hematologic/oncologic diagnosis; and concomitant COVID-19 diagnosis. Among the patients who received antimicrobials, we identified patients on antibiotics 48 hours prior to and after CMO order placement. Patients were excluded if CMO orders were reversed.

Results

384 patients met study criteria. The mean age was 67 years, and 50.5% patients were female. 31.8% of patients carried a hematologic malignancy diagnosis while the remaining had solid tumor diagnoses. 88% patients received antimicrobials at any point during their hospitalization. Of the patients who received antimicrobials during their admission, 84% received them in the 48 hours prior to transition to CMO and 15.3% continued receiving antimicrobials after CMO transition. Patients received a mean of 5.7 antibiotics. Most common indications for antimicrobials included pneumonia (22.2%), intra-abdominal infections (13.6%), sepsis (13.3%), and prophylaxis (3.5%), but most (39.8%) received antimicrobials for more than one infection or indication.

Conclusion

Hospitalized patients with active malignancy at the end of life are heavily exposed to antimicrobials. The majority of patients transitioned to CMO receive antimicrobials during their last hospital admission, and a significant subset (15.3%) continue antimicrobials after placement on CMO. Further studies are needed to investigate the potential benefits and harms of continuing antimicrobials in CMO patients, as decisions are complex and individualized.

Disclosures

All Authors: No reported disclosures.
1787. County Level Association Between the Rate of Fluoroquinolone-Resistance Gram Negative Bacteria and Fluoroquinolone Utilization in Kansas
Authors: Fulmer Robert D , Wark Kellie
Published: December 2022

Background

Kansas ranks as the 8th-worst state nationally for outpatient antibiotic prescribing, with a rate of 690 antibiotic prescriptions per 1000 population. The statewide rate of fluoroquinolone (FQ) is disproportionately higher than other antibiotic drug classes. Statewide antibiograms can be developed by health departments for antimicrobial stewardship monitoring. The purpose of this study was to investigate the correlation between the FQ resistance rate of gram-negative bacteria to FQ consumption.

Methods

A retrospective design utilizing 2018-2019 county level FQ-resistant Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa was categorized by county level based on the Kansas statewide antibiogram. Outpatient FQ utilization data was obtained from IQVIA and categorized into county level FQ rate based on prescriptions dispensed per 1000 population. Linear regression was used to compare antibiotic resistance (AR) to FQ utilization by county.

Results

Sixty-six of 123 facilities contacted for antibiogram data responded with results. Of these, 47 were critical access hospitals, and the rest were acute care hospitals or clinics. A total of 31,573 E. coli isolates, 5,942 K. pneumoniae and 5,017 P. aeruginosa isolates were represented. All 106 counties had FQ prescription data. Of the 49 counties with AR reported, FQ rates ranged from 4.6 to 105.6/1000 population. There was no statistical significance associated between counties for FQ-resistant E. coli, K. pneumoniae or P. aeruginosa with FQ-utilization rates (p=0.184, 0.572, 0.352, respectively). Comparing urban and rural regions was also compared for each AR-FQ use combination. There was statistical significance for urban P. aeruginosa FQ-resistance and FQ utilization (p=0.025), but not for urban E. coli (p=0.120) or urban K. pneumoniae (p=0.331).

Conclusion

A strong correlation was demonstrated between FQ consumption and rates of FQ-resistant P. aeruginosa within urban counties. No significant correlations were found between FQ consumption rates and other organisms. This study demonstrates additional applications for state-level antibiogram data, particularly when paired with antibiotic use data.

Disclosures

All Authors: No reported disclosures.
1794. Evaluation of Antimicrobial Susceptibility Patterns for Patients Admitted from Post-Acute Care Facilities in the Philadelphia Region
Authors: Vijapurapu Sandhya , Maguire Christina , Binkley Amanda , Binkley Shawn , Lamore Raymond
Published: December 2022

Background

Antimicrobial resistance is a rapidly emerging threat and antibiograms are a key component in guiding empiric antimicrobial selection. Patients admitted from post-acute care facilities (PACF) are at a heightened risk for infections from multi-drug resistant organisms, posing a challenge for clinicians selecting empiric therapy. It is uncommon for antibiograms to differentiate between sources of admission. This study aimed to characterize culture proven infections and the appropriateness of empiric antimicrobial regimens for patients admitted from PACF in the Philadelphia region.

Methods

This was a retrospective quality improvement study that included patients admitted from Philadelphia PACF from August 2020 to June 2021. Patients were included if they had at least one positive culture within 72 hours of admission. Appropriate therapy was determined based on a comparison of empiric antimicrobial selection and susceptibilities that resulted from collected cultures. Descriptive statistics were employed for data analysis.

Results

A total of 106 patients and 154 cultures were evaluated during the study period. The majority of patients received initial empiric coverage for Pseudomonas aeruginosa (79%) and methicillin-resistant Staphylococcus aureus (59%). Over 50% of all cultures had been obtained from urinary sources. Enterococcus spp. were the most commonly isolated gram positive organism (61%) and Escherichia coli was the most common gram negative organism (33%). A portion of patients (32.7%) did not receive appropriate empiric therapy. Discrepancies in susceptibility patterns between our internal antibiogram and PACF patients were most notable for gram negative organisms including decreased levofloxacin susceptibilities to P. mirabilis isolates (89% vs 45%). Other notable discrepancies include decreased meropenem susceptibilities to P. aeruginosa isolates (88% vs 65%). Select susceptibility patterns are reported in Figure 1.

Conclusion

Antimicrobial susceptibility was discordant amongst patients admitted from PACF in the Philadelphia region compared to our general antibiogram. The increased resistance identified supports a need to re-evaluate empiric prescribing guidelines for this specific population.

Disclosures

All Authors: No reported disclosures.
1795. Evaluation of Appropriate Daptomycin Usage in an Academic Medical Center
Authors: Daoud Nour A , VanNatta Mollie , Koppada Satya , Alam Mohammad , Khan Muhammad
Published: December 2022

Background

The usage of daptomycin at our institution has steadily increased, with a threefold increase from Jan 2020 to Jan 2022 according to Days of Therapy Data. The increased usage prompted this study to determine whether daptomycin use at our institution is appropriately indicated and supervised by the infection disease service.

Methods

We conducted a retrospective descriptive study on 74 patients who were selected randomly from a total of 234 pts who received daptomycin at our facility in Northwest Louisiana over the past two years. We studied the patient's age and gender, type of infection, indications, empiric versus targeted therapy, culture results, infectious disease consultation, and reason for early discontinuation.

Results

Seventy-four pts were included in the analysis. The median age was 53.50 (22-90 yrs), and 47 pts (63.5%) were male. The most common infections were bone and joint (37, 50.7%), followed by bacteremia (22, 30.1%), followed by infective endocarditis (4, 5.5%). The infectious disease service was consulted before administration of daptomycin in 87.3% (62 patients). In 70.3% (52 patients), daptomycin was used as targeted therapy. MRSA was the most common bacteria for which daptomycin was used (29, 42.6%), followed by Enterococcus faecalis (10, 14.7%) and Coagulase-negative staphylococcus (8, 11.8%). Fifty-five pts (74.3%) received vancomycin before switching to daptomycin. The most common indications was MRSA with vancomycin MIC ≥ 2 mcg/ml (25, 33.8%), followed by as an alternative to vancomycin in acute renal failure (14, 18.9%), followed by clinical or/and microbiological failure on the previous antibiotic regimen (10, 13.5%). Thirty-six pts (48.6%) completed their course, 20 (27%) pts had early discontinuation, 11 pts (14.9%) were lost to follow-up, 4 pts (5.4%) were still on daptomycin at the time of data collection, and 3 pts (4.1%) died during hospitalization. The most common cause of early discontinuation was the culture growing pathogen necessitating discontinuation of daptomycin (7 patients, 35%), followed by insurance issues that account for 15%.

Conclusion

Most daptomycin usage in our institution was wisely indicated under the supervision of the infectious disease service and was primarily used as targeted therapy.

Disclosures

All Authors: No reported disclosures.