bluuebunny/crossref_metadata_2025_split huggingface dataset:
1350. Optimizing Blood Culture Use in Critically Ill Children: Year One of a Multi-Center Diagnostic Stewardship Collaborative
Authors: Woods-Hill Charlotte Z , Koontz Danielle W , MPH Annie Voskertchian , PhD Anping Xie , Miller Marlene R , MD James C Fackler , PhD Elizabeth A Colantuoni , Milstone Aaron , Milstone Aaron 
Published: January 2021

Abstract

Background
Overuse of blood cultures can lead to false positives and unnecessary antibiotics. Our objective was to describe the implementation and 12-month impact of a multi-site quality improvement collaborative to reduce unnecessary blood cultures in pediatric intensive care unit (PICU) patients.

Methods
In 2018, 14 PICUs joined the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR) Collaborative, designed to understand and improve blood culture practices in PICUs. Guided by a multidisciplinary study team, sites 1) reviewed existing evidence for safe blood culture reduction, 2) assessed local practices and barriers to change, and 3) developed and implemented new blood culture practices informed by local context. We facilitated and monitored project progress through phone calls, site visits, and collaborative-wide teleconferences. We collected monthly blood culture rates and monitored for delays in culture collection as a safety balancing metric. We compared 24 months of baseline data to post-implementation data (2-14 months) using a Poisson regression model accounting for the site-specific patient days and correlation of culture use within a site over time.

Results
Across 14 sites, there were 41,986 pre-implementation blood cultures collected over 238,182 PICU patient days. The mean pre-implementation site-specific blood culture rate was 19.42 cultures/100 patient days (range 9.59 to 48.18 cultures/100 patient days). Post-implementation, there were 12,909 blood cultures collected over 118,600 PICU patient days. The mean post-implementation rate was 14.02 cultures/100 patient days (range 5.40 to 37.57 cultures/100 patient days), a 23% decrease (relative rate 0.77, 95% CI: 0.60, 0.99, p = 0.04). In 12 months post-implementation, sites reviewed 463 positive blood cultures, and identified only one suspected delay in culture collection possibly attributable to the site’s culture reduction program.
Bright STAR Collaborative Site Blood Culture Rate 100 Patient Days

Conclusion
Multidisciplinary teams facilitated a 23% average reduction in blood culture use in 14 PICUs. Future work will determine the impact of blood culture diagnostic stewardship on antibiotic use and other important patient safety outcomes.

Disclosures
James C. Fackler MD, MD, Rubicon Health LLC (Other Financial or Material Support, Founder)
1352. Pediatric azithromycin prescriptions in a healthcare system from 2016-2018
Authors: Petrone Skylar , Garavaglia Lisa , Gupta Shipra 
Published: January 2021

Abstract

Background
In 2017, the Centers for Disease Control and Prevention (CDC) estimated that 30% of all antibiotics prescribed in outpatient clinics are unnecessary, with children receiving more antibiotics than any other age group. Among those antibiotics being prescribed, azithromycin is one of the most commonly prescribed antibiotics.

Methods
We reviewed antimicrobial prescribing data of children 0 to 19 years of age who visited West Virginia University (WVU) Health system which is the flagship institution for the state. We reviewed information of patients who were prescribed azithromycin by healthcare providers between January 2016 and December 2018. We included prescribing data from urgent care centers, outpatient clinics and emergency departments. The primary visit diagnosis associated with the visit was reviewed.

Results
During the study period there were 29,983 visits identified during which antibiotics were prescribed and azithromycin was prescribed in 40.6% of those visits. The majority of visits occurred between the months of October through February (54.4%), with December having the most visits. There were 11,934 unique patients identified and only 26.5% of these patients were marked as allergic to penicillin (PCN) or amoxicillin. The distribution of the age groups for azithromycin prescriptions is shown in figure 1. The age group of 11-19 years had the highest azithromycin prescription rate (38.7%) and the most common diagnosis for this group was pharyngitis. The distribution of the common diagnoses associated with azithromycin prescriptions can be seen in figure 2 and acute otitis media (AOM) was the most common diagnosis (23.6%).
Figure 1- Age distribution of children who received azithromycin prescriptions during the study period

Figure 2- Distribution of diagnoses associated with azithromycin prescriptions

Conclusion
Acute otitis media and pharyngitis accounted for almost half of the diagnoses associated with azithromycin prescriptions. Treatment guidelines for both conditions recommend PCN-based therapy as first-line treatment unless there is a history of PCN allergy. Only a quarter of the patients had allergy documented to PCN or amoxicillin and, therefore, azithromycin would be considered a suboptimal antimicrobial choice. These results provide us with a stewardship opportunity to nudge providers to select appropriate antimicrobial based on diagnosis and history of allergy.

Disclosures
All Authors: No reported disclosures
1356. Ribavirin Use in Hospitalized Children
Authors: Otto William R , Lee Giyoung , Thurm Cary , Gerber Jeffrey , Hersh Adam 
Published: January 2021

Abstract

Background
Respiratory syncytial virus (RSV) infection is a significant cause of morbidity and mortality in immunocompromised children. Aerosolized ribavirin is approved for treatment of RSV lower respiratory tract infections. However, due to high cost, challenges to administration and uncertainty about benefit, use is limited. Recent studies in adult patients have reported similar outcomes between patients treated with aerosolized and oral ribavirin. We sought to characterize trends in use of ribavirin for hospitalized children.

Methods
We used the Pediatric Health Information System (PHIS), an administrative database which contains resource utilization data from 52 children’s hospitals, to perform a retrospective analysis of children hospitalized between January 1, 2010 through December 31, 2019 who were billed for ribavirin treatment. Data related to ribavirin use (number of courses, route of administration) and clinical characteristics were abstracted. International Classification of Diseases, 9th Revision (ICD-9) or 10th Revision (ICD-10) codes and All Patients Refined Diagnosis Related Groups (APR DRG) classifications were used to define underlying clinical conditions and illness severity. Summary statistics were used to describe patient characteristics and the use of ribavirin.

Results
Thirty-eight hospitals reported ribavirin use; 1 hospital was excluded due to inaccuracies in charge coding. We identified 837 children who received 937 courses of ribavirin (Table 1). The overall frequency of ribavirin use was unchanged over the study period, and the number of ribavirin treatment courses per hospital ranged from 1 to 228 (Figure 1). The most frequent routes of administration were inhalation (603/937, 64%) and oral (322/937, 34%). There was a decrease in the use of aerosolized ribavirin over time, with a corresponding increase in the use of oral ribavirin (Figure 2).
Table 1: Patient demographics (N=837)

Figure 1: Total ribavirin treatment courses over the study period (a) by year and (b) by treating hospital

Figure 2: (a) Route of administration (inhalation versus oral), by year during the study period and (b) use of oral ribavirin over time during the study period

Conclusion
Although overall prescribing rates of ribavirin in hospitalized children have remained stable, use varies widely across centers and the proportion of oral ribavirin use has increased over time. Comparative effectiveness studies are needed in the pediatric population to evaluate outcomes of children treated with aerosolized vs. oral ribavirin.

Disclosures
All Authors: No reported disclosures
1359. Utilization of West Virginia Pediatric Medicaid Claims Data to Guide Outpatient Antimicrobial Stewardship Interventions
Authors: Kilgore Jacob T , Piazzon Mariana M Lanata , Willis Jonathan M , Evans Joseph , Smith Michael J 
Published: January 2021

Abstract

Background
Antimicrobial resistance is a significant public health risk with overuse and misuse of antibiotics as primary drivers. West Virginia (WV) leads the nation in per capita prescribing in the outpatient setting, where the majority of antibiotic use occurs.

Methods
We analyzed outpatient pharmacy and medical claims for WV Medicaid recipients age &lt; 20 years from 1/1/2018 – 12/31/2019. Dental claims were excluded. Oral antibiotics were identified using National Drug Codes (NDCs). Key demographic variables extracted from the claims include patient age (as of December 31st of that calendar year [CY]), sex, race, ethnicity, Medicaid region, place of medical service, provider, and cost. Rates of prescribing were calculated as the number of prescriptions per 1,000 children and stratified by age, race/ethnicity, sex, and WV Medicaid region. We used geographic information system (GIS) mapping to depict geographic variation in prescribing by county. Oral antibiotic prescriptions were compared across CY 2018 and 2019 including spectrum of antibiotic coverage.

Results
In CY 2018, 204,576 pediatric patients received 237,759 antibiotics (1,162 prescriptions/1,000 children). In 2019, 201,520 pediatric patients received 227,440 antibiotics (1,129 prescriptions/1,000 children). Prescription rates were higher among females, Caucasians and a younger (0-2) age group (Table 1). Antibiotics were more commonly prescribed by non-physician (e.g. nurse practitioner, etc.), non-pediatric specialty providers. Amoxicillin, cefdinir, and azithromycin were the most commonly prescribed antibiotics across CYs. Table 2 summarizes commonly prescribed antibiotics and their associated cost. Medicaid region 4 encompassed the highest prescription rates. Figure 1 is a GIS map of prescription rates by WV county.
Table 1. West Virginia pediatric (0 – 19 years*) Medicaid patient population demographic summary by calendar year (CY).

Table 2. Oral antibiotic prescription review including cost, CY 2018-2019.

Figure 1. Geographic information system (GIS) mapping of prescriptions per 1,000 children by WV county.

Conclusion
There is significant variation in antibiotic prescribing across WV. Potential areas of stewardship intervention should focus on non-physician, non-pediatric providers in Medicaid Region 4, the southern and arguably most rural portion of the state. Secondary analysis revealed an alarmingly high total number of broad-spectrum antibiotic use compared to narrow-spectrum. Further data analysis will examine diagnosis-specific prescription practices within this population.

Disclosures
Michael J. Smith, MD, MSC.E, Kentucky Medicaid (Grant/Research Support)Merck (Grant/Research Support)
1361. Variation in Perioperative Antibiotic Use for Children Undergoing Congenital Heart Disease Surgery in U.S. Academically Affiliated Centers
Authors: Cooch Peter B , Wattier Rachel , Steurer-Muller Martina 
Published: January 2021

Abstract

Background
Perioperative antibiotics (PA) are routinely given to children undergoing congenital heart disease (CHD) surgery to prevent surgical site infection. National guidelines recommend narrow-spectrum PA (such as Cefazolin) for most CHD procedures. However, indications for broad-spectrum PA are not well established, and limited literature suggests high exposure to broad-spectrum PA in this population. We performed a contemporary, multicenter description of prevalence and variability of broad-spectrum PA exposure within the pediatric CHD surgical population.

Methods
We identified children 0-17 years admitted to U.S. academically-affiliated centers participating in the Vizient Clinical Database/Resource Manager from 2011-2018. Patients who had ICD-9 and ICD-10 codes indicating a CHD surgical procedure with intravenous antibiotics initiated the day of surgery were eligible for inclusion. Antibiotics broader than first- and second-generation cephalosporins were designated broad-spectrum. We excluded centers with 5 or fewer annual procedures. We excluded patients undergoing heart transplant, concurrent non-cardiac procedures, and those with missing medication data.

Results
19,152 hospital admissions from 24 centers met inclusion criteria. 55% of patients were male, 18% were under 30 days of age at time of surgery, and 5.1% had diagnosis codes for prematurity. Broad spectrum antibiotics were administered in 21.4% of CHD procedures during the study period. Between the 24 centers, the proportion of surgical cases given broad-spectrum PA ranged from 1.5% to 95%, which was unrelated to center annual surgical volume. Children under 30 days of age and those with prematurity were significantly more likely to receive broad-spectrum agents. Vancomycin was the primary antibiotic contributing to broad-spectrum PA exposure.

Conclusion
Substantial variation in broad-spectrum PA use was observed among children undergoing congenital heart disease surgery in academically affiliated United States centers from 2011-2018. Neonates and premature infants have the highest rates of exposure to broad-spectrum antibiotics. Standardization of perioperative antibiotics in CHD surgery is a potential intervention to limit antibiotic exposure in young infants.

Disclosures
All Authors: No reported disclosures
1362. Antibiotic Prescribing for Acute Otitis Media in Commercially Insured Pediatric Patients in the United States
Authors: Smolinski Nicole , Antonelli Patrick , Winterstein Almut 
Published: January 2021

Abstract

Background
Overprescribing of antibiotics to treat conditions that are self-limiting and do not always require antibiotics is a well-recognized concern in pediatric care. The 2013 American Academy of Pediatrics (AAP) acute otitis media (AOM) guidelines reinforced previous recommendations regarding watchful waiting for three days among patients with non-recurrent uncomplicated AOM and provided more explicit diagnostic criteria.

Methods
We conducted a retrospective cohort study using the IBM Marketscan Commercial Claims Research Databases (2008-2018). Pediatric patients 1 to 12 years old were included. We required a primary diagnosis of AOM in an outpatient setting, without AOM or other complicated ear infections within 6 months prior and no other acute infections in the 2 weeks prior to or 1 week after AOM diagnosis. Patients were classified as treated (pharmacy dispensing record of antibiotics within 3 days of diagnosis) or watchful waiting (no treatment or treatment after &gt; 3 days). We used segmented linear regression to examine changes in treatment proportions across the study period.

Results
We identified 2,640,920 pediatric AOM episodes, of which 2,033,697 (77.0%) were treated within 3 days. The majority of episodes were treated with amoxicillin (51.3%), followed by amoxicillin/clavulanate (15.3%) and cephalosporins (22.0%). Among episodes in the watchful waiting group, 18,793 (3.1%) filled a prescription within 4-7 days of diagnosis. Most patients saw a pediatrician (62.7%). A larger proportion of otolaryngologists adopted watchful waiting approaches compared to other physician types. There was no difference in chronic conditions or regional variation between the two groups. There was no immediate (p=0.31) or gradual change in treatment proportion (p=0.49) after release of the 2013 guidelines.

Conclusion
Most pediatric patients continue to be treated with antibiotics within three days of AOM diagnosis, reflecting no impact of the 2013 AAP guidelines. Physician specialty but not patient characteristics appear to determine treatment approaches.

Disclosures
Nicole Smolinski, PharMD, Nothing to disclose
1367. Reduced Ceftaroline Susceptibility Among Invasive MRSA Isolates at a Tertiary Children’s HospitalReduced Ceftaroline Susceptibility Among Invasive MRSA Isolates at a Tertiary Children’s Hospital
Authors: Sommer Lauren , Vallejo Jesus G , Hulten Kristina G , Kaplan Sheldon L , McNeil Jonathon C 
Published: January 2021

Abstract

Background
The emergence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) in the late 1990s-early 2000s complicated the empiric management of suspected staphylococcal infection in children. Rising clindamycin resistance rates in many communities adds further to management challenges. Ceftaroline, an anti-MRSA cephalosporin, represents an attractive therapy option. Little data are available, however, regarding the frequency of reduced susceptibility (RS) to ceftaroline among MRSA isolates from a general pediatric population.

Methods
Isolates were selected from an ongoing S. aureus surveillance study at Texas Children’s Hospital. Invasive MRSA isolates from 2015-2018 were included. Isolates were initially screened for ceftaroline RS with E-test; all isolates with a ceftaroline E-test MIC ≥ 1.5µg/ml underwent ceftaroline broth dilution. Ceftaroline RS was regarded as an MIC ≥ 2 µg/ml; full ceftaroline resistance was defined as an MIC ≥ 8 μg/ml. Accessory gene regulator (agr) groups were characterized by PCR.

Results
201 viable isolates were included. The ceftaroline MIC50 and MIC90 were 0.5 and 1 µg/ml, respectively (Figure 1). Six isolates had MIC ≥ 2 µg/ml (2.9%) with two having MIC ≥ 8 µg/ml (0.9%). All ceftaroline RS isolates were from healthcare associated infections. Ceftaroline RS isolates were more often associated with clindamycin-resistance and agr group II (Figure 2). Infections with ceftaroline RS were associated with central venous lines, recent ICU admission, preceding antibiotic exposure (specifically cephalosporins) and prior MRSA infection. One subject with MRSA CLABSI had a ceftaroline susceptible MRSA infection followed &lt; 1 month later by a ceftaroline resistant infection (MIC =32 μg/ml); the isolates were identical by PFGE. Only 3 subjects had previously received ceftaroline, none of which subsequently developed a ceftaroline RS isolate.
Figure 1. Ceftaroline MIC Distribution

Figure 2. Clinical And Microbiologic Associations with Reduced Ceftaroline Susceptibility

Conclusion
Ceftaroline RS occurs in 2.9% of invasive MRSA isolates in children and is most prominent among healthcare-associated infections. These isolates were associated with clindamycin resistance and agr group II. While ceftaroline RS is rare among invasive MRSA infections, the lack of preceding ceftaroline exposure is concerning and warrants careful surveillance.

Disclosures
Sheldon L. Kaplan, MD, Allergan (Research Grant or Support)Pfizer (Grant/Research Support) Jonathon C. McNeil, MD, Allergan (Research Grant or Support, Allergan provided ceftaroline powder for use in studies described in this abstract)
110. Impact of Diagnostic and Antimicrobial Stewardship on Time-to-Appropriate Therapy and Clinical Outcomes in Multi-Drug Resistant Pseudomonas Infections
Authors: McCrink Katie A , DeRonde Kailynn , Jimenez Adriana , Rosello Gemma , Natori Yoichiro , Claeys Kimberly C , Martinez Octavio , De Pascale Biagio , Perez-Cardona Armando , Abbo Lilian M , Abbo Lilian M , Vega Ana 
Published: January 2021

Abstract

Background
Timely effective therapy in multi-drug resistant (MDR) Pseudomonas (PsA) infections has a direct impact on patient survival. We aimed to determine the impact of diagnostic and antimicrobial stewardship (AMS) on time-to-appropriate therapy (TAP) and clinical outcomes of patients with MDR PsA infections utilizing novel beta-lactam/beta-lactamase inhibitors (BL/BLIs).

Methods
Retrospective cohort study of adult patients with MDR PsA infections at a 1,500-bed University-affiliated public hospital in Miami, Florida who received ≥72 hours of ceftazidime-avibactam (C/A) or ceftolozane-tazobactam (C/T). During the pre-intervention period (12/2017-12/2018), additional susceptibilities for C/A and C/T were performed upon providers’ request. In the post intervention period (01/2019 – 12/2019), we implemented automatic reflex algorithms (Figure 1) for faster identification and susceptibilities for MDR PsA, including carbapenemase producers. Results were communicated in real-time to the AMS team.
Figure 1. Reflex Testing Algorithm for MDR Pseudomonas Isolates from Any Source

Results
Seventy-six patients were included; median age was 56 years (IQR 37.5–67.0), 40 (52.6%) were in an intensive care unit at time of culture collection; median APACHE II score was 20 (IQR 15.0 – 26.0). Three isolates were carbapenemase producers (VIM = 2; KPC = 1). The most common infections were pneumonia (56.6%) and bacteremia (18.4%). We found a significant decrease in median TAP (120.1 [IQR 82.5–164.6] vs 75.9 [IQR 51.3–101.7] hours, p = 0.003). Median time from culture collection to final susceptibility results was shorter in the post-intervention group (122.2 vs 90.5 hours; p &lt; 0.001). Median length-of-stay after culture collection was numerically lower in the post-intervention group (26.0 [11.6–59.4] vs 19.7 [12.9–37.8] days; p = 0.33). Controlling for ICU admission, our intervention was not associated with decreased 30-day inpatient mortality (OR = 1.62, 95% CI 0.45–5.79).

Conclusion
Our study identified an improvement in TAP in MDR PsA infections with implementation of diagnostic and AMS initiatives. In an adequately powered study, our intervention could potentially impact patient survival through timely initiation of effective therapy with novel BL/BLIs.

Disclosures
All Authors: No reported disclosures