bluuebunny/crossref_metadata_2025_split huggingface dataset:
2032. First National Survey of Antimicrobial and Antifungal Stewardship in Japan
Authors: Moriyama Yuki , Ishikane Masahiro , Kusama Yoshiki , Matsunaga Nobuaki , Tajima Taichi , Hayakawa Kayoko , Ohmagari Norio 
Published: October 2019

Abstract

Background
To manage antimicrobial resistance, both antimicrobial stewardship (AMS) and antifungal stewardship (AFS) are needed. However, limited data show AMS and AFS practices among hospitals in Japan.

Methods
We conducted a cross-sectional nationwide study using a questionnaire distributed to hospitals that participated in a hospital epidemiology workshop in Japan in July 2018. The questions addressed activities of preauthorization, notification, and intervention within 7 or 28 days about broad-spectrum antibiotics (third- and fourth-generation cephalosporins and piperacillin–tazobactam, carbapenem, intravenous quinolone) and antifungals. Interventions to use broad-spectrum antibiotics and antifungals were compared between large (≥501 beds) and small/medium-sized (≤500 beds) hospitals.

Results
Of 240 hospitals, 39 (16%; 18 large and 21 small/medium-sized) responded. Preauthorization of using broad-spectrum antibiotics and antifungals was found in 4 (10%) and 1 (3%) hospital(s), respectively. Notification of broad-spectrum antibiotics and antifungals was found in 37 (95%) and 2 (5%) hospitals, respectively. The numbers of hospitals that intervened in the use of broad-spectrum antibiotics within 7 and 28 days were 17 (44%) and 34 (87%), respectively; those of antifungals were 3 (8%) and 10 (26%), respectively (Table 1). Interventions to use broad-spectrum antibiotics within 7 days were statistically more frequent in small-/medium-sized hospitals than in large hospitals [13 (61.9%) vs. 4 (22.2%),odds ratio = 5.7, 95% confidence interval = 1.4–23.3, p = 0.023]. All hospitals had less-frequent interventions to use antifungals within 7 days than those for antibiotics[3 (14.3%) vs. 0 (0%)] (Table 2).

Conclusion
Small-/middle-sized hospitals had more frequent interventions within 7 days of broad-spectrum antibiotics than those of large hospitals, possibly because small-/medium-sized hospitals are agile and have few barriers against interventions to use broad-spectrum antibiotics. Compared with broad-spectrum antibiotics, interventions of antifungals were less frequently conducted in all hospitals. We need to emphasize the importance of AFS in Japan. Further studies on related factors are needed.

Disclosures
All authors: No reported disclosures.
2045. GAIN (Generating Antimicrobial Stewardship Initiatives in Chicago Skilled Nursing Facilities) Collaborative Survey Results: CDC Core Elements of Antimicrobial Stewardship Compliance Assessment in 27 Chicago Skilled Nursing Facilities
Authors: Hanson Amy P , Pacilli Massimo , Xydis Shannon N , Walblay Kelly , Black Stephanie R 
Published: October 2019

Abstract

Background
Antimicrobial Stewardship Programs (ASPs) in long-term care facilities is a Centers for Medicare and Medicaid Services requirement as of 2017. The CDC recommends that ASPs in skilled nursing facilities (SNFs) fulfill 7 Core Elements: leadership commitment, accountability, drug expertise, action, tracking, reporting and education.

Methods
An electronic survey utilizing REDCap was sent to the 76 Chicago SNFs representatives (Administrator, Director of Nursing, and/or Assistant Director of Nursing). Survey questions were adopted from the CDC Core Elements of Antimicrobial Stewardship for Nursing Homes Checklist.

Results
Twenty-seven (36%) of Chicago SNFs responded. Bed size ranged from 36 – 307 (median 150). Although 93% of facilities had a written statement of leadership support for antimicrobial stewardship, only 22% cited any budgeted financial support for antimicrobial stewardship activities. While Pharmacist Consultants visited all SNFs (most visiting monthly), only 33% of SNFs had an Infectious Disease Provider that consulted on-site. Dedicated time for antimicrobial stewardship activities was less than 10 hours per week in 78% of facilities, with half of all respondents reporting less than 5 hours per week. Treatment guidelines were in place for 63% of SNFs, 56% had an antibiogram, and only 7% utilized the Loeb criteria to guide appropriate antibiotic prescribing. Many facilities tracked antimicrobial stewardship metrics (93%) and reported out to staff (70%). Annual nursing training on antimicrobial stewardship occurs more frequently (85%) than prescriber education (56%). The top 3 barriers identified in implementing ASPs were financial limitations (33%), lack of clinical expertise (33%), and provider opposition (30%). Facilities’ compliance in all seven core elements varied from partially compliant (65%), majority compliant (19%), and majority non-compliant (16%).

Conclusion
Data from this baseline survey informed focused antimicrobial stewardship initiatives for the GAIN Collaborative. Targeted areas to incorporate into facility action plans include treatment guideline development, antibiograms, annual staff antimicrobial stewardship education, and adoption of the Loeb minimum criteria for antibiotic prescribing into clinical practice.

Disclosures
All authors: No reported disclosures.
2047. GAIN (Generating Antimicrobial Stewardship Initiatives in Chicago Skilled Nursing Facilities) Collaborative: Cumulative Results of Point Prevalence Surveys Assessing Antibiotic Appropriateness in Four Chicago Skilled Nursing Facilities
Authors: Hanson Amy P , Pacilli Massimo , Xydis Shannon N , Walblay Kelly , Black Stephanie R 
Published: October 2019

Abstract

Background
Antimicrobial Stewardship Programs (ASPs) in long-term care facilities are a Center for Medicare and Medicaid Services requirement as of 2017. The CDC estimates 40–75% of antibiotic prescribing in skilled nursing facilities (SNFs) is inappropriate. Overuse of antibiotics can cause harm by increasing the risk of adverse drug events (including C. difficile infections) and antimicrobial resistance.

Methods
The GAIN Collaborative was launched to assist SNFs in improving antibiotic prescribing. A list of antibiotics prescribed was generated from the electronic health records, and a chart review was performed.

Results
Antibiotic orders from September 2018 to March 2019 were randomly selected at 4 SNFs, and 120 antibiotic courses were reviewed (23, 40, 25, and 32 at SNFs A-D). Bed size ranged from 72 to 156 (median 88). Inappropriate antibiotic prescribing ranged from 60 to 78% (median 71%) among facilities. Urinary tract infections (UTIs) were the most frequent indication (40%), followed by lower respiratory tract infections (LRTIs), and skin and soft-tissue infections (SSTIs), accounting for 26% and 19% of indications, respectively. Inappropriate prescribing rates by indication were 90% for UTIs, 78% for SSTIs, and 47% for LRTIs. The most common reasons for inappropriate antibiotic prescribing were: insufficient signs and symptoms based on the Loeb minimum criteria for starting antibiotics (43%), inappropriate agent selection (30%), and lengthy treatment durations (29%). The majority of antibiotics prescribed were β-lactams (42%) or fluoroquinolones (29%). The median antibiotic prescription duration for non-catheter-associated UTIs was 5 days, LRTIs was 7 days, catheter-associated UTIs was 10 days, prophylaxis was 10 days, and SSTIs was 13 days.

Conclusion
Inappropriate antibiotic use was common in the four Chicago SNFs assessed. Results were presented at each facility’s Quality Assurance meeting to deliver provider-focused feedback. Additionally, provider and nursing education has been conducted at the four SNFs aimed at reducing unnecessary treatment of asymptomatic bacteriuria. Any improvements in antibiotic use will be captured through repeat point prevalence surveys post-implementation of a UTI SBAR communication tool and common infection treatment guidelines.

Disclosures
All authors: No reported disclosures.
2063. Using Twitter Data and Machine Learning to Identify Outpatient Antibiotic Misuse: A Proof-of-Concept Study
Authors: Sullivan Timothy 
Published: October 2019

Abstract

Background
Outpatient antibiotic misuse is common, yet it is difficult to identify and prevent. Novel methods are needed to better identify unnecessary antibiotic use in the outpatient setting.

Methods
The Twitter developer platform was accessed to identify Tweets describing outpatient antibiotic use in the United States between November 2018 and March 2019. Unique English-language Tweets reporting recent antibiotic use were aggregated, reviewed, and labeled as describing possible misuse or not describing misuse. Possible misuse was defined as antibiotic use for a diagnosis or symptoms for which antibiotics are not indicated based on national guidelines, or the use of antibiotics without evaluation by a healthcare provider (Figure 1). Tweets were randomly divided into training and testing sets consisting of 80% and 20% of the data, respectively. Training set Tweets were preprocessed via a natural language processing pipeline, converted into numerical vectors, and used to generate a logistic regression algorithm to predict misuse in the testing set. Analyses were performed in Python using the scikit-learn and nltk libraries.

Results
4000 Tweets were included, of which 1028 were labeled as describing possible outpatient antibiotic misuse. The algorithm correctly identified Tweets describing possible antibiotic misuse in the testing set with specificity = 94%, sensitivity = 55%, PPV = 75%, NPV = 87%, and area under the ROC curve = 0.91 (Figure 2).

Conclusion
A machine learning algorithm using Twitter data identified episodes of self-reported antibiotic misuse with good test performance, as defined by the area under the ROC curve. Analysis of Twitter data captured some episodes of antibiotic misuses, such as the use of non-prescribed antibiotics, that are not easily identified by other methods. This approach could be used to generate novel insights into the causes and extent of antibiotic misuse in the United States, and to monitor antibiotic misuse in real time.

Disclosures
All authors: No reported disclosures.
2065. Reducing Inappropriate Antibiotic Prescriptions in the Primary Care Setting
Authors: Klein Marlena , Zackey Diana , Sathe Niharika , Balogun Ayobamidele S , Domadia Mona , Ferrero Gina , Glickman Cynthia , Kim SangHoon , Marden Kyle R , Piazza Michael J , Richmond Jessica , Zander Miriam , Gaughan John , Rose Lucia , Byrne Dana D , Melli Jenny 
Published: October 2019

Abstract

Background
In 2015, the CDC established the National Action Plan for Combating Antibiotic-Resistant Bacteria, with the goal of reducing inappropriate outpatient antibiotic use by 50% by 2020. Upper respiratory infections, (URIs) account for one of the top three diagnoses prompting outpatient visits, and despite viral pathogens being the etiology of most URIs, many patients are treated with antibiotics. This study aimed to reduce inappropriate antibiotics prescribing for URIs at Cooper Primary Care offices.

Methods
Using the electronic medical record, we analyzed office visits (OVs) of 63 primary care providers during the influenza season (November 1, 2017–February 28, 2018) that were associated with a URI diagnosis code and resulted in an antibiotic prescription. The intervention was a personalized digital URI score card (Figure 1) emailed to each primary care physician. It included (1) Cooper Hospitals’ Primary Care Department Average Rate of Antibiotic Prescribing for URI OVs and (2) each physician’s average rate of antibiotic prescribing for URI office visits. Data were collected post-intervention (November 1, 2018–February 28, 2019) to evaluate for changes in antibiotic prescribing patterns.

Results
Using Fischer’s Exact test we analyzed the pre vs. post-intervention rate of antibiotic prescribing for URI OVs. There were 7,295 total pre-intervention office visits. Of these, 41.03% resulted in an antibiotic prescription. There were 6,642 total post-intervention office visits. Of these, 35.85% resulted in an antibiotic prescription. There was a 5.18% overall decrease in antibiotics prescribed for all URI office visits (P < 0.001) (see Figure 2).

Conclusion
Increasing providers’ awareness of their own prescribing patterns compared with their department’s prescribing patterns utilizing a single report card decreased the rate of antibiotics prescribed for URIs by 5.18% for all URI-related office visits. Specifically, there was 10.19% decrease in antibiotics prescribed for bronchitis, which is by definition, of viral etiology. This is significant given the potential side-effects of unnecessary antibiotics, and the emergence of antibiotic resistance. Limitations include a lack of certainty in “true” inappropriate prescriptions and diagnosis coding.

Disclosures
All authors: No reported disclosures.
2068. Outpatient Antimicrobial Stewardship: Optimizing Patient Care Via Pharmacist Led Culture Review
Authors: Wattengel Bethany A , Mergenhagen Kari A , Sellick John A 
Published: October 2019

Abstract

Background
Antimicrobial stewardship programs are well established in the inpatient setting; however, progress has lagged in the outpatient setting. With a growing need for outpatient stewardship, data are needed to guide the development of new services to improve patient care. Many times, cultures are taken in the outpatient setting but results are not acted upon, leading to unnecessary re-presentations to the healthcare setting.

Methods
This study was a prospective chart review via the computerized patient record system with interventions made as needed between January 1, 2018 and January 1, 2019. Infectious Diseases received alerts when oral antibiotics for outpatient use were ordered. Cultures were reviewed daily to ensure drug-bug match and timely interventions. The primary objective of this study was to compare outcomes in patients with accepted interventions vs. rejected interventions: 30-day re-presentation rates, 30-day admission rates, and 30-day treatment failure. Descriptive statistics were used to summarize data.

Results
A total of 7,360 antibiotic orders were reviewed in real time by Infectious Diseases. Of which, 965 encounters with cultures were included in the culture review service. Pharmacists intervened on 20.1% (n = 194) of patient encounters. The majority of antibiotic prescriptions that required intervention were from the emergency department (42%) and primary care (39%), with the remaining 19% being from various outpatient specialty clinics. The most common antibiotics prescribed for patients requiring intervention were ciprofloxacin (26%), third-generation cephalosporins (22%), and sulfamethoxazole/trimethoprim (18%). The most common indication for use was urinary tract infection. The intervention acceptance rate was 76%. Intervention significantly decreased rates of 30-day treatment failure (5% vs. 28%, P < 0.0001) and 30-day admission (0.7% vs. 11%, P = 0.0005) when interventions were accepted rather than rejected.

Conclusion
Culture review service positively impacted outcomes for patients in the outpatient setting. For those antibiotic orders that required intervention, the intervention significantly decreased rates of 30-day treatment failure and 30-day admission when interventions were accepted.

Disclosures
All authors: No reported disclosures.
2070. Assessing Primary Care Physicians’ Attitudes and Perceptions Toward Antibiotic Resistance and Outpatient Antibiotic Stewardship: A National Survey
Authors: Zetts Rachel M , Garcia Andrea , Doctor Jason , Gerber Jeffrey , Linder Jeffrey A , Hyun David Y 
Published: October 2019

Abstract

Background
At least 30% of outpatient antibiotic prescriptions are unnecessary. Outpatient antibiotic stewardship can improve prescribing and minimize the threat of antibiotic resistance. We assessed primary care physicians’ (PCPs) perceptions of antibiotic resistance, inappropriate antibiotic use, and the need for and impact of antibiotic stewardship activities.

Methods
We conducted a national survey of 1,550 internal and family medicine physicians and pediatricians recruited from a medical market research panel. Quotas were established to recruit participants by geographic region and specialty. For sample representativeness, survey weights were generated according to these characteristics using the American Medical Association’s Masterfile.

Results
Among respondents, 94% agreed that resistance is a problem in the United States, but only 55% felt it was a problem for their practice; 65% of respondents agreed they had seen an increase in resistant infections in their patients over the past 5 years. Responses about inappropriate antibiotic use were similar: 91% agreed that it was a problem, but 37% agreed that it is a problem in their practice. Additionally, 60% felt they prescribed antibiotics more appropriately than their peers. For antibiotic stewardship, 91% felt it was appropriate for office-based practices, but 53% believed that discussions with patients on the appropriate use of antibiotics is sufficient to address the problem. The majority of respondents indicated they were likely, very likely, or extremely likely to implement stewardship interventions in response to feedback or incentives from payers or health departments. The activities with the strongest likelihood to spur stewardship adoption included the state health department publishing local resistance patterns (82%), a payer creating a stand-alone incentive program for stewardship (80%), or a payer including it in a broader quality incentive program (76%).

Conclusion
PCPs feel that antibiotic resistance, inappropriate prescribing, and stewardship are important in the United States, but not for their own practices. This disconnect poses a challenge for the success of outpatient stewardship programs. Incentive or data feedback activities may help encourage stewardship uptake.

Disclosures
All authors: No reported disclosures.
2093. Prescribing of Antibiotics by Provider Type Across the Veterans Health Administration (VHA), 2015–2017
Authors: Suda Katie J , Gibson Gretchen , Jurasic Marianne M , Poggensee Linda , Gonzalez Beverly , Fitzpatrick Margaret A , Echevarria Kelly , McGregor Jessina C , Evans Charlesnika T 
Published: October 2019

Abstract

Background
Antibiotic stewardship frequently targets high prescribing providers. Our objective was to determine differences by provider type in antibiotic prescribing rates, high prescribing and trends over time.

Methods
Cross-sectional study in 2015–2017 of non-trainee dental and medical providers actively practicing (defined as ≥20 VHA visits). Medical providers included all physicians and advanced practice providers (APP). Antibiotics prescribed within 7 days of a visit were included. “High prescribing” was defined as providers with visit-based rates ≥75th percentile. Chi square assessed differences in the frequency of high prescribing. Poisson and logistic regression were applied; models were clustered within the facility.

Results
At 130 VHA facilities, there were 32,000 unique medical providers and 1300 dentists actively practicing/year. From 2015–2017, overall antibiotic prescribing rates decreased by 6.4% (P < 0.0001 for trend); decreasing by 1.8% for dentists (P < 0.001) and 6.6% for all medical providers (P < 0.001). More antibiotics were prescribed/visit among dentists vs. medical providers (6.7 vs. 4.3/100 visits; IRR = 1.7). Among medical providers, APP had higher rates (5.0 vs. 4.1/100 visits; P < 0.001). Among dentists, specialty dentists had higher rates compared with general dentists (7.6 vs. 6.5/100 visits; P < 0.001), increasing by 1.9% for specialty dentists and decreasing by 3.1% for general dentists. At the facility-level, dentists who were high prescribers (≥ 75th percentile) of antibiotics were at different facilities as medical providers who were high prescribers (P < 0.001). However, there was no difference in the odds of being a high antibiotic prescriber for dentists when compared with medical providers. Specialty dentists (OR = 1.7; 95% CI: 1.4–2.1) had higher odds of being high prescribers when compared with general dentists. There was no difference among the type of medical provider.

Conclusion
As compared with physicians, dentists and APP have higher antibiotic prescribing rates, though prescribing may differ based on the frequency of infection-related visits. Facility-level interventions to curb the high use of antibiotics may not be reaching high prescribing dentists. Stewardship should be targeted to non-physician providers.

Disclosures
All authors: No reported disclosures.
2098. Applying Antimicrobial Consumption Metrics to Characterize Inpatient Stewardship Opportunities
Authors: Bohn Brian C , Neuner Elizabeth A , Athans Vasilios , Wesolowski Jill , Fraser Thomas G , Gordon Steven M 
Published: October 2019

Abstract

Background
The purpose of this study was to evaluate antimicrobial consumption metrics as a means for differentiating patient populations and antimicrobial stewardship (AMS) opportunities.

Methods
This single-center, retrospective, descriptive study included all patients from January 1, 2018 to June 30, 2018 that received ≥1 day of therapy (DOT) of any antimicrobial included in the National Healthcare Safety Network Antimicrobial Use and Resistance (NHSN AUR) module. The cohort was then grouped into 4 quartiles based on DOT (Q1 lowest; Q4 highest). The primary outcome was a Lorenz Curve of DOT per patient over the study period. Secondary outcomes included a comparison of patient characteristics and number/type of AMS-related opportunities present (using a randomized convenience sample of 25 patients per quartile). AMS opportunities were defined as any unnecessary, inappropriate, or suboptimal antimicrobial use with pharmacist intervention or potential for intervention occurring 24 hours after the antimicrobial initiation.

Results
During the 6 month study period, 24,743 patients accounted for 163,859 days present, and 13,039 (52%) received ≥ 1 DOT. After dividing the population into quartiles of antimicrobial use, median (range) DOT were as follows: Q1 [2 (1–2)], Q2 [4 (3–4)], Q3 [7 (5–10)], Q4 [20 (11–636)] (Figure 1). The top 24% of patients according to antimicrobial use accounted for 74% of total antimicrobial DOT. Patient-level DOT data are displayed by SAAR grouping in Figure 2. In the cohort of 100 patients, differences between quartiles included Infectious diseases consultation in 76% of patients in Q4 compared with 4–24% in other quartiles, ICU admission during hospitalization in 68% in Q4 compared with 28–40% in other quartiles, and any surgical procedure in 88% in Q1 compared with 48–60% in Q2–4. The number of AMS opportunities present were 4 (0.5/1000 DOT) in Q1, 13 (1.6/1000 DOT) in Q2, 28 (1.4/1000 DOT) in Q3, and 86 (0.8/1000 DOT) in Q4. The most common type of AMS opportunity differed by quartile: inappropriate prophylaxis for Q1-3, and de-escalation in Q4.

Conclusion
Evaluating antimicrobial consumption from a patient-level perspective at a large academic medical center reveals heterogeneity and variable AMS opportunities across quartiles

Disclosures
All authors: No reported disclosures.