bluuebunny/crossref_metadata_2025_split huggingface dataset:
1112. Improving Urine Culturing Practices in a Neurocritical Care Unit through a Multidisciplinary Algorithm-Based Approach
Authors: Hazen Dana , Snyderman William , Sadowski Josh , Kelley Kristen , Beeler Cole , Webb Douglas , Dbeibo Lana , Page Shannon , Desai Armisha , Rodgers Richard , Brewer Brian , Singh Ranjeet , Bortenschlager Lawrence 
Published: October 2019

Abstract

Background
Asymptomatic bacteriuria is common in hospitalized patients with urinary catheters. Inappropriate urine culturing as part of reflexive response to fever contributes to unnecessary and excessive antibiotic use, selection for resistant organisms, increased risk for Clostridium difficile infections, and false elevation in catheter-associated urinary tract infection (CAUTI) rates. This project aimed to implement an evidence-based urine culture algorithm in a 33-bed neurocritical care unit, a unit with a historically elevated CAUTI rate due to a high prevalence of noninfectious fever.

Methods
A multidisciplinary quality improvement project was initiated in August 2018 by the Infection Prevention, Quality and Safety, Neurocritical Care, Trauma, and Neurosurgery teams of an urban academic health center. The group implemented a urine culture algorithm that was adapted from the Infectious Diseases Society of America (IDSA) guidelines that clearly highlighted appropriate indications for sending urine cultures. The team agreed to utilize a urinalysis with reflex to culture as the preferred method to evaluate for CAUTI. The algorithm was implemented in September 2018. Outcomes were compared for pre-implementation (March-August 2018) and post-implementation (September 2018–February 2019).

Results
The NHSN CAUTI rate decreased from 4.52/1,000 Foley days to 1.27/1,000 Foley days (P-value 0.037) as a result of the intervention. The number of urine cultures ordered decreased by 82% after implementation. No cases of bacteremia or mortality secondary to a urinary source were identified during the project. Total days of antibiotic therapy for the unit was similar between the pre- and post-implementation time periods (P = 0.631).

Conclusion
Implementation of a urine culture algorithm in a neurocritical care unit resulted in reduced CAUTI rate with less financial and operational waste in unnecessary orders and treatment, without resulting in adverse events to patients as a result of missed diagnosis.

Disclosures
All authors: No reported disclosures.
1113. Outpatient Antimicrobial Stewardship: Targets for Urinary Tract Infections
Authors: Mergenhagen Kari A , Wattengel Bethany A , DiTursi Sara , Schroeck Jennifer , Sellick John A 
Published: October 2019

Abstract

Background
Urinary tract infections (UTIs) remain one of the most commonly diagnosed infectious diseases in the United States in both the inpatient and outpatient settings, accounting for 10.5 million outpatient visits in 2007. Of these visits, 5.4 million were seen in primary care offices. Outpatient antimicrobial stewardship programs are emerging and a focused approach to UTIs is needed to help guide new programs.

Methods
Data were collected by retrospective chart review of outpatient males at the VA Western New York Healthcare System using encounters from January 2005 to March 2018. Appropriate treatment was defined as antimicrobial prescribing in the setting of at least 2 signs/symptoms of UTI. Categorical data were analyzed using the chi-square test and continuous data using the Student t-test. Factors that differed significantly (P < 0.05) between the comparator groups were built into a multivariate logistic regression model to determine factors associated with inappropriate prescribing, which were presented as an Odds Ratio (OR) and 95% Confidence Interval (CI).

Results
A total of 607 outpatients met criteria for inclusion, of which 40% were treated inappropriately. Of the 60% treated appropriately (therapy was indicated and empiric drug choice was correct), 95% of patients received a correct dose and 57% received an appropriate duration. Several risk factors were identified for inappropriate prescribing. Female patients were more likely to be treated inappropriately, OR 4.7 (95% CI, 2.4–9.1). Patients with a higher Charlson Comorbidity Index of 5–10 were 2.9 times more likely to be treated inappropriately (95% CI, 1.8–5.0). Those patients who received a urine culture or imaging were more likely to be treated appropriately: OR 0.6 (95% CI, 0.4–0.9) and 0.5 (95% CI, 0.3–0.7), respectively.

Conclusion
Outpatient antibiotic prescribing for UTIs is suboptimal. Outpatient stewardship programs may wish to educate providers on symptoms of UTI. Interestingly, those with signs and symptoms consistent with UTI were more likely to have a urine culture and/or imaging completed suggesting that providers were aware of a true diagnosis of a UTI. Stewardship programs should pay special attention to patients with numerous comorbidities as they are often inappropriately treated.

Disclosures
All authors: No reported disclosures.
1114. Oral β-lactams for the Treatment of Escherichia coli Bacteremia Secondary to Complicated Urinary Tract Infections Including Pyelonephritis
Authors: Harrington Nicole , Doran Megan , May Stephen , Care Julianne , Laude Jillian , Lee Stephanie 
Published: October 2019

Abstract

Background
Complicated urinary tract infections (cUTI) including pyelonephritis may result in bacteremia, increasing the rate of morbidity and mortality. The Infectious Diseases Society of America recommends a fluoroquinolone as empiric therapy or trimethoprim/sulfamethoxazole as definitive therapy for acute pyelonephritis (AP). Oral β-lactams (BL) are considered sub-optimal based on historical efficacy data with aminopenicillins and variable bioavailability. Increasing resistance and toxicity with preferred agents, justifies further evaluation of oral BL for E. coli bacteremia secondary to urinary source.

Methods
This was a single-center, retrospective cohort study of patients with E. coli bacteremia secondary to AP or cUTI who received oral step-down therapy with a BL or non-BL. The primary outcome was the rate of clinical success defined by microbiological cure, clinical cure, and infection-related readmission. Secondary outcomes were time to oral step-down, total days of therapy, length of hospital stay, incidence of therapy escalation, 30-day readmissions, and antibiotic-associated adverse events.

Results
A total of 46 patients were included, with 23 patients in each group. The difference in clinical success between the BL and non-BL groups was not statistically significant (91.3% vs. 100%, P = 0.489). The most frequent oral step-down agents prescribed were cephalexin and ciprofloxacin. The median time to oral step-down was significantly lower in the non-BL group (4.39 vs. 3.41 days, P = 0.038), and the median duration of therapy in each group was 15 days. No patients required therapy escalation after oral step-down or had infection-related readmission within 30 days of discharge.

Conclusion
The observed clinical success rate of 91.3% remains consistent with previous studies evaluating oral BL as step-down therapy for Enterobacteriaceae bloodstream infections. The results of this study support the safety and efficacy of oral BL as step-down therapy for E. coli bacteremia due to cUTI, although larger studies may be beneficial.

Disclosures
All authors: No reported disclosures.
1119. Implementation of Pediatric Antimicrobial Stewardship Rounds in a Children’s Hospital
Authors: Tucker Natalie , Saleh Ezzeldin , Rodriguez Marcela 
Published: October 2019

Abstract

Background
Antimicrobial stewardship programs (ASP) are required in all acute care hospitals per The Joint Commission. ASP must adhere to the recommendations laid out by the Centers for Disease Control and Prevention, but how each ASP chooses to implement these recommendations is left to the individual program. In January 2018, we began formal antimicrobial stewardship (AMS) walking rounds, led by infectious diseases trained physician and pharmacist, in our 99-bed pediatric hospital.

Methods
In January 2018, we started twice-weekly AMS rounds on the pediatric hospitalist service. A custom-made “Antimicrobial Stewardship Patient List” was designed in our electronic medical record (EMR) to generate a list of all patients receiving antibiotics. The ASP team (comprised of an infectious diseases pharmacist and a pediatric infectious diseases physician) reviewed EMR charts to determine antibiotic prescribing appropriateness and design recommended interventions. Any recommendations and teaching points were then discussed with the hospitalist team in person. After piloting the hospitalist service, AMS rounds were extended to include the general surgery patients and finally the intensive care unit. Data on number of charts reviewed, proposed interventions, and acceptance rates were collected throughout the process. Descriptive statistics were used to assess the intervention data.

Results
In the first year of the program, 427 patient charts were reviewed with 186 identified interventions. In total, 156 (84.3%) of the interventions were accepted and implemented by the primary team. The most common types of interventions were the duration of therapy (29%), antibiotic discontinuation (16.7%), intravenous to oral conversion (11.3%), de-escalation (10.2%), and infectious diseases consult (5.9%).

Conclusion
Pediatric AMS rounds led to the successful implementation of the majority of recommended interventions. Future goals of the program include calculating days of therapy per 1000 patient-days to assess antibiotic consumption before and after AMS rounds and to expand into other services to further promote appropriate antibiotic use in hospitalized pediatric patients.

Disclosures
All authors: No reported disclosures.
1121. Pediatric Urgent Care Providers’ Approach to Antibiotic Stewardship: A National Survey
Authors: Hamdy Rana F , Nedved Amanda , Obremskey Jill C , Fung Melody , Liu Cindy , Montalbano Amanda 
Published: October 2019

Abstract

Background
A high proportion of urgent care visits are for acute infectious conditions. Emerging data have shown that outpatient antibiotic prescribing for acute respiratory conditions is highest in urgent care settings; however, this has not been specifically studied among pediatric urgent cares. The objective of this study was to survey pediatric urgent care providers about their approach to antibiotic stewardship.

Methods
Members of the Society for Pediatric Urgent Care were recruited via e-mail to participate in a quality improvement antibiotic stewardship project. A pre-implementation survey developed by study investigators was piloted with several pediatric urgent care physicians and revised based on feedback. The finalized REDCap survey was sent to participants via e-mail in March 2019. Descriptive statistics were used to analyze the survey responses.

Results
A total of 156 providers completed the survey; 83% were board-certified pediatricians. Almost all (98%) indicated that antibiotic stewardship programs are important to optimize antibiotic use in urgent care. Just over half (53%) indicated that their urgent care center provides guidelines for prescribing antibiotics for acute respiratory tract infections. Treating patients with an underlying complex medical condition was the most common reason (21%) providers would deviate from guidelines. The most commonly cited barriers to appropriate prescribing for acute respiratory infections were patient expectations (93%), psychosocial barriers (40%), lack of clear evidence-based recommendations (15%), and lack of access to guidelines on prescribing (15%).

Conclusion
Most pediatric urgent care providers feel that antibiotic stewardship is important and would not impede their clinical approach. Parental expectations of receiving antibiotics were viewed as the most common barrier to appropriate prescribing. This work will be used to promote directed interventions to improve appropriateness of antibiotic prescribing for target diagnoses in pediatric urgent care centers.

Disclosures
All authors: No reported disclosures.
1124. Impact of a Best Practice Advisory for Pediatric Patients with Staphylococcus aureus Bloodstream Infection
Authors: Lloyd Elizabeth C , Martin Emily T , Dillman Nicholas , Nagel Jerod , Gandhi Tejal N , Tribble Alison 
Published: October 2019

Abstract

Background
Infectious diseases (ID) consultation and use of optimal antibiotic therapy have been shown to improve outcomes of patients with Staphylococcus aureus bloodstream infection (SA-BSI). We investigated the ability of an electronic medical record (EMR)-based best practice advisory (BPA) to enhance adherence to these practices for pediatric patients with SA-BSI.

Methods
An EMR-based BPA for SA-BSI (Figure 1) was implemented on 8/1/2017, recommending ID consultation and optimal therapy based on mecA gene rapid testing (vancomycin if mecA-positive; cefazolin or nafcillin if mecA-negative). We conducted a quasi-experimental pre/post study to evaluate impact of the BPA. Patients <21 years old admitted to C.S. Mott Children’s Hospital with SA-BSI during the pre- (1/2015 – 7/2017) and post-intervention (8/2017 – December 2018) periods were included. Demographic and clinical data were collected via chart review. Receipt of ID consult and optimal therapy before and after intervention were compared using interrupted time series (ITS) analysis with segmented regression. Time to optimal therapy was compared with segmented Cox regression.

Results
We included 99 SA-BSI episodes (70.7% pre-intervention and 29.3% post-intervention). Pre-intervention, 68.6% of patients received an ID consult compared with 93.1% post-intervention, but this was not significant with ITS analysis (Figure 2). The proportion of patients receiving optimal therapy did not significantly increase following the intervention, but time to optimal therapy significantly decreased (Figure 3). The median time to optimal therapy decreased from 26.1 hours to 5.5 hours. Cox regression showed both an immediate decrease in time to optimal therapy (HR 3.9, P = 0.009), followed by a continued decrease over time.

Conclusion
Following implementation of a novel EMR-based intervention, ID consultation for SA-BSI increased, although this was not statistically significant due to a pre-existing trend of increasing ID consults over time. Implementation of the BPA was associated with a significant decrease in time to optimal therapy, likely due to a combination of increasing ID consultation and antibiotic guidance provided by the BPA.

Disclosures
All authors: No reported disclosures
1129. Assessment of Nurses’ Views on Antimicrobial Stewardship at a Pediatric Hospital
Authors: Yu Diana , Bateman Anne , Nolt Dawn 
Published: October 2019

Abstract

Background
Regulatory agencies strongly encourage the development of hospital-based antimicrobial stewardship (AS) programs (ASP) to support appropriate antimicrobial prescribing. One component of an ASP is a multidisciplinary team. While the initial conception centered on a physician and a pharmacist, including nurses in AS has been highlighted due to the nurse’s vital role in patient care. There are little data on nurses’ knowledge, attitudes, and practices in AS. The aim of this project was to determine ideas, concerns, and gaps in knowledge of bedside nurses at a local hospital level.

Methods
This project was conducted at an academic pediatric hospital in an urban setting. A survey was designed to obtain nurses’ attitudes and views of AS and to address their frequency and confidence of various AS activities, including triage/isolation, allergy history, obtainment of appropriate diagnostic studies, interpretation of microbiology results, antibiotic de-/escalation, intravenous-to-oral switches of antibiotics, patient/family education, and identification of antimicrobial-associated adverse events. Respondents were asked to identify barriers to AS participation and to propose educational topics of interest. The survey was sent out to nurses, with 3 weekly reminders.

Results
155 of 513 respondents initiated the survey (response rate 30.2%); however, 112 participants completed the entire survey (completion rate 72.3%). Of the respondents, 67% believed that nurses should provide AS but only 32% themselves provided AS; furthermore, 26% of the respondents felt that nurses were equipped to provide AS. The most frequent AS activity reported was patient/family education while the least reported activity was the interpretation of microbiology reports. A correlation was identified between frequency and confidence of performing various AS-related tasks (R2 = 0.95). Barriers identified by respondents included antimicrobial knowledge, other timely priorities, and inclusion of nurses on bedside rounds.

Conclusion
Although few respondents felt prepared to provide antimicrobial stewardship, the majority (74%) were interested in learning more about how nurses could be involved. We are currently developing a nurse-centric educational curriculum based on the feedback from the survey.

Disclosures
All authors: No reported disclosures.
1132. Evaluation of Broad-Spectrum Antimicrobial Therapy for Acute Mastoiditis in Pediatric Patients: An Antimicrobial Stewardship Perspective
Authors: Kim Soyoon , Moffett Brady , Pali Beth , D’Souza Jill , Dutta Ankhi 
Published: October 2019

Abstract

Background
Acute mastoiditis (AM) continues to remain a serious complication of acute otitis media in children. There is a significant variation in antimicrobial management in children with AM. Recent studies and UptoDate recommends empiric coverage with vancomycin and antipseudomonal medication in patients with AM. The purpose of this study was to evaluate the epidemiology, management and outcome of AM in pediatric patients.

Methods
A retrospective, observational study was designed evaluating epidemiology and management of AM in hospitalized pediatric patients from July 1, 2011 to June 30, 2017. Patients between 6 months and 19 years of age admitted with a diagnosis of AM as per ICD 9/10 coded were included in the study. Information regarding demographic, clinical, laboratory, microbiological, radiological, antibiotic (Abx) usage, surgical intervention and outcome were collected from medical records.

Results
A total of 97 patients were evaluated (64% male, mean age 6.6 ± 4.3 years). Cultures (Cx) were obtained in 95 patients as in Figure 1. Of the patients who grew P.aeroginosa, 2 had intracranial extension, both of which were polymicrobial and 5 did not receive empiric antipseudomonal therapy but had no complications on follow-up. Table 1 shows the most common empiric Abx therapy. Fifty-nine patients (61.5%) had a change in Abx, the most common being a ceftriaxone or a combination of clindamycin and ceftriaxone. Except for those with complicated AM, none required definitive vancomycin therapy. Thirty-two patients (33%) had a complicated mastoiditis with epidural abscess, thrombosis, and/or intracranial extension. Eighty-six patients (86.8%) required surgical intervention. Mastoidectomy was performed in 34% while others had myringotomy and tympanostomy tube placement and/or drainage of subperiosteal abscesses without subsequent complications.

Conclusion
Group A Streptococcus, Streptococcus pneumoniae and Pseudomonas were the predominant pathogens in acute AM in children. Vancomycin and empiric antipseudomonal coverage may not be needed in patients with uncomplicated AM. Broader spectrum Abx with intracranial penetration should be reserved for those with complicated AM.

Disclosures
All authors: No reported disclosures.
1133. Evaluation of Antibiotic Allergy Documentation in Pediatric Patients
Authors: Wheatley Kristin H , Sterner Lauren , Villalobos-Fry Tibisay I 
Published: October 2019

Abstract

Background
Antibiotics are the most prescribed drug class in children and use often results in reports of adverse reactions. Of these adverse reactions, allergic reactions are documented with an incidence of 10% of all antibiotic prescriptions. Documentation of the details of the reaction is incomplete in as many as 66–84% of encounters leading to increased use of broad-spectrum antibiotics and associated adverse outcomes. The purpose of this study was to determine the incidence of complete antibiotic allergy documentation and how antibiotic selection was affected in pediatric patients.

Methods
A retrospective chart review of electronic medical records was conducted for pediatric patients admitted to a pediatric unit with a documented antibiotic allergy between September 1, 2015 and May 31, 2017.

Results
The study sample included 536 encounters, 424 individual patients and 689 total allergies. Of all admissions during the study period, 10.3% of encounters had at least one antibiotic allergy documented. Approximately 40% of the encounters were in patients aged 12–17 years. A specific antibiotic was identified in 510 instances (74.0%) whereas an antibiotic class was documented in the remaining 179 instances (26.0%). Amoxicillin was the most commonly reported agent (25.4%). Rash (33.5%) and hives (14.8%) were the most commonly reported reactions. No reaction documentation was found in 78 entries (11.3%). Sixty-six entries (9.6%) did not include a date of occurrence and 452 (65.6%) did not include any specific comments regarding the allergy. Following evaluation of allergy documentation, 87 entries (12.6%) were classified as complete. Empiric broad-spectrum antibiotics were prescribed in 184 encounters (82.5%) compared with narrow-spectrum antibiotic therapy in 39 encounters (17.5%) when an allergy was documented.

Conclusion
Incomplete documentation of antibiotic allergies was identified in almost 90% of encounters within the pediatric population admitted to Lehigh Valley Reilly Children’s Hospital. Due to the preferential use of broad-spectrum antibiotics in patients with documented antibiotic allergies, an initiative is underway to standardize evaluation and documentation of allergies in patients receiving care within the health network.

Disclosures
All authors: No reported disclosures.