bluuebunny/crossref_metadata_2025 huggingface dataset:
134. Impact of an Antibiotic Stewardship Treatment and Management Algorithm for Liver Abscesses
Authors: Vanderburg Hunter , Meredith Jacqueline , Jaffa Rupal K , Aviles Cesar , Motz Benjamin M , Cochran Allyson , Shastry Vivek , Vrochides Dionisios , Medaris Leigh Ann
Published: December 2021

Background

Antibiotic prescribing for pyogenic liver abscess(es) (PLA) is highly variable with literature primarily aimed at assessing surgical intervention with a scarcity of data for antibiotic selection and duration of therapy. Given the lack of data, there is no clear consensus for treatment options or length of treatment. Our Antimicrobial Support Network (ASN) in collaboration with the hepatopancreatobiliary (HPB) team created a treatment and management algorithm to guide duration of therapy and antibiotic selection.

Methods

A retrospective, quasi-experimental cohort study was performed at Carolinas Medical Center in hospitalized patients with PLA with an HPB and/or infectious diseases consult. The primary outcome was antipseudomonal beta-lactam days of therapy (DOT) per 1000 patient days (PD) in the pre-versus post-intervention group. Secondary outcomes included rates of treatment failure at 90 days, 90-day all-cause and abscess-related hospital readmission, C. difficile and multi-drug resistant organism (MDRO) colonization at 90 days from diagnosis, and hospital length of stay (LOS). Additional a priori subgroup analyses of duration of therapy, treatment failure, all-cause and abscess-related readmissions were also conducted based on surgical intervention.

Results

A total of 93 patients were included, 49 patients in the pre-intervention group and 44 patients in the post-intervention group. Baseline characteristics were similar between the groups. The majority of liver abscesses were unilocular and monomicrobial. Anti-pseudomonal beta-lactam DOT per 1000 PD decreased by 13.8% (507.4 versus 437.5 DOT/1000 PD). Treatment failure occurred in 30.6% of pre-intervention patients and 18.2% of post-intervention patients (p = 0.165). Patients in the post-intervention group were discharged a median of 2.4 days sooner than the pre-intervention period (12.2 days vs. 9.8 days, p = 0.159). No significant differences resulted in 90-day readmission rates or 90-day C. difficile or MDRO rates.

Table 1. Primary Outcome for Patients with Pyogenic Liver Abscesses Treated Pre- and Post-Antibiotic Stewardship Algorithm

Table 2. Secondary Outcomes for Patients with Pyogenic Liver Abscesses Treated Pre- and Post-Antibiotic Stewardship Algorithm

Conclusion

The implementation of a PLA treatment and management algorithm led to a decrease in anti-pseudomonal beta-lactams without impacting clinical outcomes and a trend towards decreased LOS.

Disclosures

All Authors: No reported disclosures
135. Influence of Prescribers on Antibiotic Use among Skilled Nursing Care Residents in 29 U.S. Nursing Homes
Authors: Wilson Brigid , Marek Joseph , Jump Robin L , Jump Robin L , Song Sunah
Published: December 2021

Background

In nursing homes, federal mandates call for more judicious use of antibiotics and antipsychotics. Previous research indicates that practice patterns of nursing home practitioners, rather than resident’s signs and symptoms or overall medical conditions, drive antibiotic use. We hypothesized that nursing home practitioners who prescribe antibiotics more frequently than their peers may display a similar practice pattern for antipsychotics. Here, we examine similarities in prescribing patterns for antibiotics and antipsychotics among practitioners at 29 U.S. nursing homes.

Methods

Prescription data came from 2016 invoices from a pharmacy common to all 29 nursing homes. We defined practitioners as individuals who prescribed ≥1% of systemic medications at a nursing home and excluded practitioners without no prescriptions for anti-hypertensive drugs assuming they were not treating a general nursing home population (i.e. treating hospice or dementia patients). Using anti-hypertensive starts for standardization, we calculated the expected number of starts for both antibiotics and antipsychotics. Using funnel plots with Poisson 99% control limits for the observed-to-expected ratio, we identified practitioners whose use of either class of drugs exceeded these control limits. Practitioners were classified as high, average, or low prescribers for each class of drugs.

Results

We analyzed 129 practitioners who wrote for 113669 systemic medications. For antibiotics, 27 (20%) and 19 (15%) of practitioners were low and high prescribers, respectively. For antipsychotics, 53 (41%) and 14 (11%) were low and high prescribers, respectively (Figure 1). Among the low antibiotic prescribers, 59% (16/27) were also low antipsychotic prescribers. Among the high antibiotic prescribers, 21% (4/19) were also high antipsychotic prescribers (Figure 2).

Figure 1. (a) Funnel plot for antibiotics

(b) Funnel plot for antipsychotics

Figure 2. Type of prescriber

Conclusion

Practitioners who were low prescribers for antibiotics were also likely to be low prescribers for antipsychotics, suggesting judicious use for both classes of medications. Further understanding of the behaviors of these individuals, as well as those who are high prescribers for both classes, has implications for improving antibiotic stewardship practices in nursing homes.

Disclosures

Robin L. Jump, MD, PhD, Pfizer (Individual(s) Involved: Self): Consultant
137. Impact of Antimicrobial Stewardship Interventions on Post-Elective Caesarean Antibiotic Prophylaxis and Surgical Site Infections
Authors: Seah Xue Fen Valerie , Ong Yue Ling Rina , Poh Wei Ming Cedric , Siraj Shahul Hameed Mohamed , Kam Kai-Qian , Thoon Koh Cheng
Published: December 2021

Background

Antimicrobial stewardship programs (ASP) aim to improve appropriate antimicrobial use. Post-operative antibiotics are generally not necessary, especially those without surgical site infections risk factors (e.g. obesity). Few studies have described the impact of ASP interventions on patient outcomes especially in unique populations such as obstetrics. This study aims to evaluate the impact of ASP interventions on post-elective caesarean (eLSCS) oral antibiotic prophylaxis use and patient outcomes including SSI rates.

Methods

This pre-post quasi-experimental study was conducted over 9 months (2 months pre- and 7 months post-intervention) in all women admitted for eLSCS in our institution. Interventions included eLSCS surgical prophylaxis guideline dissemination, where a single antibiotic dose within 60 minutes before skin incision was recommended. Post-eLSCS oral antibiotics was actively discouraged in those without SSI risk factors. This was followed by ASP intervention notes (phase 1) for 3 months, and an additional phone call to the ward team for the next 7 months (phase 2). Phase 3 (next 6 months) constituted speaking to the operating consultant. The primary outcome was post-operative oral antibiotics prescription rates. Secondary outcomes included rates of 30-day post-operative SSI.

Results

A total of 1751 women was reviewed. Appropriateness of pre-operative antibiotic prophylaxis was 98% in our institution. There were 244 women pre-intervention, 274 in post-intervention phase 1, 658 in phase 2 and 575 in phase 3. Pre-intervention post-eLSCS antibiotic prescribing rates was 82% (200), which reduced significantly post-intervention to 54% (148) in phase 1, 50% (331) in phase 2 and 39% (226) in phase 3 (p< 0.001). There was no significant difference in patients who developed post-operative SSI pre-post intervention (0.8%, 2 of 242 vs. 1.9%, 28 of 1479, p=0.420) and among who received post-operative oral antibiotics compared to those without (1.9%, 17 of 905 vs. 1.5%, 13 of 846, p=0.582).

Conclusion

ASP interventions can reduce post-eLSCS antibiotic prophylaxis rates without adversely impacting patient safety.

Disclosures

All Authors: No reported disclosures
138. Implementation of an Antimicrobial Stewardship Order Set in the Emergency Department at a Quaternary Care Facility
Authors: . Al Shaqfa Salma M , El Lababidi Rania M , El Nekidy Wasim S , Hisham Mohamed , Nasef Rama , Elrefaei Hazem , Bonilla Fernanda
Published: December 2021

Background

Implementation of antimicrobial stewardship (AS) interventions in the emergency department (ED) has been associated with improved patient outcomes. One potentially promising AS strategy is the implementation of an ED-specific, evidence-based antimicrobial order set. In this study, we aimed to examine the impact of implementing an ED-specific order set (EDOS) on the appropriateness of empiric antimicrobial therapy.

Methods

We conducted a pre-post quasi experimental study on 160 adult patients presenting to the ED with suspected or confirmed common infections at our quaternary healthcare facility. The EDOS was implemented in December 2020, providing evidence-based recommendations for the management of common infectious diseases. Data was collected between September 2019 and March 2020 for the pre-EDOS implementation group and between January 2021 and April 2021 for the post-EDOS implementation group.

Pregnant women and patients with suspected or confirmed COVID-19 infection were excluded. Data were analyzed using two-sample T-test and mixed effects logistic regression. The primary study outcome was the appropriateness of antimicrobials selected, and the secondary outcomes were clinical and microbiologic cure, length of hospital stay, Clostridioides difficile infection, and the number of changes in antimicrobial therapy on transition to inpatient setting.

Results

A total of 100 ED patients pre-EDOS implementation and 60 patients post-EDOS implementation were compared. At baseline, patients in the post-EDOS group were older (59.83±20.30 years vs. 50.17±19.97 years, P=0.0037). A higher number of patients in the post-EDOS group had a history of multiple comorbidities (76.67% vs. 54%, P=0.0039). There was a higher rate of appropriate antimicrobial use in the post-EDOS group as compared to the pre-EDOS group (88.3% vs. 50%, P< 0.001). Longer hospital stays were observed in the post-EDOS group (P=0.0005). Clinical cure was similar between the two groups (96.6% vs. 94%, P=0.4568).

Conclusion

In our study, we observed higher rates of appropriate antimicrobial selection after implementation of an EDOS. Use of an EDOS may represent a valuable AS intervention to guide appropriate antimicrobial prescribing in the ED, and larger studies are needed to confirm those findings.

Disclosures

All Authors: No reported disclosures
139. Improving Skin and Soft Tissue Infection Antibiotic Duration Concordance with National Guidelines in Pediatric Urgent Care Clinics
Authors: Hamner Megan , Nedved Amanda , Austin Holly , Wyly Donna , Burns Alaina , King Diana , Lee Brian R , El Feghaly Rana E
Published: December 2021

Background

Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. Children with SSTIs often receive > 7 days of antibiotics, although current guidelines recommend 5-7 days for most diagnoses. At Children’s Mercy Hospital (CMH) urgent care clinics (UCC), only 58% patients received the recommended 5-7 days of antibiotics. We aimed to increase the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021.

Methods

We formed a multidisciplinary team in April 2020. A provider survey assessed factors influencing prescribing habits. We completed cause-and-effect analyses and developed a driver diagram (Figure 1). Interventions were chosen based on the potential for highest impact and lowest effort. Our first Plan-Do-Study-Act (PDSA) cycle provided an update on current guidelines for UCC providers. The second PDSA cycle updated prescription sentences in the electronic health record (EHR) and organized them from shortest to longest duration. The third PDSA cycle provided a project update via email to UCC providers. Our outcome measure is the percentage of patients receiving 5-7 days of antibiotics for SSTIs. Process measure is the number of updated prescriptions used. Balancing measure is the number of patients returning for SSTI within 14 days of their visit. Results are displayed using a run chart.

Results

After initiation of the project in April 2020, the percentage of patients receiving 5-7 days of antibiotics increased to 68% (Figure 2). This percentage increased to our goal of 75% after the 1st PDSA cycle (October-December 2020), 80% following the second PDSA cycle in February 2021, and 90% following the third PDSA cycle in April 2021. There was no change in balancing measure numbers.

Run Chart

Conclusion

Prior to our project, only 58% of children seen in CMH UCCs for SSTIs received the recommended antibiotic duration. By addressing the primary drivers uncovered through QI methodology, we surpassed our goal of 75%. Additional PDSA cycles are planned along with expansion to other departments. This work will allow us to expand antibiotic stewardship efforts to other infectious diagnoses as well.

Disclosures

Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)
140. Variations in Rates of Antimicrobial Use in Primary Care, in Relation to the Presence of Chronic Diseases, Québec, Canada, 2014-2017
Authors: Fortin Elise , Sirois Caroline , Quach Caroline , Simard Marc , Jean Sonia , Irace-Cima Alejandra , Magali-Ufitinema Nadine
Published: December 2021

Background

Chronic diseases may increase one’s risk of infection and ensuing complications, which in turn may lower clinicians’ tolerance threshold for antimicrobial prescription, while potential drug interactions may limit therapeutic options. Objective of the study was to measure the impact of chronic diseases on the rates of antimicrobial use in the Province of Québec.

Methods

Individuals covered by the public drug insurance plan between April 2014 and March 2017 were included in our cohort to describe rates of antimicrobial dispensing per 1,000 person-years, per age group (0-17 years old, 18-64 years old and 65 years old or over) and category of chronic disease (respiratory, cardiovascular, diabetes, mental disorder, none of these). For 2014-2017, ratios of extended-to-narrow spectrum antimicrobials were computed and multivariate Poisson regression was used to measure the impact of categories of chronic diseases on rates of total antimicrobial dispensing (in prescriptions and defined daily doses).

Results

A total of 1 259 833 children-years, 5 281 026 person-years between 18 and 64 years and 3 841 359 person-years 65 years or older were included in the study. Ratios of extended-to-narrow spectrum antimicrobials varied from 3.1 (adults 18-64 years old with no chronic disease) to 14.6 (children with no chronic disease); ratios for individuals with chronic diseases were lower in children but higher in adults. Adults with chronic respiratory diseases were twice more exposed to antimicrobials (increase of 109%) than those with none of the studied diseases (62% increase in children). In adults, antimicrobial use was also 48% higher in presence of a mental disorder (22% in children), 40% higher with diabetes (102% in children) and 31% higher with a cardiovascular disease (no data in children). These differences were all statistically significant (α = 0,05).

Conclusion

In Québec, antimicrobial dispensation was more frequent for individuals with at least one chronic disease. This raises the question of how much antimicrobial use can be reduced or improved to limit the selection of resistant bacteria.

Disclosures

All Authors: No reported disclosures
142. Effect of Discontinuation of Antimicrobial Stewardship Programs on the Antibiotic Usage Pattern and Incidence of Antibiotic Resistance in the Major Bacterial Species
Authors: Jang Wooyoung , Hwang Hyeonjun , Jo Hyun-uk , Cha Yong-Han , Kim Bongyoung
Published: December 2021

Background

The aim of this study was to analyze the effect of discontinuation of antimicrobial stewardship programs (ASP) activity on the antibiotic usage pattern.

Methods

An interrupted time series analysis assessing the trends in antibiotic use and incidence of antimicrobial resistance in major pathogens was conducted between March 2017 and April 2019 in an 859-bed university-affiliated hospital in Korea, where all ASP activities were discontinued in February 2018. The major activity of the ASP was a restrictive measure for designated antibiotics. We defined antibiotics as medication with the Anatomical Therapeutic Chemical class J01, and the antibiotic consumption was measured as days of therapy (DOT), which was then standardized per 1,000 patient-days.

Results

The use of antibiotics against multidrug-resistant pathogens increased immediately after the discontinuation of restrictive antibiotic program (41.01 and 150.99 days of therapy [DOT]/1,000 patient-days in the general ward [GW] and intensive care unit [ICU], respectively). In addition, there were positive changes for the GW and ICU (4.20 and 31.57 DOT/1,000 patient-days per month, respectively). The use of broad-spectrum antibiotics in patients in the ICU significantly decreased (-674.26 DOT/1,000 patient-days). For non-broad-spectrum antibiotics, there were positive changes for the GW and ICU (18.17 and 22.69 DOT/1,000 patient-days per month, respectively.

Conclusion

In conclusion, after discontinuation of ASP, antibiotic usage patterns rapidly returned to the patterns prior to ASP implementation.

Disclosures

All Authors: No reported disclosures
143. Antibiotic Use for Common Infections in British Columbia and Ontario: A Review of Outpatient Prescribing to Seniors from 2000 – 2018
Authors: Saatchi Ariana , Reid Jennifer , Povitz Marcus , Shariff Salimah , Silverman Michael , Morris Andrew , Patrick David M , Marra Fawziah
Published: December 2021

Background

Antimicrobials remain among the most prescribed medications in Canada, with over 90% prescribed in outpatient settings. Older adults (aged ≥65 years) prescribed antimicrobials are particularly vulnerable to adverse drug events and antimicrobial resistance. This study compared annual rates of indication-associated, outpatient prescribing to seniors across two Canadian provinces.

Methods

All outpatient, oral antimicrobials dispensed to older adults (≥65 years) were identified from administrative health databases, from 2000 to 2018. Antimicrobials were limited to outpatient use only and linked to an indication using a 3-tiered diagnostic hierarchy. When possible, a record of dispensation was matched to a tier 1 indication (always require antibiotics) first. In the absence of a tier 1 indication, priority was given to tier 2 (sometimes require antibiotics), then 3 (never require antibiotics). Prescription rates were calculated per 1000 population, and trends were examined overall, by drug class, and patient demographics.

Results

Our study included over 18 million individuals (aged ≥65 years) with a total of 23,773,552 antibiotic prescriptions issued to seniors, for common infections. In both provinces, prescribing for tier 1 diagnoses increased over the study period (BC: 44%; ON: 28%). Urinary tract infections accounted for most prescriptions within this tier (ON: 89 prescriptions/1000, BC: 129 prescriptions/1000 population by 2018). Pneumonia-associated prescribing increased by roughly 10% in both provinces. In any given study year, for both provinces, tier 3 diagnosis was the most common reason for antibiotic use, accounting for 50% of all indication-associated antibiotic prescribing. As diagnoses within this tier do not warrant prescribing all antibiotics issued are therefore inappropriate prescriptions.

Figure 1. Rates of indication-associated antibiotic use in Canadian seniors, from 2000 to 2018.

Conclusion

Elevated prescribing to seniors continues across Canadian outpatient settings. Antibiotic prescribing remains an issue of high concern with 50% of all antimicrobials prescribed to seniors, for common infections, used inappropriately.

Disclosures

All Authors: No reported disclosures
144. Antifungal Use Trends in Hospitalized Adults in the United States, 2016-2020
Authors: Kaip Emily A , Shippey Ernie , MacDougall Conan
Published: December 2021

Background

Surveillance of antimicrobial use is a cornerstone of antimicrobial stewardship, though antifungal (AF) use is less frequently characterized. AFs are a major driver of inpatient costs and their use both reflects and drives changes in fungal susceptibility patterns. We report on trends in AF use in a large sample of United States hospitals over time including predictors of AF use.

Methods

We performed a retrospective analysis of adult inpatient visits between 2016 and 2020 at hospitals contributing data to the Vizient Clinical Database/Clinical Resource Manager (www.vizientinc.com). Inpatient use of systemically administered AFs was investigated as a function of study quarter, diagnosis code, and underlying immunosuppressive condition. Changes in AF use were modeled using logistic and negative binomial regression.

Results

We examined over 23 million admissions across 470 hospitals, 43% of which were classified as teaching hospitals and 54% of which performed solid organ transplants. During the study period, 4.03% (951,284/23,565,493) of admissions were billed for one or more of the study AFs. Among admissions receiving AFs, 86% received an azole, with the most frequently used agent being fluconazole, which accounted for for 46% of total AF days. Likelihood of AF receipt during admission increased by quarter (OR 1.012, p< 0.001), controlling for length of stay, presence of fungal infection, hematologic malignancy (HM), or solid organ transplant (SOT). Odds of any receipt and days of therapy (DOT) of fluconazole, isavuconazole, posaconazole, and echinocandins increased over the study period while those of voriconazole, itraconazole, and flucytosine decreased; odds of receipt of amphotericin products increased while DOT decreased; flucytosine receipt odds increased while DOT did not change. Only 30% of admissions with AF use were associated with a documented fungal infection, with 93% of these episodes documented as candidiasis. Admissions associated with SOT or HM represented 2% and 3% of all patient-days, but 11% and 25% of total AF days, respectively.

Antifungal Utilization

Conclusion

AF use increased significantly over the study period, with changes across agents and classes. Most AF use occurred in the absence of administratively documented infection and was more common among SOT and HM patients.

Disclosures

All Authors: No reported disclosures
145. Comparing Antibiotic Use Across Inpatient Facilities with Different Antibiotic Stewardship Typologies using Machine Learning and Joint Modeling Approach
Authors: Zhang Yue , Shen Jincheng , Willson Tina M , Stenehjem Edward A , Barlam Tamar F , Drainoni Mari-Lynn , Childs Ellen , Butler Jorie M , Goetz Matthew B , Goetz Matthew B , Madaras-Kelly Karl , Caitlin M. Reasdon , Samore Matthew H
Published: December 2021

Background

Hospital antibiotic stewardship programs (ASP) aim to promote the appropriate use of antimicrobials (including antibiotics) and play a critical role in controlling antibiotic costs and antibiotic-resistant bacterial infection risk, and improving patient outcomes. However, unlike other health care quality improvement intervention programs, the ASP implementation strategies vary among healthcare facilities, and little is known about whether different types of ASP implementation will lead to the shifting of antibiotic drug use from one class to another.

Methods

We proposed an analytical framework using unsupervised machine learning and joint model approach to 1) develop a typology of ASP strategies in facilities from the Veterans Health Administration, America’s largest integrated health care system; and 2) simultaneously evaluate the impacts of different ASP types on the annual antibiotic use rates across multiple drug classes. The unsupervised machine learning method was used to leverage the structural components in the surveys conducted by the Veteran Affair (VA) Healthcare Analysis and Information group and the Consolidated Framework for Implementation Research experts from Boston University, and reveal the underlying ASP patterns in the VA facilities in 2016.

Results

We identified 4 groups in the VA facilities in terms of enthusiasm and implementation level of antibiotic control in our ASP typology. We found the facilities with high implementation level and high enthusiasm in ASP and those with high implementation level but low enthusiasm had statistically significant 30% (p-value=0.002) and 22% (p-value=0.031) lower antibiotic use rates in broad-spectrum agents used for community infections, respectively than those with low implementation level and low enthusiasm. However, the facilities with high implementation and high enthusiasm also marginally increased antibiotic use rates in beta-lactam antibiotics (p-value=0.096).

Conclusion

The developed analytical framework in the study provided an approach to the granular assessment of the impact of the healthcare intervention programs and might be informative for future health service policy development.

Disclosures

Matthew B. Goetz, MD, Nothing to disclose
146. Predictors of Long Duration Antibiotic Therapy for Urinary Tract Infections and Community-Acquired Pneumonia in Pediatric Ambulatory Care Settings
Authors: Shah Rohan M , Sun Shan , Scardina Tonya , Patel Sameer
Published: December 2021

Background

Significant variation exists in the duration of antibiotic therapy for children in ambulatory care settings. Understanding drivers of variation for common conditions such as community-acquired pneumonia (CAP) and urinary tract infection (UTI) is important to informing antimicrobial stewardship interventions.

Methods

A retrospective observational study was conducted of patients with CAP and UTI seen in outpatient clinics or discharged from the emergency room (ER) of a tertiary care children’s hospital network from 2016 – 2019. Diagnoses CAP and UTI were identified via ICD-10 coding. Only oral medications ordered for ≥ 3 and < 28 days were included. Multivariable logistic regression was performed to identify predictors of long antibiotic duration (defined as ≥ 10 days). Potential non-clinical drivers of longer duration included race, ethnicity, sex, primary language, and insurance status.

Results

A total of 2,104 prescriptions for CAP from 442 prescribers and 1,070 prescriptions for UTI from 314 prescribers were included. Antibiotic durations were ≥ 10 days in 59.9% and 47.6% of prescriptions for CAP and UTI, respectively. Long duration of therapy was more common in children discharged from the ER when compared to clinics for both CAP (OR 1.795, 95% CI: 1.107 - 2.929), and UTI (OR 5.149, 95% CI: 1.933 - 16.373). The proportion of patients with long duration of therapy increased with younger age for both diagnoses and decreased overall in the final year of the study. Race, gender, ethnicity, and primary language were not associated with prolonged duration of therapy. However, patients with Medicaid insurance were more likely to receive long duration of therapy for CAP (OR 1.337, 95% CI: 1.062 - 1.682) and UTI (1.654, 95%, CI: 1.181 - 2.325).

Conclusion

In pediatric patients in ambulatory care settings, younger age, care in the ER, and being insured through Medicaid were independently associated with prolonged duration of therapy for both UTI and CAP.

Disclosures

All Authors: No reported disclosures
147. Antibiotic Prescribing: Shorter is Also Better in the Emergency Department
Authors: Vuong Lisa , Faison Darius , Thomson Julie , Kenney Rachel , Davis Susan L , Davis Susan L
Published: December 2021

Background

Published information suggests room for improvement in antibiotics prescribed on discharge from the emergency department (ED). The objective of this study was to evaluate antibiotic prescribing in the ED for uncomplicated infections of the lower respiratory tract (LRTI), urinary tract (UTI), and skin and skin structure (SSTI).

Methods

IRB-approved retrospective cross-sectional study of patients discharged from the ED from January to June 2019 at 6 locations. Inclusion: ≥ 18 years old and uncomplicated LRTI, UTI, or SSTI. Exclusion: hospital admission. Appropriate prescribing was defined having all three of the following correct per local and national guidelines: antibiotic selection, dose, and duration. Correct duration: 5 days for LRTI and SSTI; 3 days for trimethoprim-sulfamethoxazole (TMP-SMX), 5 days for nitrofurantoin (NFT), and 7 days for beta-lactams for UTIs. Endpoints within 7 days: antibiotic escalation, readmission to ED or hospital, any outpatient contact, and report of adverse drug event (ADE). Endpoints within 90 days: Clostridioides difficile infection (CDI). Descriptive and bivariable statistics were performed.

Results

Inappropriate prescribing: 77% (304) vs. appropriate 23% (89). Infection type: 47.8% SSTI, 30% UTI, and 22.1% LRTI. SSTI was associated with the greatest proportion of inappropriate prescribing at 89.4% (Figure 1). Comparisons for inappropriate vs. appropriate groups: 15.8% vs. 22.5% for beta-lactam allergy and 23.4% vs. 19.1% for cultures drawn in ED. Most common antibiotics for inappropriate vs. appropriate: first generation cephalosporin at 70.1% vs. 7.3% (p< 0.05), TMP-SMX at 14.3% vs. 12.2% (p=0.75), and NFT at 7.8% vs. 65.9% (p< 0.05). Prescriptions considered inappropriate were primarily driven by excess duration (Figure 2). Endpoints for inappropriate vs. appropriate groups: antibiotic escalation at 6.6% (2.8% were due to cultures drawn in the ED) vs. 1.1% (p=0.06), readmission at 8.6% vs. 9.0% (p=0.9), any outpatient contact at 18.4% vs. 19.1% (p=0.89), and report of ADE at 1.3% vs. 1.1%. No CDI in either group.

Figure 1. Appropriateness of Discharge Prescriptions by Infection Type, N = 393

Figure 2. Subset Analysis: Reasons for Inappropriate Prescribing, n = 304

Conclusion

The main reason for inappropriate prescribing in the ED was excess duration of therapy, making this an area of opportunity for future antibiotic stewardship improvement.

Disclosures

Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder) Susan L. Davis, PharmD, Nothing to disclose
149. Impact of Stewardship on Antibiotic Utilization Rates During the COVID-19 Pandemic: Successes and Challenges in a Regional Hospital
Authors: Macias Ana , Elgin Jennifer , Duerson Donna , Warren Cirle A
Published: December 2021

Background

Antibiotic stewardship (AS) is at the core of patient safety and prevention of antimicrobial resistance. Healthcare providers prescribe antibiotics for COVID-19 despite low rates of bacterial co-infection. Our regional hospital had antibiotic utilization (AU) rates higher than other health systems even prior to the emergence of SARS-Cov2. We analyzed the effect AS on AU during the pandemic.

Total Antibiotic Utilization Rates Before and During COVID-19 Pandemic

Methods

Total and specific AU rates were benchmarked using BD MedMined’s medication analytics system from 2nd quarter 2019 to 1st quarter 2021. The AS team released yearly antibiogram and individual prescriber’s AU rates and performed weekly, and as needed, review of antibiotic ordering and feedback. To assist in appropriate prescribing decisions, remote educational sessions or mini-lectures and local antibiotic guidelines were developed during the pandemic period. AU rates were monitored quarterly to determine the effects of the AS interventions to prescribing practices.

Results

Total and specific AU rates were higher (up to 34% and 80%, respectively) in our index hospital compared to other non-teaching hospitals nationally prior to the pandemic. Total antibiotic utilization increased by only 5.5% in the 2nd quarter 2020, peak of AU during the pandemic. Total, vancomycin, piperacillin-tazobactam and quinolone utilization rates decreased by 19%, 41%, 38%, and 52%, respectively, at 1st quarter 2021 compared to 4th quarter 2019. Steeper decreases were noted with implementation of educational activities. Ceftriaxone use remained high and was 50% greater than comparator hospitals at 1st quarter 2021.

Conclusion

Although problematic during the COVID-19 pandemic, AS can have significant impact on provider prescribing practices and decrease total and specific antibiotic utilization rates. The use of ceftriaxone, an antibiotic commonly used for empiric bacterial coverage for community acquired pneumonia, presents as a continuing challenge.

Disclosures

All Authors: No reported disclosures
150. Improved Susceptibility of Pseudomonas aeruginosa to Cefepime (CEF) at a Veterans Tertiary Care Hospital, over a 7-Year Period (2011-2017): The Impact of Antibiotic Rotation/Cycling and Reversal of Drug Resistance in P. aeruginosa
Authors: Kuhn Ryan , Martinez Oscar , Ross Chris , Touleyrou Lauren , Natesan Suganthini Krishnan
Published: December 2021

Background

Background: Pseudomonas aeruginosa continues to be an important cause of nosocomial infections associated with a high morbidity and mortality. Despite the availability of ceftazidime-avibactam (CAZ-AVI) and ceftolozone-tazobactam (CFT-TAZO), CEF continues to be an empiric agent of choice in several institutions. Aim: To evaluate the prevalence and trend in susceptibilities of P. aeruginosa to CEF over a 7-year period, identify possible correlation with the use of CAZ, AZT, PTZ, CIP, and CAR, (DOT/1000 patient days), as a quality improvement (QI) measure for optimizing CEF use, introduce antibiotic cycling as a tool to avoid emergence of drug-resistance in P. aeuriginosa.

Methods

A retrospective review of antimicrobial susceptibility data of all isolates of P. aeruginosa, (inpatient and outpatient) at the Detroit VAMC pre and post implementation of antibiotic cycling, over a 7-year period (2011-2017) was performed. Susceptibility testing was performed by reference broth micro-dilution methods in a central laboratory. Data analysis was performed using Pearson correlation coefficient score. Being a QI project, clinical data were not reviewed.

Results

A total of 977 isolates were identified during the study period. (drug usage are in DOT/1000 PD); CAZ and AZT use surged during 2013-14 from 5 to 8 dropping in 2015-17 to < 3; PTZ usage increased to 100 during 2011-14 but dropped to 38 in 2015-17 (drug shortage); CAR use averaged at 10 until 2016 and dropped to 8 in 2017; CIP use dropped by 50% from 30 in 2012 to 15 in 2017; P. aeruginosa susceptible to CEF decreased from 88% in 2012 to 81% in 2014 mirroring the increased use of CEF, AZT, CAZ, and CIP; AG use was very low at < 5. With restrictions on the use of AZT, CAZ, and CIP, from 2014-15, CEF susceptibility increased significantly to 95.5% in 2015. Drug shortage of PTZ in 2015 and increased use of CEF from 2015-17 led to a drop in susceptibility to (82%); P. aeruginosa susceptible to CAR and AG averaged at 88% and 97% respectively (2011-17). However, reintroduction PTZ, resulted in improved susceptibility of P. aeuruginosa to CEF by 40% within a year.

Conclusion

Judicious antimicrobial use and antibiotic rotation play a significant role in reversing drug resistance in P. aeuruginosa.

Disclosures

All Authors: No reported disclosures
151. Association Between Outpatient Antibiotic Prescribing, Antimicrobial Resistance, and Initial Presentation to Inpatient Setting for Urinary Tract Infections Among Older Adults in New York State
Authors: Grillo Marissa N , Barlow Joshua , Carreno Joseph
Published: December 2021

Background

Antibiotic prescribing (AP) and resistance (AR) may influence severity of illness in urinary tract infection (UTI). Limited data exist assessing the relationship between county-level AP and AR on initial presentation to hospital for UTI. This study evaluated the association between county-level AP and AR on UTI severity of illness among hospitalized patients in New York State.

Methods

Retrospective, cross-sectional analysis, combining data from New York State Statewide Planning and Research Cooperative System (SPARCS) and previously published data on countywide antimicrobial resistance and antimicrobial prescribing. Inclusion criteria: female patients admitted to a New York inpatient setting in 2017, UTI (CCS 159), Medicare insurance. Exclusion criteria: missing countywide prescribing or resistance. All-patient refined (APR) clinical severity ≥ 3 was the primary outcome. Counties were classified as prescribing above or below the median prescribing proportion, and above or below the median prevalence of E. coli resistance for TMP-SMX and NTF. Countywide prescribing practices, antimicrobial resistance, patient factors, and location factors were evaluated for association with APR clinical severity ≥ 3 using chi-squared and logistic regression.

Results

8,024 patients met study criteria. Baseline characteristics are presented in Table 1. 3,597 (44.8%) had an APR severity of ≥ 3. Factors associated with APR severity ≥ 3 include age group (P < 0.001), ethnicity (P = 0.013), hospital county (P < 0.001), first line prescribing ≥ 45.4% (P = 0.049), E. coli TMP-SMX resistance ≥ 29.0% (P < 0.001) via chi-squared test. In the logistic regression analysis counties with higher first line prescribing was associated with decreased odds for severe infection (aOR: 0.83 [0.72 – 0.97]). Additional factors associated with severe infection are presented in Table 2.

Conclusion

Prescribing patterns may have a significant influence on initial presentation to the hospital for urinary tract infections. Outpatient antimicrobial stewardship should endeavor to promote guideline driven prescribing. Further research is needed to corroborate the findings from this cross-sectional study.

Disclosures

All Authors: No reported disclosures
152. Use of Antimicrobials among Suspected COVID-19 Patients at Selected 12 Hospitals in Bangladesh: Findings from the First Wave of COVID-19 Pandemic
Authors: Mah-E-Muneer Syeda , Hassan Md Zakiul , Al Jubayer Biswas Md Abdullah , Akhtar Zubair , Das Pritimoy , Rahman Fahmida , Islam Md Ariful , Chowdhury Fahmida
Published: December 2021

Background

Antimicrobials are empirically used in COVID-19 patients resulting in inappropriate stewardship and increased antimicrobial resistance. Our objective was to assess antimicrobial use among suspected COVID-19 in-patients while waiting for the COVID-19 test report.

Methods

From March to August 2020, we collected data from in-patients of 12 tertiary-level hospitals across Bangladesh. We identified suspected COVID-19 patients; collected information on antimicrobial received within 24 h before and on hospitalization; and tested nasopharyngeal swab for SARS-CoV-2 using rRT-PCR. We used descriptive statistics and a regression model for data analysis.

Results

Among 1188 suspected COVID-19 patients, the median age was 34 years (IQR:2–56), 69% were male, 40% had comorbidities, 53% required oxygen, and 1% required ICU or ventilation support after admission. Antibiotics were used in 92% of patients, 47% within 24 h before, and 89% on admission. Patients also received antiviral, mostly favipiravir (1%) and antiparasitic drugs particularly ivermectin (3%). Third-generation cephalosporin use was the highest (708;60%), followed by macrolide (481;40%), and the majority (853;78%) who took antibiotics were SARS-CoV-2 negative. On admission, 77% mild and 94% moderately ill patients received antibiotics. Before admission, 3% patients had two antibiotics, and on admission, 27% received two to four classes of antibiotics at the same time. According to WHO AWaRe classification, the Watch group antibiotics were mostly used before (43%) as well as on admission (80%). Reserve group antibiotic particularly linezolid was used in 1% patients includes mild cases on admission. Antibiotic use on admission was higher among severely ill patients (AOR = 11.7;95%CI:4.5–30.1) and those who received antibiotics within 24 h before hospital admission (AOR = 1.6;95%CI:1.0–2.5).

Antimicrobials used among suspected COVID-19 patients and SARS-CoV-2 positive and negative patients 24 h before and on hospital admission at 12 selected hospitals in Bangladesh, March–August 2020

Antimicrobials used on admission among suspected COVID-19 patients according to disease severity at 12 selected hospitals in Bangladesh, March–August 2020

Conclusion

Antimicrobial use was highly prevalent among suspected COVID-19 in-patients in Bangladesh. Initiating treatment with Watch group antibiotics like third-generation cephalosporin and azithromycin among mild to moderately ill patients were common. Promoting antimicrobial stewardship with monitoring is essential to prevent blanket antibiotic use, thereby mitigating antimicrobial resistance.

Disclosures

All Authors: No reported disclosures
154. Antibiotic Use During Three Separate Waves of the COVID-19 Pandemic at a Large Academic Medical Center in Detroit, MI
Authors: Sivakumar Deepika , Herbin Shelbye R , Yost Raymond , Scipione Marco R
Published: December 2021

Background

Inpatient antibiotic use early on in the COVID-19 pandemic may have increased due to the inability to distinguish between bacterial and COVID-19 pneumonia. The purpose of this study was to determine the impact of COVID-19 on antimicrobial usage during three separate waves of the COVID-19 pandemic.

Methods

We conducted a retrospective review of patients admitted to Detroit Medical Center between 3/10/19 to 4/24/21. Median days of therapy per 1000 adjusted patient days (DOT/1000 pt days) was evaluated for all administered antibiotics included in our pneumonia guidelines during 4 separate time periods: pre-COVID (3/3/19-4/27/19); 1st wave (3/8/20-5/2/20); 2nd wave (12/6/21-1/30/21); and 3rd wave (3/7/21-4/24/21). Antibiotics included in our pneumonia guidelines include: amoxicillin, azithromycin, aztreonam, ceftriaxone, cefepime, ciprofloxacin, doxycycline, linezolid, meropenem, moxifloxacin, piperacillin-tazobactam, tobramycin, and vancomycin. The percent change in antibiotic use between the separate time periods was also evaluated.

Results

An increase in antibiotics was seen during the 1st wave compared to the pre-COVID period (2639 [IQR 2339-3439] DOT/1000 pt days vs. 2432 [IQR 2291-2499] DOT/1000 pt days, p=0.08). This corresponded to an increase of 8.5% during the 1st wave. This increase did not persist during the 2nd and 3rd waves of the pandemic, and the use decreased by 8% and 16%, respectively, compared to the pre-COVID period. There was an increased use of ceftriaxone (+6.5%, p=0.23), doxycycline (+46%, p=0.13), linezolid (+61%, p=0.014), cefepime (+50%, p=0.001), and meropenem (+29%, p=0.25) during the 1st wave compared to the pre-COVID period. Linezolid (+39%, p=0.013), cefepime (+47%, p=0.08) and tobramycin (+47%, p=0.05) use remained high during the 3rd wave compared to the pre-COVID period, but the use was lower when compared to the 1st and 2nd waves.

Figure 1. Antibiotic Use 01/2019 to 04/2019

Conclusion

Antibiotics used to treat bacterial pneumonia during the 1st wave of the pandemic increased and there was a shift to broader spectrum agents during that period. The increased use was not sustained during the 2nd and 3rd waves of the pandemic, possibly due to the increased awareness of the differences between patients who present with COVID-19 pneumonia and bacterial pneumonia.

Disclosures

All Authors: No reported disclosures
156. Evaluation of Trends in Antimicrobial Use and Proportion of Culture Positive Gram-Negative/Gram-Positive Pathogens Comparing Prior to and During the SARS-CoV-2 Pandemic: A Multicenter Evaluation
Authors: Puzniak Laura A , Bauer Karri A , Yu Kalvin , Gupta Vikas
Published: December 2021

Background

Increased risk for bacterial co-infections has been described in the pathogenesis of primary viral infections. We evaluated trends in incidence of antibiotic use (abx) and culture positive Gram negative/Gram positive (GN/GP) pathogens in US hospitalized patients prior to and quarterly during the SARS-CoV-2 pandemic.

Table. Trends in antimicrobial use, duration, and positive GN/GP pathogen results.

Methods

We conducted a multi-center, retrospective cohort analysis of all hospitalized patients from 241 US acute care facilities with >1-day inpatient admission between 7/1/19-5/15/21 in the BD Insights Research Database (Franklin Lakes, NJ USA). SARS-CoV-2 infection was defined as a positive PCR during or ≤7 days prior to hospitalization. Admissions with abx prescribed ≥24 hrs and a GN/GP non-contaminant, positive culture were evaluated.

Results

During the pre-pandemic period (7/19 – 2/20) 30% (600,116/2,001,793) admissions were prescribed abx ≥ 24 hrs and 5.3% were positive for a GN/GP pathogen (Table 1). During the SARS-CoV-2 pandemic, abx use ≥ 24 hrs (66.2%) and positive GN/GP culture (8.4%) was highest in SARS-CoV-2 positive patients followed by patients negative for SARS-CoV-2 (abx ≥ 24 hrs 36.7%; GN/GP pathogens 6.8%), and SARS-CoV-2 not tested (abx ≥ 24 hrs 27.5%; GN/GP pathogens 4.5%). GN/GP positive culture was consistent by quarter during the pandemic for SARS-CoV-2 positive patients, whereas SARS-CoV-2 negative and not tested patients had the highest proportion of antibiotics received and positive pathogens in the first three months of pandemic. SARS-CoV-2 positive patients with positive GN/GP culture had the longest median abx duration. (Table 1) The prevalence of abx usage was highest in all groups for all abx during the early pandemic and then declined over time with the largest declines in SARS-CoV-2 positive patients. (Table 2)

Conclusion

This study highlights the impact of viral infections on both prescribing practices and prevalence of bacterial pathogens. Approximately two-thirds of SARS-CoV-2 positive patients received an antibiotic despite a low percentage of positive cultures, however aggregate antimicrobial use overall was similar prior to compared to during the SARS-CoV-2 pandemic. These data may inform opportunities for stewardship programs and antibiotic prescribing in the current and future viral pandemics.

Disclosures

Laura A. Puzniak, PhD, Merck & Co., Inc. (Employee) Karri A. Bauer, PharmD, Merck & Co., Inc. (Employee, Shareholder) Kalvin Yu, MD, BD (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)
158. National Cross-Sectional Study of Factors Influencing the Decision of Prescribing Penicillin as First Choice among Dentists in Japan
Authors: Koizumi Ryuji , Ishikane Masahiro , Kusama Yoshiki , Tsuzuki Shinya , Asai Yusuke , Shimada Yasuyuki , Tanaka Chika , ono Akane , Kaneko Akihiro , Ohmagari Norio
Published: December 2021

Background

Antimicrobial stewardship programs are needed to improve antimicrobial use among not only physicians but also dentists. This study aimed to investigate the factors influencing the decision of prescribing penicillin as first choice among dentists at clinics in Japan.

Methods

We conducted a nationwide cross-sectional study of dental clinics in Japan between July and September 2020. Data on the following were collected using questionnaires: basic information, types of antimicrobials stocked, first-choice antimicrobials, and knowledge and practice of antimicrobial resistance and infectious endocarditis. Using logistic regression, odds ratios (ORs) and 95% confidence intervals (CIs) were estimated to assess the factors influencing penicillin prescription.

Results

Among the 1700 participating dental clinics, 342 dental clinics responded. The median age of the study cohort was 57 (49–65) years, and there were 298 (87.1%) men. The first choice of antimicrobials was third-generation cephalosporin (169 [49.4%]), followed by penicillin (103 [30.1%]) and macrolide (19 [5.6%]). In multivariate analysis, clinics with stocked penicillin (OR = 27.30 [95% CI: 12.04–63.00]) and with more than two dentists (OR = 0.48 [95% CI: 0.24–0.92]) were associated with penicillin use as first choice.

Conclusion

This is the first study investigating the factors influencing the decision of prescribing penicillin as first choice among dentists in Japan. Further studies evaluating the relationships between penicillin use as first choice and stocked penicillin in the clinic and the number of working dentists are needed.

Disclosures

All Authors: No reported disclosures