bluuebunny/crossref_metadata_2025_split huggingface dataset:
221. Comparison of dental antibiotic prescribing between Australia, England, the United States and British Columbia in 2017
Authors: Teoh Leanne , Thompson Wendy , Hubbard Colin , Patrick David M , Marra Fawziah , Mamun Abdullah A , Campbell Allen , Suda Katie 
Published: January 2021

Abstract

Background
Antibiotic resistance is recognised as a major public health burden. Dentists overprescribe antibiotics and prescribe for unnecessary indications. Tracking and investigating prescribing practices by healthcare professionals provides insights needed to inform targeted antibiotic stewardship interventions. It is unclear how dental antibiotic prescribing patterns differs between countries. The aim of this study was to compare antibiotic prescribing by dentists in Australia, England the United States (US) and British Columbia (BC).

Methods
This was a cross-sectional study of dispensed dental antibiotic prescriptions between January 1 and December 31, 2017, from Australia, England, US and BC. Dispensed dental antibiotic prescriptions included those from outpatient pharmacies and healthcare settings. Outcome measures included the proportion of dental antibiotic prescriptions by location and prescribing rates by population.

Results
English dentists prescribed 1.6 times more antibiotics than those in Australia, and dentists in BC and US prescribed around twice more than Australian dentists. (Australia: 33.2 prescriptions/1000population; England: 53.5 prescriptions/1000population; US: 72.6 prescriptions/1000 population; BC: 65.0 prescriptions/1000 population). The types of antibiotics prescribed were similar across all countries, where penicillins were the predominant class prescribed (66.8–80.5% of antibiotic prescriptions). US dentists and dentists in BC prescribed more clindamycin compared to the dentists in other countries.

Conclusion
Dentists in the US, England and BC prescribed at relatively higher rates than Australian dentists. The findings from this study should initiate an evaluation by dentists of their prescribing practices and responsibilities regarding their contribution towards antibiotic resistance. Further investigations can be aimed at determining country-specific factors that influence dental antibiotic prescription.

Disclosures
Leanne Teoh, BDSc(Hons) BPharm(Hons), Australian Government Research Training Program Scholarship (Other Financial or Material Support, Scholarship awarded for the PhD candidature)
222. Comparison of Outpatient Antibiotic Prescriptions in a High Prescribing State, 2016–2018
Authors: Evans Christopher D , Ouedraogo Youssoufou , Keaton Amelia , Staub Milner 
Published: January 2021

Abstract

Background
About 80% of antibiotic prescriptions are written in outpatient settings. Outpatient antibiotic use (AU) is highest in the Southern United States. Tennessee consistently has one of the highest AU rates in the country. Previous analyses found that 1,195 prescriptions were filled in Tennessee per 1,000 total population in 2016. Moreover, 50% of all outpatient antibiotic prescriptions were written by 9.3% of prescribers. We sought to assess Tennessee outpatient antibiotic prescribing trends, comparing 2016 with 2018 data.

Methods
The Tennessee IQVIA outpatient antibiotic prescription dataset from January 1 to December 31, 2018 was analyzed and compared to 2016 results. Orally administered antibacterial agents were included. Patients &lt; 20 years old were classified as pediatric. County level population data were obtained from the Tennessee Department of Health. Antibiotic prescription rates were calculated as antibiotics prescribed per 1,000 population in the specified age group. Analysis was performed using SAS 9.4.

Results
The statewide AU rate decreased from 1,195 in 2016 to 1,074 in 2018 per 1,000 population. Consistent with the previous analysis, female patients (1,288), those over 65 years (1,459), and those &lt; 2 years (1,372) had the highest rates of AU in 2018. Lower rates were observed in all age groups in 2018 except for the 3–9 years group. While narrow penicillins and macrolides remain the most frequently prescribed antibiotics, amoxicillin-clavulanate and ciprofloxacin fell out of the top five antibiotics used in adults, and amoxicillin-clavulanate fell out of the top five antibiotics used in pediatrics. Similar to 2016, 9.2% (3,098) of the providers contributed to 50% of the total prescriptions in 2016, and 2,090 of the 2,994 (69.8%) 2016 highest prescribing providers were also among the highest prescribers in 2018.

Conclusion
Despite a decline in outpatient antibiotic prescription volume, Tennessee remains one of the nation’s highest prescribing states. While a decline in broad spectrum antibiotic prescriptions may indicate a shift to more appropriate usage, these data do not include indication, excluding appropriate use assessment. Identifying and focusing antibiotic stewardship interventions for consistently high prescribers remains a priority for Tennessee.

Disclosures
All Authors: No reported disclosures
225. Evaluating Appropriateness of Antibiotic Prescribing in Pediatric Inpatients
Authors: Ray Michael J , McCracken Caitlin M , Tucker Kendall J , Yu Diana , Underwood Margaret , Wu Erin , Kastelic Kylee , Nolt Dawn , McGregor Jessina C 
Published: January 2021

Abstract

Background
Antibiotic appropriateness is the gold standard for informing antimicrobial stewardship efforts to optimize prescribing. The objectives of this study were to evaluate appropriateness of antibiotics for resistant gram-positive infections in pediatric inpatients and identify factors associated with inappropriate prescribing.

Methods
We included pediatric inpatients between July 2017 and July 2018 where an antibiotic typically used for resistant Gram-positive infections (per NHSN) was administered. We developed an algorithm based on laboratory data and diagnosis codes to categorize each antibiotic day of therapy as appropriate, inappropriate, or indeterminate. If indeterminate, we reviewed charts to assess appropriateness. We calculated total, appropriate, and inappropriate days of therapy (DOT) overall and per patient-day. We evaluated clinical characteristics and indications as potential predictors of inappropriate DOT using Chi-squared or Kruskal-Wallis tests.

Results
Among 591 included encounters, we assessed 708 total antibiotic courses. The algorithm allowed for classification of 422 encounters (71%) and the remaining 171 encounters (29%) were classified using manual record review. The most frequent antibiotics were vancomycin (68%) and clindamycin (29%). Patients received a median of 3 days of gram-positive agent therapy per visit, or 5 per every 10 patient-days. Most common indications for gram-positive therapy were surgical prophylaxis (28% of encounters) and empiric therapy (10%) (Figure 1). Of the 1,754 total days of therapy assessed, 94.8% were ruled appropriate. Thirty-one (4.4%) courses were classified as at least partially inappropriate among 27 unique encounters (4.6%). There was a median of 2 inappropriate days among those with any inappropriate therapy. The reason for inappropriate rulings for empiric or prophylaxis indications was most often “longer than necessary duration,” which was the case for 16 of 21 (76%) occurrences.
Figure 1. Appropriate and Inappropriate Days of Therapy (DOT) by Indication and Antibiotic

Conclusion
Inappropriate antibiotic use for Gram-positive infections was low in our patient population for the agents studied. We identified limiting the duration for patients receiving prophylactic or empiric therapy as a potential stewardship intervention target.

Disclosures
All Authors: No reported disclosures
228. Fluoroquinolone Prescribing for Diabetic Foot Infections following an FDA Drug Safety Communication for Aortic Aneurysm Risk
Authors: Li Catherine , Mercuro Nicholas J , Chapin Ryan , Gold Howard , McCoy Christopher 
Published: January 2021

Abstract

Background
Fluoroquinolones were commonly prescribed for hospitalized patients with diabetic foot infection (DFI) at our institution, included in 69% of empiric antibiotic regimens from 2011–2014. On December 20, 2018, the U.S. Food and Drug Administration (FDA) issued a Drug Safety Communication regarding the risk of aortic aneurysm with fluoroquinolones. The objective of this study was to assess the impact of the FDA Communication on antibiotic prescribing for DFI.

Methods
This was a single-center quasi-experimental study of hospitalized patients initiated on antibiotics for DFI before (February-December 2018) and after (February-December 2019) the 2018 FDA Communication. Patients with concomitant infections or documented beta-lactam or fluoroquinolone allergies were excluded. The primary outcome was inpatient days of fluoroquinolone therapy. Secondary outcomes included days of beta-lactam therapy and Outpatient Parenteral Antibiotic Therapy (OPAT) enrollment. Variables were compared using the Pearson’s chi square, Fisher’s exact, and Mann Whitney U tests, as appropriate. A logistic regression was performed to identify predictors for inpatient receipt of fluoroquinolones.

Results
A total of 198 patients were included. Baseline characteristics were similar between groups (Table 1). After the FDA Communication, the median duration of inpatient fluoroquinolones decreased from 3 [0–5.5] to 0 [0–1] days (p&lt; 0.001). The duration of antipseudomonal beta-lactams increased from 0 [0–2] to 2 [0–6] days (p&lt; 0.001). OPAT enrollment increased from 16.5% to 29.7% (p=0.028), with a corresponding increase in peripherally inserted central catheter placement (15.5% to 25.7%, p=0.074). There was no difference in outpatient fluoroquinolone prescribing over time. Incidence of re-infection, readmission for DFI, and antibiotic adverse events were similar between groups (Table 2).
Table 1

Table 2

Conclusion
Inpatient fluoroquinolone prescribing for DFI decreased significantly following the 2018 FDA Communication, followed by an increase in antipseudomonal beta-lactam use and OPAT enrollment. FDA statements can influence institutional antibiotic prescribing and transitions of care decisions, representing an opportunity for education by Antimicrobial Stewardship programs.

Disclosures
All Authors: No reported disclosures
229. Hospitalists Antimicrobial Scorecard Improves Antibiotic Prescribing at a Community Teaching Hospital
Authors: Sessa Julia , Jacoby Helen , Blain Bruce , Avery Lisa 
Published: January 2021

Abstract

Background
Measuring antimicrobial consumption data is a foundation of antimicrobial stewardship programs. There is data to support antimicrobial scorecard utilization to improve antibiotic use in the outpatient setting. There is a lack of data on the impact of an antimicrobial scorecard for hospitalists. Our objective was to improve antibiotic prescribing amongst the hospitalist service through the development of an antimicrobial scorecard.

Methods
Conducted in a 451-bed teaching hospital amongst 22 full time hospitalists. The antimicrobial scorecard for 2019 was distributed in two phases. In October 2019, baseline antibiotic prescribing data (January – September 2019) was distributed. In January 2020, a second scorecard was distributed (October – December 2019) to assess the impact of the scorecard. The scorecard distributed via e-mail to physicians included: Antibiotic days of therapy/1,000 patient care days (corrected for attending census), route of antibiotic prescribing (% intravenous (IV) vs % oral (PO)) and percentage of patients prescribed piperacillin-tazobactam (PT) for greater than 3 days. Hospitalists received their data in rank order amongst their peers. Along with the antimicrobial scorecard, recommendations from the antimicrobial stewardship team were included for hospitalists to improve their antibiotic prescribing for these initiatives. Hospitalists demographics (years of practice and gender) were collected. Descriptive statistics were utilized to analyze pre and post data.

Results
Sixteen (16) out of 22 (73%) hospitalists improved their antibiotic prescribing from pre- to post-scorecard (χ 2(1)=3.68, p = 0.055). The median antibiotic days of therapy/1,000 patient care days decreased from 661 pre-scorecard to 618 post-scorecard (p = 0.043). The median PT use greater than 3 days also decreased significantly, from 18% pre-scorecard to 11% post-scorecard (p = 0.0025). There was no change in % of IV antibiotic prescribing and no correlation between years of experience or gender to antibiotic prescribing.

Conclusion
Providing antimicrobial scorecards to our hospitalist service resulted in a significant decrease in antibiotic days of therapy/1,000 patient care days and PT prescribing beyond 3 days.

Disclosures
All Authors: No reported disclosures
230. Impact of 10-day versus 5-day Duration Default on Length of Antibiotic Outpatient Prescriptions from the Emergency Department
Authors: Watts Amber M , Holt Shannon 
Published: January 2021

Abstract

Background
Antimicrobial stewardship programs (ASP) traditionally focus on inpatient care; however there is a growing effort to optimize antibiotic prescribing at transitions of care. Longer than necessary discharge prescriptions increase risk of antimicrobial resistance, C. difficile infection and adverse events. In order to minimize unnecessary antibiotic exposure, the health system updated the electronic medical record (EMR) outpatient antibiotic prescription default from 10 days to 5 days. The objective of this study was to assess the impact of a 10-day versus 5-day EMR antibiotic outpatient prescriptions default on length of therapy for patients discharged from the Emergency Department (ED).

Methods
This is a retrospective, single-system cohort study evaluating ED discharge prescriptions before and after transition from a default duration of 10 days to 5 days. Discharge prescriptions were collected and screened from December 2019 through January 2020 in the control group and March 2020 through April 2020 in the intervention group. Outpatient prescriptions were included for primary diagnoses of urinary tract infection (UTI), community-acquired pneumonia (CAP), skin and soft tissue infections (SSTI), diverticulitis, or dental infections. The primary outcome was the incidence of prescriptions written for a &lt; 5 day duration.

Results
The study included 3060 of 9651 (32%) prescriptions in the control group and 1610 of 4938 (33%) prescriptions in the intervention group. The mean age was 38 years old with 61% female. The most common primary diagnoses were SSTI (n=1633, 35%) and UTI (n=1633, 32%). The mean duration for discharge prescriptions was similar between groups (8.44 vs. 8.30 days). The incidence of outpatient antibiotic prescriptions for &lt; 5 days was not significantly different between groups (10.72% vs 10.56%, p=0.996). There was an improvement in duration of therapy, with more prescriptions &lt; 5 days for SSTI (2.96% vs. 7.64%, p=0.860) and dental infections (3.30% vs. 10.86%, p=0.808).

Conclusion
Implementation of a shorter default duration for antibiotic outpatient prescriptions from the ED did not significantly increase the incidence of prescriptions written for &lt; 5 days. There was an improvement in duration for SSTI and dental infections after implementation.

Disclosures
All Authors: No reported disclosures
235. In outpatient clinics serving Veterans, antibiotic prescriptions precede a minority of antibiotic-associated adverse events
Authors: Wilson Brigid , Bej Taissa A , Banks Richard , Briggs Janet , Song Sunah , Jump Robin , Jump Robin , Perez Federico 
Published: January 2021

Abstract

Background
An estimated 30% of antibiotic prescriptions in outpatient settings may be inappropriate. Antibiotic exposure increases an individual’s risk of Clostridioides difficile infection (CDI) and acquiring drug-resistant pathogens. To quantify the increased risk of CDI and drug-resistant pathogens posed by antibiotics prescribed in outpatient visits, we examined a two-year cohort of patients seen in primary care clinics at VA Community-Based Outpatient Clinics (CBOC) associated with a large VA Medical Center.

Methods
Among patients with an in-person visit at 13 CBOCs in 2018–2019, we examined rates of antibiotic-associated adverse events (AEs), defined as community-onset CDI or acquisition of resistant Gram-negative bacteria (R-GNB), in the 90 days following those visits. For each visit, we used administrative databases to determine if systemic antibiotics were prescribed, if there was an associated infectious diagnosis, and the subsequent occurrence of AEs. We summarized quarterly rates of prescribed antibiotics and AEs, characterized patients with and without AEs, and estimated the risk ratio of AE for an antibiotic prescription.

Results
Following 236,665 primary care visits, we observed 62 and 225 AEs due to CDI and R-GNB, respectively (0.12% combined rate) among 278 patients (5 with both). Patients who developed CDI or R-GNB had a higher Charlson Comorbidity Index (3.6 ± SD 3.0 and 2.68 ± SD 2.7, respectively) compared to those without AEs (0.72 ± SD 1.3; Table). The rate of new antibiotic prescriptions was 4% in visits without and 10% in visits with a subsequent AE, yielding a risk ratio of 2.5 (95% CI: 1.7–3.7). The rates of both antibiotic prescribing and AE were steady over the examined two-year period (Figure).
Table

Figure

Conclusion
Among all patients with a CBOC visit between 2018–2019, an AE, defined as CDI or R-GNB acquisition, was observed following only 0.1% of primary care visits. Among patients who experienced an AE, only 10% of primary care visits preceding those events included a new antibiotic prescription. While this analysis does not address antibiotics during inpatient stays or prescribed by specialty clinics, these findings suggest that among Veterans, outpatient antibiotic exposure may have only a modest contribution to the risk of AE.

Disclosures
Robin Jump, MD, PhD, Accelerate (Grant/Research Support)Merck (Grant/Research Support)Pfizer (Grant/Research Support, Advisor or Review Panel member)Roche (Advisor or Review Panel member) Federico Perez, MD, MS, Accelerate (Research Grant or Support)Merck (Research Grant or Support)Pfizer (Research Grant or Support)
236. Incorporating Clinical Guidance into Computerized Prescriber Order Entry May Reduce Fluoroquinolone Utilization for the Treatment of Diverticulitis at a Rural Community Health System
Authors: Tirupathi Raghavendra , Miller Benton , Logsdon Jarett 
Published: January 2021

Abstract

Background
Fluoroquinolones are associated with many adverse effects. As a result, many hospitals are investigating methods to reduce fluoroquinolone use. Computerized prescriber order entry (CPOE) provides an opportunity to develop and implement clinically guided order sets that discourage the use of fluoroquinolones. To date, there are few studies investigating the effect of clinically guided order sets on medication utilization. This study aims to investigate the hypothesis that incorporating clinical guidance and leveraging antimicrobial stewardship into a CPOE diverticulitis order set would reduce fluoroquinolone use in the treatment of diverticulitis.

Methods
A diverticulitis order set was revised to provide guided antibiotic selection based on a patient’s penicillin allergy. Patients were split into two groups based on admission date relative to the implementation date of the revised order set. Fluoroquinolone use was compared between both groups. The primary outcome was the percentage of patients who were ordered a fluoroquinolone-containing regimen during their stay. The secondary outcome was the percentage of regimens that contained a fluoroquinolone. A subgroup analysis was conducted exclusively on patients whose antibiotics were ordered with the diverticulitis order set.

Results
494 patients were included in the study. 316 patients in the pre-order set group, 178 patients in the post-order set group. 56% of patients in the pre-group received a fluoroquinolone in their regimen versus 46% of patients in the post-group (RR=0.82; 95% CI 0.68–0.99, p = 0.028). 49% of regimens in the control group contained a fluoroquinolone versus 39% of regimens in the experimental group (RR=0.78; 95% CI 0.64–0.95; p = 0.012). 77.5% of patients in the control subgroup received a fluoroquinolone in their regimen versus 42.4% of patients in the experimental subgroup (RR=0.55; 95% CI 0.36–0.84, p = 0.0062). Fluoroquinolone days of therapy decreased from 90.6 to 58.6 from 2018–2019. Clostridioides difficile infections also decreased during this time frame.
Table 1: Average fluoroquinolone days of therapy per 1000 patient days

Figure 1: Percentage of Diverticulitis Orders by Antibiotic Regimen: Pre- and Post-Order Set Change. CFP=cefepime, Metro=metronidazole, PIP-TZ=piperacillin-tazobactam, AM-SB=ampicillin-sulbactam, CIP=ciprofloxacin, Levo=levofloxacin, FQ=fluoroquinolone

Figure 2: Fluoroquinolone days of therapy per 1000 patient days from 2016–2020.

Conclusion
Our findings support the hypothesis that incorporating clinical guidance into a CPOE order set would reduce fluoroquinolone use for the treatment of diverticulitis.
Figure 3: Indicence of Clostridioides difficile infection per 1000 patient days

Disclosures
All Authors: No reported disclosures
244. The Double-Edged Sword of Cost Effectiveness in Evaluating Antimicrobial Stewardship Interventions
Authors: Zmerli Omar , Chamieh Amanda , Saliba Sanaa , Afif Claude , Azar Eid 
Published: January 2021

Abstract

Background
The multiple classical benefits of reducing antimicrobial consumption extend beyond the impact on rates of antimicrobial resistance and infections to include a cost-saving effect of 100,000$-300,000$ per intervention as estimated by the CDC. However, the recent introduction of novel antimicrobial molecules with a high price tag and the fall in the prices of older agents presents a substantial challenge in maintaining cost-effectiveness.

Methods
We retrieved from the antimicrobial stewardship program(ASP) database the consumption of the Gram-negative broad-spectrum antibacterial agents (GNBS): imipenem, meropenem, ertapenem, piperacillin-tazobactam, amikacin, colistin, ceftazidime, ceftolozane-tazobactam and cefepime from January 2015-August 2019 at Saint George Hospital(SGH), a 333-bed tertiary care center in Lebanon. The yearly cost of all antibacterials consumed during this period were obtained from SGH billing records. GNBS consumption was calculated as Daily Defined Doses (DDD)/1000 Patient Days(PD) per WHO guidelines.

Results
The carbapenem consumption significantly dropped from a peak of 205 DDD/1000PD in 2015 to 33 DDD/1000PD in 2019. This drop was not accompanied by an increase in the consumption of other GNBS. The total use of GNBS dropped by 54% from 288 DDD/1000PD in 2015 to 132 DDD/1000PD by August 2019. Currently, SGH serves a yearly average of 82,000 patient-days. Hence, this reduction in total GNBS consumption corresponds to 12,792 fewer daily defined doses of antimicrobial therapy per year.
The average annual cost of all antibacterials at SGH is 1,100,000 $ (U.S. Dollars), ranging from 955679 $ to 1340109 $ for the period 2015–2019. (Table 1)
Consumption of Gram-negative Broad-Spectrum Antimicrobial Agents and Cost of Antibiotics at Saint George Hospital, Lebanon

Conclusion
The striking decrease in GNBS consumption, namely carbapenems, was not mirrored with a reduction of total antibacterial cost. Although novel antimicrobials carry great potential, they come at a significant increase in overall cost. Modeling ASP interventions solely around cost-effectiveness will limit the better placement of these new agents in institutional therapeutic guidelines. Strict continuous analysis of consumption, antimicrobial resistance, and cost within an ASP provides a proactive and vigilant approach to navigate through the complexity of difficult to treat bacterial infections.

Disclosures
All Authors: No reported disclosures