bluuebunny/crossref_metadata_2025_split huggingface dataset:
2008. Outcomes of Patients with Positive Procalcitonin Levels Who Do Not Receive Continued Antibiotics
Authors: George Jamie , Kale-Pradhan Pramodini , Johnson Leonard B 
Published: October 2019

Abstract

Background
Procalcitonin (PCT) is a biomarker used to direct continued use of antibiotic therapy in patients with sepsis and community-acquired pneumonia. There is a lack of data on outcomes of patients with a positive PCT who do not receive continued antibiotics. We compared outcomes in patients with positive PCT levels who received antibiotics <24 hours to those who received ≥ 24 hours.

Methods
A single-center, retrospective study to compare outcomes of adult patients with positive PCT (>0.25 μg/L) levels based on antibiotic duration. A report of hospitalized patients from January to June 2018 was generated and screened for inclusion criteria. Data collection included demographics, microbiologic data, Charlson Weighted Index of Comorbidity (CWIC), ICU admission, length-of-stay (LOS), and in-hospital mortality. Continuous and categorical variables were analyzed using Student’s t-test and Chi-square, respectively.

Results
443 of 998 patients met the inclusion criteria. 113 patients (25.5%) received <24 hours of antibiotics (Group 1) and 330 patients (74.5%) received ≥ 24 hours (Group 2). Group 1 had a higher CWIC, lower mean PCT and were less likely to have positive cultures (see table). Mean LOS was significantly different between the groups. ICU admission and mortality were not found to be different between the groups. While Group 1 had higher rates of noninfectious causes of mortality and Group 2 had higher rates of infectious, the differences were not significant. Among patients who died in-hospital, 47.6% vs. 63.2% had acute or chronic renal failure in Group 1 vs. Group 2, respectively.

Conclusion
Patients with elevated PCT levels are a heterogenous group. There was no overall difference in mortality between the two groups indicating that the interpretation of positive PCT results was overall appropriate in this study. Clinicians need to consider noninfectious causes of elevated PCT when evaluating patients.

Disclosures
All authors: No reported disclosures.
2019. Multicentric Antimicrobial Point Prevalence Survey in Four Tertiary Care Hospitals in Southern India
Authors: Prakash Shilpa , Wilson Arun , Warrier Anup R , Babu Rachana , Joy Sonya , Rathish Balram 
Published: October 2019

Abstract

Background
Antibiotic consumption data are scarce in the subcontinent. Defined Daily Doses (Doses) and Days of Therapy (DOT)-based metrics both have inherent disadvantages limiting their application in resource-limited settings primarily in terms of resource hours.. Point Prevalence Study (PPS) offers an offer an initial feasible step for describing antimicrobial use and identifying targets to reduce inappropriate use. Aim of the present study was to use PPS to identify quantitative and qualitative aspects of antimicrobial consumption.

Methods
A cross-sectional hospital-based PPS was conducted in 4 tertiary care hospitals—Aster Medcity (Kochi, Kerala), Aster MIMS (Calicut, Kerala), Aster Ramesh (Guntur, Andhra Pradesh), and Aster CMI (Bengaluru, Karnataka)—based on a standardized format derived from the GLOBAL-PPS initiative and WHO resources.

Results
The total number of patients surveyed was 944.42.7% patients had a standing antibiotic order, out of which 19.80%patients were receiving reserve antimicrobials (WHO classification). 76.23% of prescriptions were used empirically, 16.08% were used as prophylaxis meanwhile 7.67% had a culture-based indication. The overall DOT (per 1000 patient-days) for all antimicrobials in the 4 centers were 86.54, 64.19, 93.71 and 85.93 respectively with a cumulative mean DOT of 82.59. Reserve antimicrobials DOT were 26.28, 14.83, 28.08 and 19.61, respectively, with a mean of 22.2. The most common class of antimicrobial prescribed was β lactam -β lactamase inhibitors (BL/BLI) 27.3% while Carbapenems (8.16%) was the most common amongst reserve antimicrobials. Out of all the prescriptions only 7.67% had indications documented. Documented errors of dosing were seen in 8 patients. Adherence to monitoring for ADE was done in 92.57%.

Conclusion
The study reveals antibiotic use in almost 40% of patients under survey with a DOT of 82.59 per 1000 patient-days. Improving empirical use of antimicrobials, BL/BLI focused intervention and improved documentation has been identified as potential areas for intervention based on this study.The study also highlights the scope of PPS as an effective tool in resource-limited setting to define and refine antimicrobial use and contribute toward antimicrobial stewardship as well as other activities aimed reducing antimicrobial resistance across a range of settings.

Disclosures
All authors: No reported disclosures.
2021. Comparison of Patterns of National Oral Antibiotic Use Between All Dentists and Medical Doctors in Japan in 2016 Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB)
Authors: Ishikane Masahiro , Tanaka Chika , Kusama Yoshiki , Tsuzuki Shinya , Muraki Yuichi , Yamasaki Daisuke , Tanabe Masaki , Ohmagari Norio 
Published: October 2019

Abstract

Background
Antimicrobial resistance (AMR) is a global threat for both dentists and medical doctors. The Japanese national action plan on AMR targets a 50% reduction in the use of oral broad-spectrum antimicrobials by 2020 compared with its use in 2013. However, no study has compared the pattern of oral antimicrobial use (AMU) in outpatient settings between all dentists and medical doctors in Japan using the national database of health insurance claims and specific health checkups (NDB).

Methods
Data of oral AMU in outpatient settings prescribed by both all dentists (n = 104,533) and medical doctors (n = 319,480) in Japan in 2016 were evaluated using NDB collected by the Ministry of Health, Labor and Welfare of Japan; the data accounted for 98% of the total claim data in Japan. Antimicrobials were classified by the World Health Organization (WHO) defined Anatomical Therapeutic Chemicals Classification. WHO measures the number of AMU using defined daily dose per 1,000 inhabitant-days (DIDs).
The pattern of oral AMU between all dentists and medical doctors in Japan in 2016 was compared.

Results
The values of oral AMU in outpatient settings among all dentists (n = 104,533) and medical doctors (n = 319,480) in Japan were 1.20 and 12.11, respectively. The proportions of AMU among dentists were cephalosporins, 65.1%; macrolides, 18.9%; quinolones, 5.5%; and penicillin, 8.7%. In contrast, the proportions of AMU among medical doctors were cephalosporins, 23.1%; macrolides, 36.9%; quinolones, 22.2%; and penicillin, 8.1%. There were differences in the pattern of oral AMU between dentists and medical doctors (P < 0.001) (Table 1).

Conclusion
Although the value of total oral AMU among dentists was 9.9% of medical doctors, the proportion of cephalosporin use, which was thought to be inappropriate prescribing, was higher among dentists than among medical doctors. Further studies that are adjusted to patients’ characteristics are needed.

Disclosures
All authors: No reported disclosures.
2039. Antibiotic Stewardship in Burn and Chronic Wound Centers in Nepal
Authors: Nauriyal Varidhi , Dhoj. Joshi Rajesh , Raj Poudel Suresh , Banstola Laxman , Joshi Anip , Acharya Arjun , Bahadur Thapa Buddhi , Shrestha Basudha , Maki Gina , Shakya Malika , Man. Joshi Nilesh , Karki Kshitij , Bajracharya Deepak , Gudipati Smitha , Zervos Marcus , Kaljee Linda , Prentiss Tyler , Rai Shankar 
Published: October 2019

Abstract

Background
Data surrounding antibiotic stewardship (AMS) in burn and chronic wound centers in low- and middle-income countries (LMIC) are limited. Given the long-term nature of the wounds, increased risk of infection and the potential for further infections being treated with antibiotics, burn and chronic wound centers represent a unique opportunity for antimicrobial stewardship.

Methods
Three hospitals that maintain long-term burn or chronic wound wards were selected in two regions in Nepal. A post-prescription review and feedback program (PPRF) was instituted in these departments, and locally salient antibiotic practice guidelines were developed based on international and local standards by the research team and local experts. Chosen physicians at each facility were trained as master physician champions. Champions subsequently trained physicians in their wards and ensured that guidelines were followed by prescribing physicians. Baseline and post-intervention phases covered 5 months each during 2018–2019. During the post-intervention phase, physician champions reviewed antimicrobial use at 72 hours and made one of the three recommendations if the antibiotic course was deemed unjustified: changing the antibiotic, stopping the antibiotic course, or de-escalation of the antibiotic.

Results
482 patients were enrolled throughout the duration of the study, with 241 patients in each of the baseline and post-intervention periods. The average length of stay was 8.0 days in baseline (range 3–48 days) vs. 6.4 days (range 3–70 days) during post-intervention. Between baseline and post-intervention, IV antibiotics decreased from 1,161 antibiotic-days per 1,000 patient-days (PD/1,000) to 1,137 PD/1,000. Oral antibiotics decreased from 101 PD/1,000 to 77 PD/1,000. In addition, cephalosporins decreased from 526 PD/1,000 to 474 PD/1,000, and aminoglycosides decreased from 264 PD/1,000 to 117 PD/1,000.

Conclusion
Appropriate antimicrobial use is vital in patients with a long length of stays in the hospital to reduce the development of multi-drug-resistant organisms. This intervention showed that a post-prescription review and feedback model can have impact in chronic wound and burn centers in Nepal and be further adapted for use in other LMIC.

Disclosures
All authors: No reported disclosures.
2064. Applying Human Factors and Ergonomics to Inform a Successful Fluoroquinolone Restriction Intervention: A Mixed Methods Pilot Study
Authors: Tischendorf Jessica , Brunner Matthew , Schulz Lucas , Barker Anna K , Lepak Alexander , Lepak Alexander , Knobloch Mary J , Wright Marc-Oliver , Safdar Nasia 
Published: October 2019

Abstract

Background
Antimicrobial stewardship programs (ASPs) can reduce the incidence of hospital-onset Clostridioides difficile infection (HO-CDI) by limiting unnecessary exposure to high-risk antibiotics, including fluoroquinolones (FQ). However, restriction policies are challenging to implement and sustain. In a mixed methods study, we explored the barriers, facilitators and efficacy of an FQ restriction policy to reduce HO-CDIs among high-risk patients.

Methods
Our ASP instituted a pilot FQ restriction policy in our ICU and solid-organ transplant wards. We evaluated 24 months of pre- and post-intervention data, including: FQ and alternative agent use, length of stay (LOS), readmission rate, mortality and HO-CDI. We conducted 12 semi-structured interviews with front-line providers, applying the Systems Engineering Initiative for Patient Safety framework to examine perceptions of FQ use, prescribing indications, perceived relationships between FQ use and HO-CDI, and barriers imposed by FQ restrictions. Time-series analysis was performed to evaluate FQ and HO-CDI data.

Results
FQ use decreased from an average of 111.6 days of therapy (DOT) per 1,000 patient-days pre-intervention to 19.8 DOT/1,000 patient-days (P < 0.0001). Average readmission rate, LOS on pilot units, total antibiotic use, and use of cefepime decreased after FQ restriction. Conversely, use of ceftriaxone, aminoglycosides and piperacillin–tazobactam all increased. The average HO-CDI rate was significantly lower post-intervention, although time series analysis showed a post-intervention increase in the trend in infection rate compared with the pre-intervention trend. Qualitative analysis of interviews revealed β-lactam allergy and pending discharge were barriers to FQ restriction; a patient’s history of CDI and pharmacist involvement in antimicrobial decision-making facilitated FQ restriction.

Conclusion
An FQ restriction policy significantly decreased FQ use without adversely affecting readmission rate, LOS or mortality. Knowledge of barriers and facilitators to FQ use optimization among front-line staff can inform future successful ASP interventions. Further investigation into the effect of FQ restriction on HO-CDI is needed.

Disclosures
Alexander Lepak, MD, Paratek Pharmaceuticals: Research Grant; Tetraphase Pharmaceuticals: Research Grant.
2069. A Unique Approach to Outpatient Antibiotic Stewardship in Rural Southern Ohio
Authors: Ramey Lara K , Byers David K , DeLille Eli 
Published: October 2019

Abstract

Background
A five county rural community in southern Ohio was identified as having significantly higher than average rates of antibiotic use. The hospital system serving this area, Southern Ohio Medical Center (SOMC), began initial efforts in antimicrobial stewardship focusing on inpatient prescribing. However, most antimicrobial consumption occurs in the outpatient setting. Early attempts to improve antibiotic prescribing focused on only provider education and resulted in little change. Providers felt they were performing well, or their patients were more complex and prescribing the antibiotics was warranted. SOMC partnered with the state Quality Improvement Organization, HSAG, to design an intervention to address these challenges.

Methods
All outpatient and emergency room encounters with acute bronchitis and upper respiratory infection (URI) (ICD-10 codes [J00, J06.9, and J20.X]) were included in the analysis. Using criteria from a National Quality Forum measure, concomitant diagnoses were excluded to identify encounters where an associated condition may indicate the case is more complex. A 6-month baseline and two additional 6-month remeasurement periods were analyzed. Providers were given letters, peer-to-peer antimicrobial data comparison, and in-person feedback with guideline-driven recommendations for these conditions.

Results
Baseline analysis indicated 50% of all encounters without a coded concomitant diagnosis resulted in antibiotic prescriptions. There was a reduction in the overall rate at each remeasurement period, to 34% and then 12%. This resulted in a 76% relative improvement rate (RIR) overall at the final remeasurement period. At baseline, the highest volume setting, urgent care, had a prescribing rate of 71%. Urgent-care prescriptions reduced each remeasurement to 45% and 13%, resulting in an 81% RIR.

Conclusion
Implementing a robust outpatient stewardship program in a rural nonacademic setting is not without unique challenges. By using peer comparison of provider performance data on prescribing habits in uncomplicated patients with URI and acute bronchitis in addition to education, the rate of appropriate antibiotic use improved.

Disclosures
All authors: No reported disclosures.
2075. Transforming Outpatient Antimicrobial Stewardship Through a Clinical Surveillance System
Authors: Portman David B , Pattison Victoria M 
Published: October 2019

Abstract

Background
Multiple studies have highlighted the predominance of inappropriate antibiotic prescribing in the outpatient setting, thus making an area ripe for antimicrobial stewardship interventions. One way to identify intervention opportunities and monitor performance metrics is through utilization of a clinical surveillance system (CSS).

Methods
In October 2017, TheraDoc (DSS Inc.) was obtained which serves as a CSS. Upon installation, the antimicrobial stewardship committee designed the alerts found in Figure 1 that would be utilized to identify potential interventions. Alerts that were deemed to be of high value or time sensitive were to be emailed to pharmacists involved with antimicrobial stewardship. It was theorized that this method would help transform outpatient antimicrobial stewardship from a predominately retrospective approach, to a prospective approach. Outpatient stewardship metrics were compared for pre- and post-CSS implementation to evaluate the impact of a CSS. The pre-implementation group (PreCSS) represented outpatient stewardship interventions that occurred January 2017 through June 2017 where all antibiotic prescriptions were reviewed. The post-implementation group (PostCSS) represented outpatient stewardship interventions that occurred April 2018 through September 2018 which were predominantly driven by CSS alerts.

Results
The PostCSS group had substantially fewer charts reviewed compared with the PreCSS group (267 vs. 1,415). In addition, the PostCSS group completed 77.6% more interventions compared with the PreCSS group (87 vs. 49). Thirty-one less charts were reviewed per one intervention, which led to 469 less minutes of chart review per one intervention. See Figure 2 for list of interventions. The PostCSS group received a significant increase in consults due to the direct approach to interventions compared with the PreCSS group (45 vs. 11).

Conclusion
The use of a clinical surveillance system has demonstrated an efficient way to transition outpatient antimicrobial stewardship to a prospective, interventional approach.

Disclosures
All authors: No reported disclosures.
2109. Liposomal Amphotericin B-associated Nephrotoxicity in Obese and Non-obese Patients
Authors: Tritle Brandon , Peterson Logan , Olson Jared , Benefield Emily , Cariello Paloma F , Benefield Russell J 
Published: October 2019

Abstract

Background
Liposomal amphotericin B (L-amb) is an important antifungal agent which exhibits significant rates of dose-dependent nephrotoxicity. Animal studies demonstrate only small amounts of L-amb distribute into adipose tissue and obese animals show greater risk of nephrotoxicity with L-amb administration. This study aims to determine whether obese patients are at a higher risk of nephrotoxicity with weight-based doses of L-amb.

Methods
We performed a multi-center, retrospective cohort study of nephrotoxicity with L-amb in obese (BMI > 30) and non-obese adult patients at University of Utah Health and Intermountain Healthcare from January 1, 2014 through December 31, 2018. Our primary outcome was the rate of nephrotoxicity as determined by AKIN criteria. Patients receiving at least one dose of L-amb were identified for inclusion. Patients were excluded if they were already on a renal replacement at the time of L-amb initiation or they received L-amb prior to admission.

Results
We included 221 patients, 47 (21%) were obese and 174 (79%) were non-obese. Median total body weight was 109 kg in obese patients compared with 70 kg in non-obese patients. Dosage based on ideal body weight was higher in the obese group (median 6.9 mg/kg vs. 4.9 mg/kg). Obese patients were significantly more likely to experience acute kidney injury (AKI) than non-obese patients (55% vs. 37%, P = 0.03). Patients who experienced nephrotoxicity received a higher average daily dose than those who did not (365 mg vs. 333 mg, P = 0.03), had a higher median cumulative dose (3,130 mg vs. 1,700 mg, P < 0.001), and had a higher median total body weight (79.6 kg vs. 71.9 kg, P = 0.04.). Additionally, daily dose normalized to total body weight was not associated with AKI (median 4.7 mg/kg in patients with AKI vs. 4.8 mg/kg in patients without AKI, P = 0.86). However, daily dose normalized to ideal body weight was associated with AKI (median 5.5 mg/kg in patients with AKI vs. 4.9 mg/kg in patients without AKI, P = 0.02).

Conclusion
We identified a higher rate of nephrotoxicity among obese patients receiving L-amb compared with non-obese patients. These data suggest that dosing L-amb based on total body weight places obese patients at a higher risk of nephrotoxicity. This should be considered when assessing the risks and benefits of this dosing strategy in obese patients.

Disclosures
All authors: No reported disclosures.
2131. Multicenter Evaluation of Meropenem/Vaborbactam MIC Results for Enterobacteriaceae Using MicroScan Dried Gram-Negative MIC Panels
Authors: Garner Omai , Traczewski Maria M , Beasley Denise , Harrington Amanda , DesJarlais Sharon , Hastey Christine , Brookman Regina , Lockett Zabrina , Chau Jennifer , Zimmer Barbara 
Published: October 2019

Abstract

Background
A multicenter study was performed to evaluate the accuracy of meropenem/vaborbactam on a MicroScan Dried Gram-negative MIC (MSDGN) Panel when compared with a frozen CLSI broth microdilution reference panel.

Methods
For efficacy, an evaluation was conducted at three US sites by comparing MIC values obtained using the MSDGN to MICs using a CLSI broth microdilution reference panel. A total of 560 Enterobacteriaceae clinical isolates were tested using the turbidity and Prompt®* methods of inoculation. For challenge, 95 Enterobacteriaceae isolates were tested on MSDGN panels at one site. For reproducibility, a subset of 14 organisms was tested on MSDGN panels at each site. MSDGN panels were incubated at 35 ± 2°C and read on the WalkAway System, the autoSCAN-4 instrument, and read visually. Read times for the MSDGN panels were at 16–20 hours. Frozen reference panels, prepared according to CLSI/ISO methodology, were inoculated using the turbidity inoculation method. All frozen reference panels were incubated at 35 ± 2°C and read visually. Frozen reference panels were read at 16–20 hours. FDA/CLSI breakpoints (µg/ml) used for interpretation of MIC results were: Enterobacteriaceae ≤ 4/8 S, 8/8 I, and ≥ 16/8 R.

Results
When compared with frozen reference panel results, essential and categorical agreements for isolates tested in the Efficacy and Challenge are as follows (see table). Reproducibility among the three sites were greater than 95% for all read methods for both the turbidity and Prompt* inoculation methods.

Conclusion
This multicenter study showed that meropenem/vaborbactam MIC results for Enterobacteriaceae obtained with the MSDGN panel correlate well with MICs obtained using frozen reference panels using FDA/CLSI interpretive criteria. * PROMPT® is a registered trademark of 3M Company, St. Paul, MN, USA. Beckman Coulter, the stylized logo and the Beckman Coulter product and service marks mentioned herein are trademarks or registered trademarks of Beckman Coulter, Inc. in the United States and other countries. Vabomere® (Meropenem/Vaborbactam) is a registered trademark of Melinta Therapeutics, Inc.

Disclosures
All authors: No reported disclosures.