bluuebunny/crossref_metadata_2025_split huggingface dataset:
1327. Vancomycin Dosing by AUC24/MIC in Comparison to Traditional Trough Dosing in Office Infusion Centers (OICs)
Authors: Luu Quyen , Adams John S , Metzger Brian S , Hengel Richard L , Bhattacharyya Rishi , Rhoads David N , Couch Kimberly A , Schroeder Claudia P , Van Anglen Lucinda J 
Published: January 2021

Abstract

Background
New vancomycin (VAN) guidelines have been published, with recommendations that dosing in patients (pts) with methicillin-resistant S. aureus (MRSA) infections be guided by VAN area under the concentration-time curve from 0 to 24 h to MIC ratio (AUC24). The guidelines emphasize daily AUC24 values should be between 400-600 mg*h/L to maximize efficacy and minimize likelihood of acute kidney injury (AKI). Our physicians and clinical pharmacists currently use trough levels to manage outpatient VAN dosing with a general target of 15-20 mg/L. The current pharmacokinetic (PK) model provides an option for dosing using trough or calculated AUC24.

Methods
We identified pts receiving VAN for S. aureus infections (default MIC of 1 mg/mL) from 2018-2020. We conducted a PK evaluation of pts with ≥1 trough level and compared it to model predicted AUC24. Data collected included pt characteristics, VAN regimen, trough concentrations, PK evaluation, and AKI, defined as a 50% decrease in CrCL from baseline. A Bayesian PK model was used to calculate predicted dosing based upon trough concentrations (DoseMeRx®, Moorestown, NJ).

Results
100 pts (mean age: 61±15 yrs, 62% male) from 6 OICs were included, with 82% treated for MRSA and 18% for methicillin-sensitive S. aureus infection. Mean initial dose of VAN in the OIC was 2.6±1 g/d in divided doses, most frequently every 12 hrs (68%). Median duration of outpatient therapy was 28 days [IQR, 16-36]. 69% received VAN in the hospital prior to the OIC. 100 pts had 239 trough levels with a corresponding PK analysis. Mean trough levels were 17.1±6.4 mg/L. Mean corresponding AUC24 was 498±98 mg*h/L. The relationship between trough and AUC24 is shown in Fig 1. 25 evaluations indicated an AUC24 &lt; 400, with 8 (32%) resulting in a dose increase. 13 evaluations indicated AUC24 &gt; 600, with 6 (46%) resulting in a subsequent dose decrease. 4 pts developed reversible AKI, all with AUC24 &gt; 540. Use of AUC24 for dosing provided opportunities to adjust dosing in 38/239 evaluations (16%).
Figure 1. Relationship between Trough and AUC24 (n=239)

Conclusion
This PK evaluation showed a correlation between trough levels and AUC24 with opportunities for VAN dose adjustment using AUC24, and to identify pts at risk for developing AKI. Dosing with AUC24 is particularly useful in the outpatient setting in which true trough evaluations can be difficult to obtain.

Disclosures
Brian S. Metzger, MD, MPH, Allergan (Speaker’s Bureau)Cumberland (Speaker’s Bureau)Melinta (Speaker’s Bureau) Richard L. Hengel, MD, Merck & Co. (Other Financial or Material Support, Grant Steering Committee Member) Kimberly A. Couch, PharmD, MA, FIDSA, FASHP, Allergan (Speaker’s Bureau) Lucinda J. Van Anglen, PharmD, Merck & Co. (Grant/Research Support)
106. Impact and Evaluation of BioFire® FilmArray® Respiratory Panel on Clinical Decision Making and Antibiotic Prescribing
Authors: Manatrey-Lancaster Jenna J , Bushman Amanda , Caliguri Meagan , Espinoza Rossana Rosa 
Published: January 2021

Abstract

Background
The BioFire® FilmArray® respiratory panel (RFA) has been proposed as a tool for timely diagnosis and treatment of respiratory tract infections. However, the impact of the RFA on clinical decision making, most notably antibiotic prescribing, de-escalation and duration has been varied.

Methods
We aimed to determine the impact of RFA results on antibiotic days of therapy (DOT) depending on patient disposition. We conducted a retrospective chart review of adults who had an RFA performed within 48 hours of admission or presentation to the emergency departments (ED) of 3 hospitals in Des Moines, Iowa, between March 3 and March 16, 2019. Patients were excluded if they had a non-respiratory infection with defined indication for antibiotics. RFA results were categorized as influenza, non-influenza virus or negative. Negative binomial regression models were used to calculate rate ratios (RR) for the association between RFA result and DOT.

Results
A total of 486 total patients were included. Patients were divided according to disposition status, with 243 patients admitted and 243 discharged from the ED. Among inpatients, the median DOT was 2 (IQR 0–7). The results of the adjusted analysis for inpatient are shown on Table 1. In this group, RFA result was not associated with DOT (p=0.598 for non-influenza viruses and 0.706 for negative RFA), while having a urine culture done was independently associated with higher rate ratio of DOT (RR 1.85, 95% CI 1.32–2.59; p&lt; 0.001). Among patients discharged from the ED, the median DOT was 0 (0–8). The results of the adjusted analysis for this group are shown on Table 2. Compared to patients with influenza, those with non-influenza viruses had a RR for DOT of 4.18 (95% CI 1.16–14.9; p=0.028) and those with a negative RFA had an RR for DOT of 5.24 (95% CI 1.99–13.8; p= 0.028).
Adjusted analysis for the association between Respiratory Film Array results and Days of Therapy among hospitalized patients

Adjusted analysis for the association between Respiratory Film Array Results and Days of Therapy among patients discharged from the ED

Conclusion
Among inpatients, RFA results did not impact DOT, and in this group, antibiotic use was driven by urine cultures. In contrast, among patients discharged from the ED, a non-influenza virus or a negative RFA was associated with much higher rates of DOT. Our results suggest that different strategies need deployment in the ED compared to inpatient services in order to guide utilization of rapid molecular tests and antibiotic use.

Disclosures
All Authors: No reported disclosures
1330. Development of a Pediatric Emergency Department (ED) Uropathogen Antibiogram and Empiric Urinary Tract Infection (UTI) Treatment Algorithm
Authors: Dass Akshith M , Broadbent Eleanor K , Schanz Caitlin , Louden Nicole , Hansen Lizbeth , Hirsch Elizabeth B , Boeser Kimberly D , Norton Laura E 
Published: January 2021

Abstract

Background
Antimicrobial Stewardship efforts in adult ED settings lead to improved patient outcomes and fewer adverse events. However, there are limited data on incorporation of multiple interventions to assist with empiric and definitive antibiotic therapy selection, particularly in the pediatric ED setting. The purpose of this project was to create an antibiogram and empiric UTI treatment algorithm for use in a pediatric ED.

Methods
This is a multi-phase program implementation in a pediatric ED. Patients aged 2 months -18 years presenting to the ED between January to December 2018 with an ICD10 code for cystitis or pyelonephritis and collection of urine culture were included. Patients were excluded if they were admitted to an inpatient unit or they had a polymicrobial urine culture result. The antibiogram was prepared by including the first isolate of a species from each patient in the given time frame using Clinical and Laboratory Standards Institute recommendations.

Results
A total of 145 unique patients with 160 ED encounters were included in phase I of the project. Median patient age was 5 years (IQR 1.4-8). Discharge diagnosis for 75% of the 160 ED encounters was pyelonephritis. Urogenital flora was cultured from 19.4% of cultures and 21.2% of cultures were without any growth. The most common pathogen isolated was E. coli (39.4%). For ages 2 months – 18 years, susceptibility of urinary E. coli isolates was 95.5% for nitrofurantoin, 92.5% each for ceftriaxone and ciprofloxacin, and 85.1% for cefazolin. Cefdinir and cephalexin were the empiric antibiotics prescribed on discharge 76.3% of the time. After consideration of factors such as antimicrobial stewardship and spectrum of activity, cephalexin was chosen as the treatment of choice for the 2 months – 11 years age group. For children ≥ 12 years, nitrofurantoin was selected as preferred treatment for uncomplicated cystitis while cephalexin was selected as preferred treatment for pyelonephritis.
M Health Fairview University of Minnesota Masonic Childrens ED 2018 E coli isolate antibiogram

Conclusion
An empiric UTI treatment algorithm incorporating local antimicrobial susceptibility pattern alongside recommendations from national organizations was created. Phase II of the project will evaluate the implementation of the algorithm to determine its impact on readmission rates and antibiotic/pathogen mismatch.

Disclosures
Elizabeth B. Hirsch, PharmD, Merck (Grant/Research Support)Nabriva Therapeutics (Advisor or Review Panel member)
1334. A Qualitative Assessment of Drivers of Antimicrobial Prescribing for Pediatric Patients in Diverse Ambulatory Settings
Authors: Spencer Hillary , Katz Sophie E , Audet Carolyn , Banerjee Ritu , Banerjee Ritu 
Published: January 2021

Abstract

Background
Antimicrobial prescribing rates vary across ambulatory settings and provider types. We sought to identify and compare non-clinical drivers of antimicrobial prescribing for children across diverse outpatient settings.

Methods
We recruited physicians and advanced practice providers (APPs) working in primary care, urgent care (walk-in and pediatric after-hours clinics), and retail health clinics affiliated with Vanderbilt University Medical Center (Table 1). We conducted in-person or telephone interviews using an interview guide created through an iterative process of literature review and sequential pilot testing with residents and administrators from included settings. All interviews were recorded and transcribed verbatim. Analysis is ongoing using inductive methods. The study was IRB approved with a waiver of consent.

Results
Among the 38 providers interviewed to date, 22 (58%) were APPs. Twenty-eight (74%) interviews were conducted by telephone. In a closed-ended question, most providers (82%) identified “guideline recommended” as the primary factor informing their prescribing decisions. Providers perceived that guideline concordant care was determined by a complex interaction of patient, provider, and setting factors (Figure). A major theme identified by providers was that standardized antibiotic prescribing practices within each clinic setting and the larger community was perceived to inform parental expectations. Additionally, shaping parental expectations in a way that aligns with guidelines is a process that happens over time rather than being a one-time event. (Figure, Table 2)

Conclusion
In all outpatient settings, providers caring for children cited clinical guidelines as the most important factor influencing antibiotic prescribing. Providers felt that adherence to guidelines had downstream benefits including standardization of prescribing practices which may shape parental expectations in a way that aligns with guidelines, thus facilitating guideline-concordant care in future encounters. These findings can inform design of outpatient stewardship interventions. Additional provider recruitment and analysis by provider and setting type is ongoing.

Disclosures
Hillary Spencer, MD, MPH, NIH (T32 grant support) (Grant/Research Support)
1338. Analysis of Prescription Guideline Adherence in Pediatric Outpatient Pneumonia Treatment
Authors: Heck Carly , Martin Judith , Kurs-Lasky Marcia 
Published: January 2021

Abstract

Background
Background: Antibiotic resistance is a major public health concern. A modifiable intervention is outpatient antibiotic stewardship. The goal of this study was to review the electronic health records (EHR) of children diagnosed with community acquired pneumonia (CAP) to compare patients who received non-guideline concordant therapy with those prescribed recommended therapy.

Methods
Methods: This was a retrospective chart review of 300 children (6 months to 6 years old) with an outpatient diagnosis of CAP between July 2017 and June 2019. 45 Children’s Hospital of Pittsburgh (CHP) and UPMC Children’s Community Pediatrics (CCP) practices were included. CHP practices are academic-based with trainees involved in visits, while CCP practices do not include trainees. First-line recommended therapy was defined as amoxicillin, second-line therapy as azithromycin or amoxicillin-clavulanate, and all other prescriptions were defined as other. Patients prescribed first-line therapy were compared to patients with second-line therapy or other. If first-line therapy was not prescribed, the EHR was manually reviewed for justification. If drug allergy was listed, the medication allergy and type of reaction were recorded.

Results
Results: In this study the minority of children (43%) were prescribed first-line therapy. This group was younger (57 vs. 63 months of age), more likely to be Non-white (80%), and seen at the CHP locations than those prescribed non-guideline concordant therapy. The average symptom duration was shorter, heart rate and respiratory rate were higher and the presence of fever was more common in the first-line therapy group. Justification for non-guideline therapy was most often reported as to provide coverage for atypical organisms. The most common drug allergy recorded was amoxicillin, and urticaria with unknown timing was the most common type of reaction.
Demographics

Comparison Results

Justification for Second-line / Other Therapy and Drug Allergy Results

Conclusion
This project observed a high proportion of children being prescribed non-guideline concordant therapy for a diagnosis of CAP. Age, race, practice location, and severity of illness measures showed a statistically significant difference between groups. This study highlights the importance of education which reviews the current guidelines and the most likely pathogens for children with CAP.

Disclosures
All Authors: No reported disclosures
1341. Blood Volume Collected for Blood Cultures in Infants with Suspected Neonatal Sepsis in the NICU
Authors: Altez Maria S Rueda , Soghier Lamia , Campos Joseph M , Bost James , Gai Jiaxiang , Hamdy Rana F 
Published: January 2021

Abstract

Background
Blood cultures have high sensitivity to detect bacteremia in septic neonates when &gt;=1 ml of blood is collected. Neonatologists often cite low confidence in microbiologic sampling as rationale for continuing antibiotics without a focus of infection despite negative blood cultures, resulting in prolonged antimicrobial therapy. We aim to describe the blood culture sample volumes in NICU patients, to identify factors associated with sample volumes &lt; 1ml, and to compare the sample volumes of patients treated for culture-negative sepsis with those with bloodstream infections and those treated for a ≤72-hour sepsis rule-out

Methods
Data from this observational cohort study were collected retrospectively and prospectively from NICU patients with blood cultures obtained from September 2018 to February 2019. Clinical data were collected through chart review. All inoculated culture bottles were weighed for volume calculation. We determined the association of age, weight, sample source, and time of collection with volume &lt; 1mL. Continuous variables were analyzed using Wilcoxon-Mann-Whitney, and categorical variables using chi-squared test. For aim 3, the volumes of the groups were compared using analysis of variance.

Results
A total of 310 blood cultures were identified, corresponding to 159 patients. Of these, 49 (16%) were positive. Among the negative blood cultures, 86% were collected in patients who subsequently received antibiotics (Figure 1). Median inoculated volume was 0.6 ml (IQR: 0.1-2.4). Weight and age at time of culture collection, source of sample, and time of collection were not significantly associated with the inoculation of &lt; 1ml of blood. Median volume of blood was 0.6ml (0.3-0.6) for sepsis rule-out, 0.6ml (0.2-0.6) for bloodstream infection, and 0.6ml (0.6-1.4) for culture-negative sepsis. No difference was found among the three groups (p=0.54)
Figure 1. Classification of blood cultures identified during study period

Conclusion
The blood volume collected for cultures in the NICU is lower than recommended. Clinical and environmental characteristics are not significantly associated with the inoculated volume. The volume of blood sampled does not differ in patients with culture-negative sepsis, bloodstream infection and sepsis rule-out, and should not be a justification for longer duration of antibiotic therapy

Disclosures
All Authors: No reported disclosures
1343. Clinical Outcome of Penicillin Skin Testing as an Antimicrobial Stewardship Initiative in the pre-surgical clinic in a community hospital
Authors: rahbani peggy , Monroe-Duprey Laura 
Published: January 2021

Abstract

Background
Penicillin (PCN) allergy is a serious adverse reaction that prevents use of first line therapy. 10% of the population reports a PCN allergy, however less than 1% is truly allergic. Elimination of false allergies significantly impacts patient’s lives and decreases antimicrobial resistance and cost. Penicillin Skin Testing (PST) is a tool to support antimicrobial stewardship (ASP) and to optimize allergy de-labeling. The goal of this pilot study was to implement a pharmacy-nurse driven PST service in the outpatient pre-surgical clinic in a community hospital and to assess the impact of PST on the usage of vancomycin as the pre-op prophylaxis agent.

Methods
In May 2019 a single-center, prospective pilot in the outpatient clinic for pre-surgical adult patients with a documented PCN allergy was approved. Patients were identified via a PCN allergy report, generated from the electronic medical record and interviewed by the ASP pharmacist to identify the type of reaction. The study excluded patients if they were unable to give informed consent, if they took anti-histamines within 72 hours of the test, or if the allergy is clinically insignificant. The nurse administered the test and the ASP pharmacist read the results, documented them in the system, and counseled patients.

Results
A total of 155 patients with PCN allergy qualified for PST and only one patient had a true allergy. 154 patients had a negative test and their allergy was deleted in their electronic health system. In addition, those patients received cefazolin as the antibiotic of choice before their surgery which is narrower spectrum and has less side effects compared to vancomycin. Furthermore, all patients were counseled and acknowledged the impact of the results. After performing PST there was an overall 39% decrease in vancomycin DOT/1000 in the surgical population (2018 May-Dec Average DOT/1000 patient Days=3.75 vs 2019 May-Dec Average DOT/1000 patient Days=2.3. (p &lt; 0.005))

Conclusion
The PST service offers an efficient method to collect a detailed PCN allergy history and de-label patients accordingly. PST helps reduce the pre-surgical prophylaxis use of broad spectrum agents and allergy testing significantly increases patient satisfaction

Disclosures
All Authors: No reported disclosures
108. Impact of Accelerate Pheno System in the Management of Gram-Negative Rod Bacteremia
Authors: Ganapathiraju Iaswarya , Bushman Amanda , Espinoza Rossana Rosa 
Published: January 2021

Abstract

Background
Early pathogen identification and initiation of appropriate antimicrobial therapy is key in the management of Gram-negative rods (GNR) bloodstream infection (BSI). The Accelerate Pheno System (ACC) has been shown to reduce time to GNR identification compared to traditional culture-based methods. We aimed to determine the impact of ACC on the management of GNR BSI in the setting of a well-established antimicrobial stewardship program (ASP).
Table 1

Methods
ACC was introduced in our institution on February 2019. Due to issues incorporating ACC, of patients with GNR BSI, 74% had ACC done and 26% had reporting through traditional methods. This allowed for the design of a retrospective cohort study (instead of a pre-post analysis) to evaluate the association of interest. We included adult patients admitted to three affiliated hospitals in Des Moines, Iowa with BSI due to Enterobacteriales from February 2019 to February 2020. Exclusion criteria were Emergency Department visit only and death within 48 hours of blood culture collection. Primary outcomes were length of hospital stay, days to therapy optimization and in-hospital mortality. Continuous variables were compared by non-parametric methods and categorical variables were compared by Chi-square and Fisher-exact test. Logistic regression models were used to calculate odds ratio for the impact of the intervention on therapy optimization.

Results
A total of 268 patients were analyzed. The median length of stay among patients who had ACC done was 5.2 days (IQR 3.6–8.7) and in those on who ACC was not done it was 5.5 (IQR 3.8–8.9) (p=0.54). No differences in in-hospital mortality were found (p=0.942).
Changes in therapy and missed opportunities for optimization according to whether ACC was done are shown in Table 1. Patients who had ACC done had 99% higher odds of de-escalation within 48 hours of blood culture collection compared to patients who did not have it done (95% CI 1.01–3.92; p=0.044).

Conclusion
In the context of hospitals with baseline short length of stay and a well-established ASP, performing ACC was associated with higher odds of de-escalation within 48 hours of blood culture collection but did not impact length of stay or mortality among patients hospitalized with GNR BSI.

Disclosures
All Authors: No reported disclosures