bluuebunny/crossref_metadata_2025 huggingface dataset:
143. Initial Impact of COVID-19 on Ambulatory Antibiotic Prescribing for Respiratory Viral Infections
Authors: Escobar Zahra Kassamali , Bouchard Todd , Lansang Jose Mari , Thomassen Scott , Huang Joanne , Lynch John B , May Larissa , Kvak Staci , D’Angeli Marisa A , Bryson-Cahn Chloe
Published: January 2021

Background

Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one third of this usage is considered unnecessary. In 2019, our institution implemented the MITIGATE Toolkit, endorsed by the Centers for Disease Control and Prevention to reduce inappropriate antibiotic prescribing for viral respiratory infections in emergency and urgent care settings. In February 2020 we identified our first hospitalized patient with SARS-CoV(2). In March, efforts to limit person-to-person contact led to shelter in place orders and substantial reorganization of our healthcare system. During this time we continued to track rates of unnecessary antibiotic prescribing.

Methods

This was a single center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. We provided monthly individual feedback to urgent care prescribers, (Sep 2019-Mar 2020), primary care, and ED providers (Jan 2020 – Mar 2020) notifying them of their specific rate of unnecessary antibiotic prescribing and labeling them as a top performer or not a top performer compared to their peers. The primary outcome was rate of inappropriate antibiotic prescribing.

Results

Pre toolkit intervention, 14,398 patient visits met MITIGATE inclusion criteria and 12% received an antibiotic unnecessarily in Jan-April 2019. Post-toolkit intervention, 12,328 patient visits met inclusion criteria and 7% received an antibiotic unnecessarily in Jan-April 2020. In April 2020, patient visits dropped to 10–50% of what they were in March 2020 and April 2019. During this time the unnecessary antibiotic prescribing rate doubled in urgent care to 7.8% from 3.6% the previous month and stayed stable in primary care and the ED at 3.2% and 11.8% respectively in April compared to 4.6% and 10.4% in the previous month.

Conclusion

Rates of inappropriate antibiotic prescribing were reduced nearly in half from 2019 to 2020 across 3 ambulatory care settings. The increase in prescribing in April seen in urgent care and after providers stopped receiving their monthly feedback is concerning. Many factors may have contributed to this increase, but it raises concerns for increased inappropriate antibacterial usage as a side effect of the SARS-CoV(2) pandemic.

Disclosures

All Authors: No reported disclosures
1702. Assessing the Safety and Efficacy of Valganciclovir Dosing for Cytomegalovirus Prophylaxis in Solid Organ Transplant Recipients on Hemodialysis
Authors: Yee Jason , Saunders-Hao Patricia , Miko Leandra , Rana Meenakshi
Published: January 2021

Background

Valganciclovir is the standard of care used for the prevention of Cytomegalovirus (CMV) infections among solid organ transplant (SOT) recipients. Currently there is minimal guidance for prophylaxis in SOT recipients undergoing intermittent hemodialysis (IHD). At Mount Sinai Hospital (MSH), the current practice for CMV prophylaxis in SOT recipients on IHD is valganciclovir 450 mg every other day (Q48H) or three-times weekly (TIW). This study aims to evaluate the safety and effectiveness of these dosing regimens in SOT recipients on IHD.

Methods

A single-center, retrospective chart review study was conducted among all MSH SOT recipients on valganciclovir 450 mg Q48H or TIW for CMV prophylaxis and undergoing IHD for at least 30 days. The primary study outcome was the safety of using these valganciclovir doses determined by the incidence of leukopenia, thrombocytopenia, and the administration of growth colony stimulating factor (GCSF). The secondary outcome were the incidences of CMV viremia and CMV disease while on prophylaxis.

Results

Eighteen transplant encounters satisfied the inclusion and exclusion criteria. The majority were liver (7, 38.9%) and kidney (5, 27.8%) transplants. Thirteen (72.2%) recipients were on valganciclovir 450 mg Q48H dosing, while 5 (27.8%) were on valganciclovir 450 mg TIW dosing. Both the mean platelet count nadir (131 ± 93 vs 161 ± 115) and mean white blood cell count nadir (3.4 ± 2.5 vs 5.1 ± 3.8) were lower in the Q48H regimen. Four patients (22.2%) in the Q48H regimen group required GCSF vs none (0.0%) in the TIW regimen. No patient had a detectable CMV viral load while on either prophylactic dose. Two (11.1%) CMV high risk patients on the every other day dosing regimen and one (5.6%) CMV moderate risk patient on the three times weekly regimen developed CMV viremia about 2-3 months after their prophylaxis was stopped.

Table 1. Baseline Demographics.

Table 2. Primary Outcomes

Table 3. Secondary Outcomes

Conclusion

Valganciclovir 450 mg TIW may be safer than and as efficacious as Q48H dosing for prophylaxis in SOT recipients on chronic IHD. This data supports the use of three times weekly dosing as standardized practice at MSH, however more data is necessary to determine a conclusive result.

Disclosures

All Authors: No reported disclosures
1705. Treatment of Disseminated Adenovirus with Cidofovir in a Patient with HIV and ESRD
Authors: Dieringer Thomas D , Pham Christine , Goodman-Meza David
Published: January 2021

Background

Adenovirus is a common cause of upper respiratory infections and gastroenteritis. Severe adenovirus infections and disseminated disease are known to occur in immunocompromised hosts. Cidofovir has been associated with clinical improvement in patients with severe or disseminated disease in which immunosuppression cannot be readily reversed or those unresponsive to supportive care. However, a narrow therapeutic index has limited its clinical use particularly in patients with end-stage renal disease (ESRD).

Methods

We present a case of disseminated adenovirus in a well-controlled person living with HIV (PLWHIV) treated successfully with dose-reduced cidofovir in the setting of ESRD on hemodialysis (HD) at the University of California Los Angeles. A literature review was conducted to investigate the treatment of severe adenovirus disease and use of cidofovir in patients with ESRD.

Results

Our patient is a 59 year-old woman who presented with fever, non-productive cough, and diarrhea. She is living with HIV/AIDS with virologic control and CD4 count of 470 treated with dose adjusted lamivudine, tenofovir alafenamide, and dolutegravir in the setting of ESRD on HD, chronic hepatitis B, and group I pulmonary hypertension. Her course was complicated by development of multifocal pneumonia with hypoxemic respiratory failure requiring high-flow nasal cannula. Adenovirus PCR was detected in stool, respiratory, and serum samples. Given high risk intubation, dose-reduced cidofovir 0.5 mg/kg weekly was given twice over three weeks with symptomatic improvement, elimination of serum adenovirus DNA, and without development of adverse medication-related effects.

Sixteen primary and review articles were identified discussing adenovirus pathology and treatment. A single pharmacokinetic study outlined a dosing regimen for cidofovir of 0.5 mg/kg weekly which provided comparable serum drug levels in asymptomatic patients with ESRD on HD compared to controls with adequate renal function.

Conclusion

This case report illustrates although there is limited data to establish the efficacy and safety of cidofovir for treatment of disseminated adenovirus infections in ESRD patients, dose-reduced cidofovir 0.5 mg/kg weekly while on HD appears to have been effective and well tolerated.

Disclosures

All Authors: No reported disclosures
1709. Influenza Surveillance in the U.S. Department of Veterans Affairs (VA): 2019-2020 Season
Authors: Lucero-Obusan Cynthia , Schirmer Patricia , Oda Gina , Holodniy Mark
Published: January 2021

Background

VA conducts annual surveillance for seasonal influenza. VA’s large elderly population is at higher risk for influenza complications, including hospitalization and death. Herein we summarize VA’s 2019-20 national surveillance data for influenza activity and vaccinations.

Methods

Influenza telephone triage, influenza-like-illness (ILI) encounters and antiviral prescriptions plus outpatient visits, laboratory testing (antibody tests excluded), hospitalizations and deaths for influenza were obtained from VA data sources (9/29/19-5/16/20) and compared to prior seasons and national CDC FluView data. Influenza vaccinations were captured starting 8/1/2019. Vaccination rates were calculated based on VA users during the fiscal year.

Results

Surveillance metrics are presented (Table). ILI visits ranged from 0.9%-3.1% during the season. Influenza activity peaked during 2020 Weeks 6-7 and dropped rapidly beginning in Week 12, matching trends reported by CDC for influenza activity (Figure 1). Testing revealed 23,357 influenza positives out of 162,102 tests performed (14.4%). 17% of laboratory-confirmed influenza cases were hospitalized (compared to 23% during the prior season) with a median length of 3 days. Total influenza positives, telephone triage encounters, outpatient visits and antiviral use were higher than the prior season, whereas coded hospitalizations and deaths were fewer (Table, Figure 2).

Table. VA Influenza Surveillance Measures, 2014-2015 through 2019-2020 Seasons.

Figure 1. Comparison of select VA and CDC Influenza Indicators. Influenza positive laboratory tests and % positive (top) and influenza hospitalizations (bottom), by Season.

Figure 2. Comparison of Key VA Influenza Indicators, by Season.

Conclusion

The 2019-20 influenza season was of moderate severity when compared to prior seasons and continues to track well with national CDC data. Overall, vaccination levels have increased modestly and high-dose/adjuvanted vaccine administration increased from 6 to 26% of total vaccine given over the seasons evaluated. Influenza activity dropped precipitously after Week 12 even though testing for influenza remained high in the setting of COVID-19. This may have been influenced by widespread social distancing and masking measures adopted in response to COVID-19.

Disclosures

All Authors: No reported disclosures
144. Little evidence of same-day, oral antibiotic prescribing at ambulatory surgery centers
Authors: King Laura M , Hicks Lauri , Tsay Sarah Kabbani; Sharon , Fleming-Dutra Katherine E
Published: January 2021

Background

The objective of our study was to describe oral antibiotic prescriptions associated with procedures in ambulatory surgery centers (ASC) to evaluate if there are major national opportunities to improve antibiotic use in this setting.

Methods

We identified surgical procedures in ASCs and oral antibiotic prescriptions in the IBM® MarketScan® Commercial 2018 database, a large convenience sample of privately-insured individuals aged < 65 years. We excluded visits with same-day hospitalizations and those with infectious diagnoses that may warrant antibiotic treatment. We included only antibiotic prescriptions dispensed on the same day as an ASC visit. We calculated the number of visits and oral antibiotic prescriptions and the percent of visits with oral antibiotic prescriptions overall, and by patient age group (< 18 and 18–64 years), antibiotic class, and procedure type. We also calculated median antibiotic course length. Across-group comparisons were evaluated using chi-square tests.

Results

In 2018, 918,127 ASC visits with surgical procedure codes were captured, of which 37,032 (4.0%) were associated with same-day oral antibiotic prescriptions. The percent of visits with antibiotic prescriptions was significantly higher among children compared to adults (9.4% vs 3.8%; p< 0.01); however, adults accounted for 89% of prescriptions. Respiratory/nasal and urinary tract system procedures were most frequently associated with antibiotic prescriptions (Figure). Median course length was 5 (interquartile range 3–7) days. The most common antibiotic class was cephalosporins (49.6% of prescriptions), followed by penicillins (12.6%) and fluoroquinolones (10.9%).

Figure. Percent of ambulatory surgery center visits with same-day antibiotic prescriptions by procedure category, IBM® MarketScan® Commercial Database, 2018

Conclusion

Only 4% of ASC procedures were associated with same-day oral antibiotic prescriptions, suggesting antibiotics are not commonly prescribed in ASCs on the day of surgical procedures. Additionally, the observed 5-day median duration may suggest that some of these courses are intended for treatment rather than prophylaxis. Our estimates represent lower bounds for oral antibiotic prescriptions in this setting, as we only captured same-day prescriptions. However, our findings suggest that ASC facilities may not be high-impact targets for national, public health antibiotic stewardship efforts.

Disclosures

All Authors: No reported disclosures
1713. Factors Associated with Viral Rebound post Blip in Patients from a Community HIV Clinic
Authors: Sanchez Eduardo , Borgman Jody , Joffe Aviva , Holdsworth Catherine
Published: January 2021

Background

Blips are detectable increases in the HIV viral load (VL) that occur after therapy has effectively suppressed the virus to an undetectable level. There is no clear etiology for the development of blips. The association between blips and viral failure remains unclear.

Methods

This retrospective chart review aimed to clinically characterize patients who developed blips in a community HIV clinic in north Philadelphia between 2014-2018. A blip was defined as a single detectable VL < 500 copies/mL which appears between two undetectable VL measurements. Multivariate analysis was performed to examine the relationship of certain variables and viral rebound (VR) in patients with blips. Viral rebound was defined as post blip VL > 200 copies/mL that was not followed by an undetectable viral load.

Results

Of a total of 666 patients, 225 (33.7%) had at least 1 blip. 59% were male and 41% were female. The majority were African American (84.4%). Sixty seven percent were heterosexuals and 25.7% were MSM. Analyzing CD4 counts at the moment of blip, 68% had >500 cells/mm3. The average value of the blips was 85 copies/mL with 48.8% of the patients having a blip between 20-50 copies/mL. Most of the patients were on INSTIs (49.5%) followed by NNRTIs (35.6%). Of the 225 patients, 148 had at least 1 year of follow up post-blip. Those who were followed for less than 1-year post-blip were not included in the statistical analysis to find potential factors associated with VR. Thirty-two (21.6%) patients developed rebound. The multivariate analysis showed that being male and having a higher blip value were factors associated to increased likelihood of VR. Factors associated to decreased likelihood of rebound were the use of NNRTIs at blip and an HIV transmission factor that was not heterosexual sex (MSM and IDU). All of these associations were noted to be statistically significant.

Conclusion

The variables that were found to be associated to viral rebound could help guide clinicians during the surveillance of patient’s with blips. Further research in larger cohorts would help clarify the role of these variables in patients who develop treatment failure.

Disclosures

All Authors: No reported disclosures
1717. Relationship between Neighborhood Census-tract Level Poverty and Respiratory Syncytial Virus (RSV)-associated Hospitalizations in U.S. adults, 2015-2017
Authors: Holmen Jenna , Reingold Art , Bye Erica , Kim Lindsey , Anderson Evan J , Bennett Nancy M , Chai Shua , Kirley Pam Daily , Muse Alison , Talbot Helen , Monroe Maya , Rothrock Gretchen , Whitaker Michael , Bryanna Cikesh
Published: January 2021

Background

In the U.S., RSV is increasingly recognized as a cause of hospitalization for adults with respiratory illness. In adults > 50 years of age, it accounts for up to 12% of medically-attended acute respiratory illnesses and has a case fatality proportion of ~ 6–8%. Poverty can have important influences on health on both the individual level as well as the community level. Few studies have evaluated the relationship of RSV and poverty level, and no identified studies have evaluated this relationship among adults. We evaluated the incidence of RSV-associated hospitalizations in adults across multiple sites in the U.S. by census-tract (CT) level poverty.

Methods

Medical record data abstraction was conducted for all adults with a laboratory-confirmed RSV infection admitted to a hospital within the Centers for Disease Control and Prevention’s Emerging Infections Program catchment areas within California, Georgia, Maryland, Minnesota, New York, and Tennessee during the 2015–2017 RSV seasons (October-April). Patient addresses were geocoded to their corresponding CT. CTs were divided into four levels of poverty, as selected in prior publications, based on American Community Survey data of percentage of people living below the poverty level: 0–4.9%, 5–9.9%, 10-19.9%, and ³20%. Incidence rates were calculated by dividing the number of RSV cases in each CT poverty-level (numerator) by the number of adults living in each CT poverty level (denominator), as determined from the 2010 US census, and standardized for age.

Results

There were 1713 RSV case-patients with demographic characteristics (Table 1). The incidence of RSV-associated hospitalizations of adults increased with increasing CT level poverty (Figure 1 and Table 2). The risk of RSV-associated hospitalization was 2.58 times higher in census tracts with the highest (20%) versus the lowest (< 5%) percentages of individuals living below the poverty level.

Table 1: Demographic characteristics of adults with an RSV-associated hospitalization, 2015-2017.

Figure 1. Age-adjusted incidence rate of RSV-associated hospitalizations of adults by census-tract poverty level, 2015-2017

Table 2. Incidence rate ratios for RSV-associated hospitalizations of adults by census-tract poverty level, 2015-2017.

Conclusion

The incidence rate of RSV-associated hospitalization in adults appears to have a positive association with increasing CT level of poverty; however, this trend reached significance only among cases living in CTs with higher percentages of poverty (≥ 10%).

Disclosures

Evan J. Anderson, MD, Sanofi Pasteur (Scientific Research Study Investigator)
147. Pharmacist Attitudes Towards Using Clinical Decision Support in Community Pharmacies to Promote Antibiotic Stewardship in the Treatment of Uncomplicated UTI
Authors: Sayood Sena , Suda Katie , Durkin Michael
Published: January 2021

Background

Prior studies of prescribing practices have shown that providers frequently choose non-guideline concordant treatment regimens to treat uncomplicated urinary tract infection (UTI). It has also been shown that uncomplicated UTI can be treated safely, and in a guideline concordant manner, by non-physician providers using an algorithm over the phone. The purpose of this study was to assess pharmacist attitudes towards using a clinical decision support (CDS) tool that would be used to evaluate and manage patients presenting with complaints of UTI in the community pharmacy setting.

Methods

We conducted semi-structured interviews of community pharmacists (n = 21) from 2019 to 2020 until thematic saturation was reached. Pharmacists were questioned about their attitudes towards stewardship, workflow, interactions with patients and providers, and interest in using a computerized CDS tool. Interviews were recorded, transcribed, and de-identified. Coding and analysis of the interviews was performed using NVivo version 12.

Results

Pharmacists were interviewed with practice experience ranging from 2 to 54 years (median 13, IQR 6, 27). All pharmacists expressed interest in using CDS to assist with patient evaluations and stewardship. They reported that patients routinely use the community pharmacy as a first stop for medical advice and that they have several interactions per day with patients in which they counsel them on a variety of issues, including UTI. Their assessment and management decisions of UTIs were based on personal knowledge and not on any standard of care. Communication difficulties with primary care offices often delayed management of these patients and lack of information sharing made it difficult for pharmacists to engage in stewardship practices.

Conclusion

Community pharmacies are an important point of contact for patients and represent a significant opportunity to implement outpatient stewardship interventions. Pharmacists had an overwhelmingly favorable response to the prospect of using a CDS tool, both to help in patient evaluation and to promote antimicrobial stewardship. Based on these results we can conclude that it would be feasible to pilot a CDS tool in community pharmacies to further evaluate its safety and efficacy in the treatment of UTI.

Disclosures

All Authors: No reported disclosures
149. Unmet Informational Needs among Nursing Home Residents Receiving Antibiotics: A Qualitative Study
Authors: Carter Eileen , DeForge Christine E , Pogorzelska-Maziarz Monika , Mackson Grace , Stone Patricia W , Shang Jingjing
Published: January 2021

Background

Antibiotics are commonly used in the nursing home (NH) setting and increase residents’ risk for opportunistic and painful infections. Existing evidence of NH residents’ experiences and attitudes towards antibiotic use is limited. We aimed to explore NH residents’ experiences and perceptions of the benefits and risks to antibiotic treatment.

Methods

Two researchers conducted one-on-one semi-structured interviews with residents residing in a large not-for-profit NH in New York City. Interviews were audio-recorded and transcribed verbatim. Researchers coded the transcripts using thematic analysis in NVivo 12.

Results

A total of 26 residents engaged in individual interviews. Participants had a mean age of 76. Most were white (81%), female (58%) and had attended college (58%). Four thematic findings emerged: 1) participants’ involvement in antibiotic treatment decisions; 2) perceived benefits and risks to antibiotics; 3) unmet informational needs; and 4) suggestions to overcome informational needs. Participants described varied involvement in antibiotic treatment decisions, in which some participants described insisting antibiotics from their clinicians and others described leaving antibiotic treatment decisions entirely to the judgement of clinicians. Benefits of antibiotics were well-articulated, yet risks (side effects including antibiotic resistance) to antibiotics were poorly described. Participants reported unmet information needs, including concerns regarding potential drug interactions. Information needs were described to result from a lack of communication with NH staff and/or poor memory among NH residents. Participants suggested that NH residents receive written material regarding their antibiotic prescriptions and provided the types of information that would be helpful for NH residents to know. Descriptions of themes and representative quotes are provided in Figure.

Table. Thematic Findings and Representative Quotes

Conclusion

NH residents expressed a lack of understanding of risks to antibiotic use, unmet informational needs regarding their antibiotic treatments and articulated suggestions to address these information needs.

Disclosures

All Authors: No reported disclosures
151. An Electronic Algorithm to Better Target Antimicrobial Stewardship Program (ASP) Efforts for Children Hospitalized with Community-Acquired Pneumonia (CAP)
Authors: Gerber Jeffrey , Grundmeier Robert , Hamilton Keith W , Hicks Lauri , Neuhauser Melinda M , Frager Nicole , Menon Muida , Kratz Ellen , Jaskowiak Anne , Cressman Leigh , James Tony , Omorogbe Jacqueline , Lautenbach Ebbing
Published: January 2021

Background

Pediatric antibiotic stewardship programs (ASPs) have been successful in decreasing inappropriate antibiotic use. However, they require considerable time and effort. Approaches to increase ASP efficiency are urgently needed. We developed and validated an electronic algorithm to identify inappropriate antibiotic use in children hospitalized with community-acquired pneumonia (CAP).

Methods

At Children’s Hospital of Philadelphia (CHOP), we used ICD-10 diagnostic codes to identify inpatient patient encounters for pneumonia between 3/15/17 – 3/14/18 for which patients received a systemic antibiotic in the first 48 hours of hospitalization. Exclusion criteria included transfer from another facility, intensive care unit admission or death in first 48 hours, immunocompromising condition, or specific comorbidities. We randomly selected 150 subjects. Inappropriate antibiotic use based on chart review served as the basis for assessment of the electronic algorithm which was constructed using only data in the electronic health record (EHR). Criteria for appropriate prescribing, choice of antibiotic, and duration of therapy were based on established CHOP and IDSA/PIDS guidelines.

Results

Of 148 eligible subjects, median age was 3.8, 48% were female, and 129 (86%) were admitted to a general pediatrics service. On chart review, 147 (99%) subjects were correctly diagnosed with CAP. Of these subjects, the choice of initial antibiotic(s) was appropriate in 133 (90%). Of the 147 subjects, 137 (93%) had an appropriate duration of therapy. Test characteristics of the EHR algorithm (compared to chart review) are noted in the Table.

Conclusion

In pediatric patients hospitalized with CAP, the electronic algorithm for identifying inappropriate prescribing, antibiotic choice, and duration was highly accurate. This algorithm could have considerable utility in targeting ASP initiatives. The impact of interventions based on this algorithm should be tested in the future

Test Characteristics of Electronic Algorithm for Inappropriate Prescribing, Agent, and Duration

Disclosures

All Authors: No reported disclosures
152. Applying A Difference-in-Difference Analysis to Assess Effect of Antimicrobial Stewardship Strategies on Changes in Antimicrobial Use
Authors: Chou Ann F , Zhang Yue , Jones Makoto M , Graber Christopher J , Goetz Matthew B , Madaras-Kelly Karl , Samore Matthew H , Glassman Peter A
Published: January 2021

Background

About 30–50% of inpatient antimicrobial therapy is sub-optimal. Health care facilities have utilized various antimicrobial stewardship (AS) strategies to optimize appropriate antimicrobial use, improve health outcomes, and promote patient safety. However, little evidence exists to assess relationships between AS strategies and antimicrobial use. This study examined the impact of changes in AS strategies on antimicrobial use over time.

Methods

This study used data from the Veterans Affairs (VA) Healthcare Analysis & Informatics Group (HAIG) AS survey, administered at 130 VA facilities in 2012 and 2015, and antimicrobial utilization from VA Corporate Data Warehouse. Four AS strategies were examined: having an AS team, feedback mechanism on antimicrobial use, infectious diseases (ID) attending physicians, and clinical pharmacist on wards. Change in AS strategies were computed by taking the difference in the presence of a given strategy in a facility between 2012–2015. The outcome was the difference between antimicrobial use per 1000 patient days in 2012–2013 and 2015–2016. Employing multiple regression analysis, changes in antimicrobial use was estimated as a function of changes in AS strategies, controlling for ID human resources in and organizational complexity.

Results

Of the 4 strategies, only change in availability of AS teams had an impact on antimicrobial use. Compared to facilities with no AS teams at both time points, antibiotic use decreased by 63.9 uses per 1000 patient days in facilities that did not have a AS team in 2012 but implemented one in 2015 (p=0.0183). Facilities that had an AS team at both time points decreased use by 62.2 per 1000 patient days (p=0.0324).

Conclusion

The findings showed that AS teams reduced inpatient antibiotic use over time. While changes in having feedback on antimicrobial use and clinical pharmacist on wards showed reduced antimicrobial use between 2012–2015, the differences were not statistically significant. These strategies may already be a part of a comprehensive AS program and employed by AS teams. In further development of stewardship programs within healthcare organizations, the association between AS teams and antibiotic use should inform program design and implementation.

Disclosures

All Authors: No reported disclosures
155. Development of antibiotic classification for measuring antibiotic usage in Korean hospitals using a modified Delphi method
Authors: Kim Bongyoung , Yoon Young Kyung , Kim Dong-Sook , Jeong Su Jin , ahn Song Vogue , Park Sun Hee , Kwon Ki Tae , Kim Hong Bin , Park Yoon Soo , kim Shin-Woo , Kiem Sungmin , Choi Jun yong
Published: January 2021

Background

In 2019, the project about developing a system for measure and benchmark antibiotic usage in each hospital was launched. As the basic work for the project, we developed ‘antibiotic classification for measuring antibiotic usage in Korean hospitals’ using a modified Delphi method.

Consensual definition of antibiotic components according to the antibiotic classification in Korean hospitals.

Methods

The study consisted of two series of modified Delphi studies and was performed from July to August 2019. The study ‘antibiotic classification in Korean hospitals’ was performed first and followed by the study ‘antibiotic components according to the antibiotic classification in Korean hospitals’. Each Delphi study included two rounds of surveys in order to gather opinions and refine the information related to each study. We recruited a total of 12 panels including infectious diseases physicians (10), professor of preventive medicine (1), and the researcher of Health Insurance Review & Assessment Service (1). The questions for the Round 1 survey in each study were adopted from the antibiotic classification of the NHSN.

Results

As for the first study, the response rate of each round was 58.3% (7/12) and 75.0% (9/12), respectively. Most of the subjects of the NHSN’s antibiotic classification for adults were accepted except ‘antibacterial agents posing the highest risk for Clostridioides difficile infection’ (CVR = -1.000). On the contrary, all subjects for children were rejected. Finally, a total of 6 classifications were accepted. They were i) broad-spectrum antibacterial agents predominantly for hospital-onset infections, for adult (CVR = 1.000), ii) broad-spectrum antibacterial agents predominantly used for community-acquired infections, for adult (CVR = 1.000), iii) antibacterial agents predominantly used for resistant gram-positive infections, for adult (CVR =1.000), iv) narrow-spectrum beta-lactam agents, for adult (CVR = 1.000), v) antibacterial agents predominantly used for extensive antibiotic resistant gram-negative bacteria, for adult (CVR = 1.000), and vi) total antibacterial agent (CVR = 1.000).

Conclusion

this study provides antibiotic classification for measuring antibiotic usage in Korean hospitals. This classification may guide to develop a system for measuring of antibiotic usage in each Korean hospital.

Disclosures

All Authors: No reported disclosures
156. Evaluating Antibiotic Use and Developing a Tool to Optimize Prescribing in a Pediatric HIV Clinic in Eswatini
Authors: Streatfield Ashish E , Ness Tara , Simelane Tandzile T , Guffey Danielle , Lukhele Bhekemusa , Kay Alexander
Published: January 2021

Background

Antibiotic resistance is an emerging global health issue, fueled by inadequate surveillance systems and the absence of antimicrobial stewardship. In resource-limited settings, antimicrobial use is often based on clinical evaluation rather than microbiologic evidence, making treatment guidelines and the education of healthcare providers paramount to ensuring appropriate antimicrobial prescribing. In a human immunodeficiency virus (HIV) clinic for children and their families in Eswatini, we sought to understand the use of antibiotics and identify specific areas for improvement.

Methods

We performed a retrospective patient chart review as part of a quality improvement (QI) initiative to assess antimicrobial use before and after implementation of a standardized antimicrobial guide. For each prescribing period, 100 random patient encounters were selected for review to observe if the indication for antibiotics, duration, and dose were consistent with World Health Organization (WHO) guidelines. Two physicians reviewed each encounter to determine the appropriateness of antibiotic use using a structured abstraction tool, with a third resolving discrepancies. Results were analyzed using a chi-square test of proportions and a structured survey was performed to assess perceptions of the guide.

Results

After the implementation of an antimicrobial guide, there was a significant decrease in the proportion of clinic visits with an antibiotic prescribed (p < 0.001). Incorrect indication for antimicrobial use decreased from 20.4% in the initial period, to 10.31% and 10.2% but did not reach significance (p=.0621) in the subsequent periods after implementation. Incorrect dose/duration decreased from 10.47% in the initial period to 7.37% and 3.1% in the subsequent periods, but this was also was not significant (p = 0.139). All prescribers who completed the survey used the antimicrobial guide and felt that it positively impacted their prescribing patterns.

Conclusion

Our study found that an antibiotic guide reduced and improved the prescription of antimicrobials. Antimicrobial stewardship is a global problem and this data demonstrates that practical solutions can have a lasting impact on antimicrobial prescribing in low resource settings.

Disclosures

All Authors: No reported disclosures
158. A multi-site, prospective study of antimicrobial prescribing practices in three low- or middle-income country hospitals
Authors: Rolfe Robert J , Muro Florida , Lyamuya Furaha , Kwobah Charles M , Sheng Tianchen , Piyasiri Dammalage Lasanthi Bhagya , Bodinayake Champica K , Nagahawatte Ajith , Yarrington Michael E , Drew Richard H , Kussin Peter S , Watt Melissa H , Anderson Deverick J , Woods Christopher W , Mmbaga Blandina T , Tillekeratne L Gayani
Published: January 2021

Background

Antimicrobial stewardship programs (ASPs) are being developed internationally to mitigate the misuse of antimicrobials. An understanding of current practices and prescribing patterns is necessary to determine targets to develop context-specific ASPs in low- and middle-income country (LMIC) hospitals.

Methods

We conducted a prospective study of patients admitted to the adult medical wards at three LMIC tertiary care centers in 2018- 2019: a 1,800-bed public hospital in Galle, Sri Lanka; a 991-bed public hospital in Eldoret, Kenya; and a 630-bed private hospital in Moshi, Tanzania. Information regarding antimicrobial therapy received during hospitalization, indications for antimicrobial therapy, and duration of antimicrobial use were extracted from the medical record.

Results

In total, 3150 patients were enrolled: 1297 in Sri Lanka, 750 in Kenya, and 1103 in Tanzania. Antimicrobial use prevalence varied between the three sites, with 56.0% of patients receiving antimicrobials during hospitalization in Sri Lanka, 56.5% in Kenya, and 35.4% in Tanzania. Third-generation cephalosporins were used most frequently in Kenya (70.0%) and Tanzania (73.1%), whereas amoxicillin/ clavulanic acid was used most frequently in Sri Lanka (48.4%). Lower respiratory tract infection was the most common indication for antimicrobial use in all three locations: 37.4% in Sri Lanka, 27.8% in Kenya, and 49.2% in Tanzania. No clear indication for antimicrobial use was documented among 11.6% patients receiving antimicrobials in Sri Lanka, 32.8% in Kenya, and 10.5% in Tanzania. In Tanzania, 8.6% of the patients had documentation of input from the microbiology or infectious diseases teams compared to less than 1% in either Sri Lanka or Kenya. Pertinent culture data related to the primary indication for antimicrobials was present in 16.1% (Sri Lanka), 6.1% (Kenya), and 7.4% (Tanzania).

Conclusion

Unclear documentation for antimicrobial use was common in all three sites and most patients on antimicrobial therapy did not have pertinent culture data. Improving documentation and the capacity of the local microbiology laboratories could be initial targets for ASPs in these LMIC hospitals.

Disclosures

All Authors: No reported disclosures
163. Automation of an Inpatient Provider Specific Antimicrobial Use Report
Authors: Weslander Erin , Shovlin Brandon , Green Michael D
Published: January 2021

Background

The use of individual prescriber report cards has shown to be an effective strategy in optimizing antimicrobial use in the pediatric outpatient setting. This is more difficult in an inpatient setting with prescribing often being done by a resident, but the decisions regarding antimicrobials are often made by the attending physician. This concept was tackled at a tertiary children’s hospital but was a manual and time-consuming process. The purpose of this review is to compare provider specific antimicrobial use between a manual chart review and an automated report.

Methods

An automatic report was developed that calculates antimicrobial days of therapy per 1000 patient days for each Pediatric Intensive Care Unit (PICU) attending provider. The software used was Business Objects that interfaces with the Electronic Medical Record. The provider is attached to daily antimicrobial use based on the attending to write a note that day. The provider was attached to patient days based on the number of days per patient they wrote notes.

Results

One week including 96 patients was chart reviewed and compared to the automated report prospectively. The automatic report days of therapy and patient days per PICU provider were within 10% of the chart review. Two months of the previous manual chart review was compared to the same two months with the automated report, which was also within 10%. Average quarterly hospital PICU antimicrobial days of therapy per 1000 patient days during the calendar year of 2019 in the Pediatric Health Information System (PHIS) were compared quarterly to the automated report, which was also within 10%.

Conclusion

An automated report that connects the attending to antimicrobial orders by attaching it to the note writer was found to be comparable to manual chart review as well as an average of use for the PICU compared to the national database PHIS. This automation can help decrease workload and optimize efforts for specific interventions and education that can be distributed with the PICU attending antimicrobial use report.

Disclosures

All Authors: No reported disclosures
166. Barriers to implementing antimicrobial stewardship programs in low- or middle-income country settings: findings from a multi-site qualitative study
Authors: Rolfe Robert J , Kwobah Charles M , Muro Florida , Ruwanpathirana Anushka S , Lyamuya Furaha , Bodinayake Champica K , Nagahawatte Ajith , Piyasiri Dammalage Lasanthi Bhagya , Sheng Tianchen , Bollinger John W , Zhang Chi , Drew Richard H , Kussin Peter S , Anderson Deverick J , Woods Christopher W , Watt Melissa H , Mmbaga Blandina T , Tillekeratne L Gayani
Published: January 2021

Background

Antimicrobial resistance has been named as one of the top ten threats to health in the world. The World Health Organization has endorsed the implementation of hosptial-based antimicrobial stewardship programs (ASPs) to reduce antimicrobial resistance. We conducted a qualitative study to determine perceived barriers to the development and implementation of ASPs in low- and middle-income countries (LMICs).

Methods

We conducted 46 interviews with medical doctors at tertiary care hospitals in Sri Lanka (22 doctors), Kenya (12), and Tanzania (12). Interviews assessed knowledge and receptiveness to ASPs and barriers to implementing ASP protocols. Interviews were conducted in English, audio recorded, and transcribed. The interviews discussed knowledge of antimicrobial resistance and ASPs, current antimicrobial prescribing practices, access to diagnostics, receptiveness to ASPs, and perceived barriers to implementing ASPs. Data analysis followed procedures of applied thematic analysis, and used NVivo software. A codebook included structural themes based on the interview questions and emerging inductive themes. Two independent reviewers coded the interviews, and the coding was combined and reviewed for consensus. Themes were synthesized, with comparisons made across the three sites.

Results

Medical doctors from all three sites discussed multiple barriers to improving antimicrobial prescribing: prohibitively expensive antimicrobials, limited antimicrobial availability, resistance to change current practices regarding antimicrobial prescribing, and limited diagnostic data. The most frequent of these barriers discussed in all three locations was limited drug availability, mentioned by 12/22 physicians in Sri Lanka, 5/12 in Tanzania and 8/12 in Kenya. Improved education was a suggested component of ASPs in all three sites: 7/22 in Sri Lanka, 6/12 in Tanzania, and 6/12 in Kenya.

Conclusion

The study highlighted several important issues in determining the next steps for the implementation of ASPs in these LMIC hospitals. Improving drug availability and improving education to change physicians’ antimicrobial prescribing practices are important targets that could be addressed by ASPs in these facilities.

Disclosures

All Authors: No reported disclosures
167. Communication is Key: A Multifaceted Approach to Improving Essential ASP Metrics in Surgical Services
Authors: Britt Rachel S , Reynoso David , Keiser Philip H , Ferren R Scott
Published: January 2021

Background

Despite widespread antimicrobial resistance, suboptimal antimicrobial use is common, particularly among surgical services. Studies show that antimicrobial stewardship programs (ASPs) effectively improve antimicrobial use and decrease adverse events. However, evidence for optimal ASP intervention in surgical departments is lacking, and some surgical services perceive ASPs negatively. This study aimed to evaluate the effect of several collaborative ASP interventions and workflow changes on the non-acceptance rate (NAR) of ASP recommendations and antimicrobial use among surgical services.

Methods

This was a retrospective, pre-post study of services in the department of surgery at a 681-bed, academic medical center between 12/01/2018 and 5/31/2020. Throughout 10/2019 and 11/2019, the core ASP, which consists of two infectious diseases physicians and two infectious diseases pharmacists, performed several interventions with surgical services. These included meetings with the chairman, vice chairs, and division chiefs of the surgery department, a grand rounds presentation to surgical house staff, and monthly surgeon NAR reporting to the chairman. Also, per feedback from surgeons, the ASP began to communicate recommendations directly to attending surgeons instead of residents or via ASP notes in the medical record. Data for the pre-period was collected from 12/2018 to 9/2019; data for the post-period was collected from 12/2019 to 5/2020. Wilcoxson rank sum, chi-square, and Fisher’s exact tests were used to compare outcomes.

Results

The ASP communicated 353 recommendations to surgical services in the pre-period, and 181 in the post-period. ASP offered most recommendations to trauma (n=244), cardiothoracic (n=60), and plastic surgery (n=54) during the study periods. NAR decreased post-intervention overall (43% vs 29%, p=0.0013) and in trauma surgery (63% vs 47%, p=0.03). Mean monthly days of therapy per 1000 patient days trended towards a decrease post-intervention (1105 vs 1044, p=0.26). Cost per 1000 patient days decreased post-intervention ($27,677.91 vs $19,766.31, p =0.0075).

Conclusion

A communicative and adaptive approach to ASP in surgical services improved NAR and antimicrobial costs and trended towards a reduction in antimicrobial use.

Disclosures

All Authors: No reported disclosures
168. Creation and Internal Validation of a Clinical Predictive Model for Fluconazole Resistance in Patients with Candida Bloodstream Infection
Authors: Rauseo Adriana M , Olsen Margaret A , Larson Lindsey , Stwalley Dustin , Hsueh Kevin , Powderly William , Spec Andrej
Published: January 2021

Background

IDSA guidelines on candidemia recommend fluconazole as first-line therapy in patients considered low risk for fluconazole resistant infections. However, there is currently no mechanism to determine risk of resistance, and most community hospitals cannot perform rapid sensitivity testing, leading to prolonged use of echinocandin therapy. This study aims to develop a clinical predictive model to identify patients at low risk for fluconazole resistance where first-line use of fluconazole therapy would be acceptable without requiring resistance testing.

Methods

We performed a retrospective cohort analysis of all hospitalized adult patients with a positive blood culture for Candida spp. from 2013 to 2018. Fluconazole resistance was determined using Sensititre™ YeastOne™ YO9 AST Plate, with cutoffs defined for each Candida species based on Clinical and Laboratory Standards Institute performance standards for antifungal testing (M60) in all patients. Using backwards stepwise regression, we developed a multivariable logistic regression model to identify factors associated with fluconazole resistance in patients in Candida bloodstream infection, including only variables with clinical plausibility and p < 0.1 in bivariable analysis. Stepwise regression was performed on bootstrapped samples to test individual variable stability and estimate confidence intervals. We used graphs of observed vs expected values to assess model performance across the probability spectrum.

Results

We identified 539 patients with Candida bloodstream infection from 2013–2018, of which 13.4% (72/539) were fluconazole resistant. Increased risk of fluconazole resistance was associated with age (1.12 [1.01, 1.24]), bacterial septicemia (2.14 [1.20, 3.79]), receipt of previous azole therapy (5.47 [2.92, 10.26]), bone marrow transplant (2.63 [1.31, 5.29]), and myelodysplastic syndrome (3.13 [1.14, 8.60]). The model predicted fluconazole sensitivity well (c-statistic 0.788) and all the variables were stable (Figure 1).

Figure 1. Graph comparing observed versus expected probability of fluconazole resistance. Bars included on the top parameter of the graph indicate the number of individuals, illustrating the distribution of the sample.

Conclusion

The presented model provides a potential tool for identifying the 80% of patients at low enough risk for fluconazole resistance to receive empiric therapy with azoles and reduce use of echinocandins.

Disclosures

Margaret A. Olsen, PhD, MPH, Merck (Grant/Research Support)Pfizer (Consultant, Grant/Research Support) Dustin Stwalley, MA, AbbVie Inc (Shareholder)Bristol-Myers Squibb (Shareholder) Andrej Spec, MD, MSCI, Astellas (Grant/Research Support)Mayne (Consultant)Scynexis (Consultant)