bluuebunny/crossref_metadata_2025_split huggingface dataset:
145. Monthly Antibiotic Prescribing Peer Comparison Combined with In-person Education Decreases Antibiotic Prescribing for Acute Respiratory Infections
Authors: Kolo Shelby J , Taber David J , Washburn Ronald G , Pleasants Katherine A 
Published: January 2021

Abstract

Background
Inappropriate antibiotic prescribing is an important modifiable risk factor for antibiotic resistance. Approximately half of all antibiotics prescribed for acute respiratory infections (ARIs) in the United States may be inappropriate or unnecessary. The purpose of this quality improvement (QI) project was to evaluate the effect of three consecutive interventions on improving antibiotic prescribing for ARIs (i.e., pharyngitis, rhinosinusitis, bronchitis, common cold).

Methods
This was a pre-post analysis of an antimicrobial stewardship QI initiative to improve antibiotic prescribing for ARIs in six Veterans Affairs (VA) primary care clinics. Three distinct intervention phases occurred. Educational interventions included training on appropriate antibiotic prescribing for ARIs. During the first intervention period (8/2017-1/2019), education was presented virtually to primary care providers on a single occasion. In the second intervention period (2/2019-10/2019), in-person education with peer comparison was presented on a single occasion. In the third intervention period (11/2019-4/2020), education and prescribing feedback with peer comparison was presented once in-person followed by monthly emails of prescribing feedback with peer comparison. January 2016-July 2017 was used as a pre-intervention baseline period.
The primary outcome was the antibiotic prescribing rate for all classifications of ARIs. Secondary outcomes included adherence to antibiotic prescribing guidance for pharyngitis and rhinosinusitis. Descriptive statistics and interrupted time series segmented regression were used to analyze the outcomes.

Results
Monthly antibiotic prescribing peer comparison emails in combination with in-person education was associated with a statistically significant 12.5% reduction in the rate of antibiotic prescribing for ARIs (p=0.0019). When provider education alone was used, the reduction in antibiotic prescribing was nonsignificant.

Conclusion
Education alone does not significantly reduce antibiotic prescribing for ARIs, regardless of the delivery mode. In contrast, education followed by monthly prescribing feedback with peer comparison was associated with a statistically significant reduction in ARI antibiotic prescribing rates.

Disclosures
All Authors: No reported disclosures
148. Post-Extraction Infection and Antibiotic Prescribing Among Veterans Receiving Dental Extractions
Authors: Caniff Kaylee E , Young Lisa R , Truong Shawna S , Gretchen Gibson , Jurasic Marianne M , Poggensee Linda , Fitzpatrick Margaret A , Evans Charlesnika T , Suda Katie J 
Published: January 2021

Abstract

Background
Dentists prescribe 10% of outpatient antibiotics in the United States, equating to 24.5 million prescriptions annually. However, there is a paucity of data regarding adjunctive antibiotic use in tooth extractions. This study compared post-extraction infections following dental extractions with and without adjunctive antibiotics. Post-extraction infection risk factors and antibiotic prescribing patterns were also investigated.

Methods
This was a retrospective cohort of Veterans with tooth extraction(s) in any Veterans Affairs dental clinic from 1/1/17-12/31/17. A stratified random sample was selected by geographic region, type of extraction (surgical/non-surgical) and post-extraction antibiotic receipt to ensure inclusion of subjects in each of these categories. Subjects who received an antibiotic were compared to those who did not for the occurrence of post-extraction infection as documented in the health record by infectious signs/symptoms or diagnosis. Multivariable regression was performed to identify factors associated with antibiotic receipt.

Results
A sample size of 374 was needed to achieve statistical power based on a 10% risk of infection post-extraction. Nationally, 69,610 patients met inclusion criteria, of which 404 were randomly selected for inclusion. Antibiotics were prescribed to 154 patients (38.1%). There was no difference in post-extraction oral infection among subjects who did and did not receive antibiotics (4.5% vs. 3.2%, p=0.59). Risk factors for post-extraction infection could not be identified due to the low frequency of this outcome. Subjects who received antibiotic prescriptions were more likely to have a greater number of teeth extracted (OR=1.1; 95% CI 1.03–1.2), documentation of acute infection at time of extraction (OR=3.0; 95% CI 1.6–5.8), molar extraction (OR=1.8; 95% CI 1.1–2.9) and extraction performed by an oral maxillofacial surgeon (OR=2.3; 95% CI 1.5–3.6) or specialty dentist (OR=5.8; 95% CI 2.1–16.2).

Conclusion
Infectious complications were not significantly different among Veterans undergoing tooth extraction who did and did not receive post-extraction antibiotics. Antibiotic prescribing for tooth extraction may be a potential area of focus for outpatient antimicrobial stewardship efforts.

Disclosures
All Authors: No reported disclosures
150. Using audit-and-feedback to improve antibiotic-prescribing in Emergency Departments: a quasi-experimental study across 4 sites in the Veterans Health Administration
Authors: Livorsi Daniel J , Nair Rajeshwari , Dysangco Andrew , Aylward Andrea , Alexander Bruce , Smith Matthew , Kouba Sammantha , Perencevich Eli N 
Published: January 2021

Abstract

Background
Antibiotic-prescribing in Emergency Departments (EDs) is often inappropriate. In this study, we evaluated whether audit-and-feedback could improve antibiotic use in EDs.
Figure 1. Comparison of antibiotic-prescribing between the pretest and intervention periods at 2 intervention EDs and 2 control EDs

Methods
We pilot tested an audit-and-feedback intervention using a quasi-experimental study design at 2 intervention and 2 matched-control EDs with a 12-month pretest and a 12-month intervention period. At intervention sites, 27 of 31 (87.1%) clinicians were enrolled; at baseline, they received 1) one-on-one education about antibiotic-prescribing and 2) individualized feedback with comparisons to local peers. Feedback included personalized antibiotic-prescribing data for all ED visits and specifically for viral acute respiratory infections (ARIs); feedback was updated quarterly. The primary outcome was the antibiotic-prescribing rate for ED visits not resulting in hospitalization, and it was assessed using a segmented regression analysis of monthly time series data. Manual chart reviews were performed to assess guideline-concordant management (i.e. prescribing an antibiotic when indicated and not prescribing when not indicated) for 5 ARIs plus cystitis.

Results
In the pre-test and intervention periods, intervention sites had 28,146 and 27,396 visits compared to 31,439 and 32,295 visits at control sites. After implementation started, intervention sites saw an immediate decrease in antibiotic use (-10.3%, p=0.15) compared to a 1.5% increase (p=0.88) at control sites. By the end of the intervention period, there was an 8.9% decrease in antibiotic use at intervention sites compared to a 3.4% decrease at control sites [relative risk ratio (RRR) -3.3% (95% CI, -8.4 to +1.7), Figure 1]. Guideline-concordant management improved from 52.1% to 72.2% (p&lt; 0.01) at intervention sites compared to 51.3% to 58.2% (p=0.13) at control sites. Intervention and control sites had similar changes in 30-day outcomes, including late antibiotic prescriptions and hospitalizations.

Conclusion
After the implementation of audit-and-feedback at 2 EDs, antibiotic use did not significantly decrease compared to 2 control EDs but guideline-concordant management improved. Future studies should include more study sites to improve statistical power and also evaluate the effectiveness of more frequent and specific feedback.

Disclosures
Daniel J. Livorsi, MD, MSc, Merck and Company, Inc (Research Grant or Support) Rajeshwari Nair, PhD, Merck and Company, Inc. (Research Grant or Support)
153. Development of a Pathway for Removal of Inappropriate Penicillin Allergy Labels in Hospitalized Patients
Authors: Shweta Fnu , Gurram Pooja , Almeida Natalia E Castillo , Challener Douglas , Cano Edison J , Park Miguel , Narayanan Prasanna , Skrupky Lee , Volcheck Gerald , Virk Abinash 
Published: January 2021

Abstract

Background
More than 90% of reported penicillin allergies are found inaccurate when formally assessed. These allergy labels lead to decreased utilization of first-line beta-lactam antibiotics, and adverse clinical outcomes. The objective of this study was to develop a multi-disciplinary approach to decrease inaccurate labeling among hospitalized patients with documented penicillin allergy.

Methods
A team of clinicians, pharmacists, and nurses utilized the DMAIC quality strategy to improve accuracy of penicillin allergy labeling. Allergic reactions were stratified to develop a penicillin allergy de-labeling algorithm (Figure 1). Admission to the intensive care unit (ICU) for anaphylaxis was defined as a balancing measure. We reviewed baseline data from patients with a documented penicillin allergy admitted to a single inpatient floor at Mayo Clinic, Rochester between June and October 2019. A cause and effect diagram was used to conduct a root cause analysis. The intervention was then applied to patients who reported penicillin allergy admitted to the same floor from November 2019 to January 2020. Study data were collected and basic descriptive statistics generated.
Figure 1: Penicillin allergy delabeling algorithm

Results
96 patients were included in the control group with mean age of 71 years (range 65–84 years) and 55% females. Breakdown of documented allergic reactions are represented in Figure 2. 58 (60%) received an antibiotic for a median duration of 1.5 days (IQR: 0 – 6). Of these, 7(12%) received penicillin-class antibiotics, and 41 (70.6%) received non-beta-lactam antibiotics. 2 (2%) of these patients were de-labeled without any penicillin skin tests. Detailed metrics of each PDSA cycle are shown in Table 1. During PDSA cycle 2, inaccurate penicillin documentation was removed in 9/19 (47.4%) of hospitalized patients. There were no ICU admissions for anaphylaxis.
Figure 2: Graphic representation of proportion of type of documented allergic reactions to penicillin

Table 1: Metrics and outcomes at baseline and during successive PDSA cycles

Conclusion
Various factors contribute to penicillin allergy mislabeling. Our comprehensive algorithm addresses nuances of penicillin allergic reactions and increased accurate penicillin allergy labeling in 47.4% of the cases. Beta-lactam use also increased to 37% through our pilot project while maintaining patient safety. A multi-disciplinary and patient-centered approach aligned with institutional workflows is necessary to improve patient outcomes.

Disclosures
All Authors: No reported disclosures
154. Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Adults with Acute Pharyngitis
Authors: Lautenbach Ebbing , Hamilton Keith W , Grundmeier Robert , Neuhauser Melinda M , Hicks Lauri , Jaskowiak Anne , Cressman Leigh , James Tony , Omorogbe Jacqueline , Frager Nicole , Menon Muida , Kratz Ellen , Gerber Jeffrey 
Published: January 2021

Abstract

Background
Although most antibiotic use occurs in outpatients, antibiotic stewardship programs (ASPs) have primarily focused on inpatients. A major challenge for outpatient ASPs is lack of accurate and accessible electronic data to target interventions. We developed and validated an electronic algorithm to identify inappropriate antibiotic use for adult outpatients with acute pharyngitis.

Methods
In the University of Pennsylvania Health System, we used ICD-10 diagnostic codes to identify patient encounters for acute pharyngitis at outpatient practices between 3/15/17 – 3/14/18. Exclusion criteria included immunocompromising conditions, comorbidities, and concurrent infections that might require antibiotic use. We randomly selected 300 eligible subjects. Inappropriate antibiotic use based on chart review served as the basis for assessment of the electronic algorithm which was constructed using only data in the electronic health record (EHR). Criteria for appropriate prescribing, choice of antibiotic, and duration included positive streptococcal testing, use of penicillin/amoxicillin (absent b-lactam allergy), and 10 days maximum duration of therapy.

Results
Of 300 subjects, median age was 42, 75% were female, 64% were seen by internal medicine (vs. family medicine), and 69% were seen by a physician (vs. advanced practice provider). On chart review, 127 (42%) subjects received an antibiotic, of which 29 had a positive streptococcal test and 4 had another appropriate indication. Thus, 74% (94/127) of patients received antibiotics inappropriately. Of the 29 patients who received appropriate prescribing, 27 (93%) received an appropriate antibiotic. Finally, of the 29 patients who were appropriately treated, 29 (100%) received the correct duration. Test characteristics of the EHR algorithm (compared to chart review) are noted in the Table.

Conclusion
Inappropriate antibiotic prescribing for acute pharyngitis is common. An electronic algorithm for identifying inappropriate prescribing, antibiotic choice, and duration is highly accurate. This algorithm could be used to efficiently assess prescribing among practices and individual clinicians. The impact of interventions based on this algorithm should be tested in future work.
Test Characteristics of Electronic Algorithm for Inappropriate Prescribing, Agent, and Duration

Disclosures
All Authors: No reported disclosures
157. A Multidisciplinary Approach to Carbapenem Stewardship at a Large Community Hospital in Brooklyn, New York
Authors: Simon Samuel , Li Rosanna , Lin Yu Shia , Mayer Suri , Chapnick Edward , Ghitan Monica 
Published: January 2021

Abstract

Background
Carbapenem-resistant gram-negative organisms are a continuously mounting threat, underscoring the need for effective antimicrobial stewardship interventions to improve the use of carbapenems. We sought to implement several multidisciplinary antimicrobial stewardship interventions beginning in January 2019 in an effort to reduce unnecessary meropenem use and the incidence of carbapenem-resistant gram-negatives.

Methods
Prospective audit and feedback was utilized daily in combination with weekly stewardship rounds between an Infectious Diseases pharmacist and physician in the Intensive Care Units. A second Infectious Diseases physician attended weekly interdisciplinary rounds on meropenem high-use units. Meropenem Days of Therapy (DOT) per 1,000 patient days and the incidence of meropenem resistant Pseudomonas aeruginosa and Klebsiella pneumoniae were compared by the chi-square test of proportions.

Results
Between 2018 and 2019 the institution’s meropenem DOT per 1,000 patient days decreased 33%, from 57 to 38 days per 1,000 patient days (difference, 19 days per 1,000 patient days; p&lt; 0.001). In the hospital antibiogram, the meropenem susceptibility of Pseudomonas aeruginosa over the same time period increased from 71% to 77% of isolates (difference, 6%; p = 0.009). A non-significant decrease in the susceptibility of meropenem to Klebsiella pneumoniae was also observed from 92 to 90% (difference, 2%: p = 0.1658).

Conclusion
These data support the need for antimicrobial stewardship efforts targeting broad-spectrum antimicrobials such as meropenem. In the setting of a sustained decrease in meropenem use over 12 months, we observed a significant improvement in the percent susceptibility rate of Pseudomonas aeruginosa to meropenem for the first time in five years.

Disclosures
All Authors: No reported disclosures
159. A Novel Framework to Guide Antibiotic Stewardship Nursing Practice
Authors: Manning Mary Lou , Pogorzelska-Maziarz Monika , Carter Eileen , Monsees Elizabeth 
Published: January 2021

Abstract

Background
In 2017, the International Council of Nurses - a federation of more than 130 national nurses associations, representing the more than 20 million nurses worldwide - issued a statement supporting the position that nurses “play a central role in patient care and interdisciplinary communication and, as such, are in a key position to contribute to reducing antimicrobial resistance and critical for the function of antimicrobial stewardship (AS) programs.” Evidence suggests that frontline nurses are enthusiastic to participate in AS activities but lack context and a non-antibiotic prescriber frame of reference.
Antibiotic Stewardship Nursing Practice: The SCAN-P Framework®

Methods
Drawing from a review of the antibiotic, environmental, and social sciences stewardship literature and interviews with AS thought leaders, we developed a framework to provide context and to guide AS nursing practice and education. Over a six month period, the framework was vetted with over 30 nurse and non-nurse clinicians and critiqued by frontline nurses engaged in AS patient care activities. The framework went through more than ten iterations, resulting in the SCANP framework (shown in Figure).

Results
The novel SCANP Framework consists of three concentric circles, sharing a common core to prevent patient harm and optimize antibiotic use. The outer circle - S - represents scope and standards of nursing practice and nursing code of ethics. Nursing practice is guided by individual country’s standards and codes. The second ring - C - culture and context represents organizational culture and local-level social/behavioral context. The extent to which nurses can successfully engage in AS with their interdisciplinary colleagues is highly dependent on how nursing is positioned within the organization. The third ring - ANP - represents current and emerging AS Nursing Practices that support the safe and responsible use of antibiotics.

Conclusion
Recommendations to expand AS programs to include nurses have generated national and international support. But nurse engagement in AS has received limited contextual attention. To fill the gap, we created a practical, globally applicable AS organizing framework to guide nurses, and leaders charged with nursing development and education, foster interdisciplinary dialogue on advancing AS endeavors.

Disclosures
All Authors: No reported disclosures
162. Assessment of Beta-lactam Allergies as Rationale for Receipt of Vancomycin for Surgical Prophylaxis
Authors: Tucker Kendall J , Ham YoungYoon , Holmer Haley K , McCracken Caitlin M , Sukerman Ellie , Lewis James , McGregor Jessina C 
Published: January 2021

Abstract

Background
Beta-lactam (BL) antibiotics are first-line agents for most patients receiving antimicrobial prophylaxis in surgical procedures. Despite evidence showing low cross-reactivity between classes of BLs, patients with allergies commonly receive vancomycin as an alternative to avoid allergic reaction. The objective of this study was to identify potentially inappropriate use of vancomycin surgical prophylaxis among patients with reported BL allergies.

Methods
Adult patients (≥18 years) receiving vancomycin for surgical prophylaxis with a reported penicillin and/or cephalosporin allergy at our institution between August 2017 to July 2018 were retrospectively evaluated for potential eligibility for penicillin allergy testing and/or receipt of standard prophylaxis. Surgery type and allergy history were extracted from the electronic medical record. Per our institution’s penicillin-testing protocol, patients with IgE-mediated reactions &lt; 10 years ago were eligible for penicillin skin testing (PST), mild reactions or IgE-mediated reaction &gt; 10 years ago were eligible for direct oral amoxicillin challenge, and severe non-IgE mediated allergies were ineligible for penicillin allergy evaluation or BL prophylaxis.

Results
Among 830 patients who received vancomycin for surgical prophylaxis, 196 reported BL allergy and were included in the analysis (155 with penicillin allergy alone; 21 with cephalosporin allergy; 20 with both cephalosporin and penicillin allergy). Approximately 40% of surgeries were orthopedic. Six patients were ineligible for BL prophylaxis. Per institutional protocol, 73 of 155 patients (48%) may have qualified for PST; 81 of 155 (52%) patients may have received a direct oral amoxicillin challenge. Only 3 of 22 patients with history of methicillin-resistant Staphylococcus aureus appropriately received additional prophylaxis with vancomycin and a BL.

Conclusion
Patients with BL allergies often qualify for receipt of a first-line BL antibiotic. An opportunity exists for improved BL allergy assessment as an antimicrobial stewardship intervention. Future studies should evaluate outcomes associated with BL allergy evaluation and delabeling in patients receiving surgical prophylaxis.

Disclosures
All Authors: No reported disclosures
164. Avoiding Complacency: Assessing the Perceived Impact and Value of Antimicrobial Stewardship at a Academic Medical Center
Authors: Lee Matthew S , McCoy Christopher 
Published: January 2021

Abstract

Background
Multi-disciplinary engagement and education remain key measures for Antimicrobial Stewardship Programs (ASPs). Over 3 years, our ASP has undergone key changes to pre-authorization review, post-prescriptive activities, and core team members, coinciding with a 30% increase in stewardship interventions.
The objectives of this study were to evaluate the familiarity of Nursing, Pharmacy and Prescribers at our academic medical center regarding ASP activities and services, as well as perceived impact on patient care and value. Secondary objectives were to determine what resources are currently utilized and areas for improvement.

Methods
Distinct surveys were distributed to three participant groups: Nurses, Pharmacists, and Prescribers (Housestaff, Advanced Practice Providers, and staff physicians). Questions were developed to assess familiarity, perceived value, and overall satisfaction with the ASP. Additional items included questions on the current use of ASP resources and educational engagement. Survey results were compared to a similar survey conducted 3 years amongst the same participant groups.

Results
The survey was delivered electronically to 3367 Prescribers, Nurses and Pharmacists. 403 responders completed the survey (208 Nurses, 181 Prescribers, and 18 Pharmacists). Familiarity was lowest amongst Nurses, but almost doubled compared to 2016 (Figure). Prescribers cited “restricted antibiotic approval”, “de-escalation”, and “alternative therapies relative to allergies” as the three most common interaction types, similar to 2016. ASP interactions continued to be rated “moderate” or “high” value (88.4% vs 89.15% in 2016), however, face-to-face interactions were preferred by only 4% of responders (unchanged compared to 2016). Prescribers also responded uncommon use of ASP online resources (20%) and clinical decision support tools (34%). 78% of responders expressed desire for increased ASP-related education.

Conclusion
As ASPs evolve, it is important to constantly evaluate impact and value, and identify areas for growth. Despite ASP familiarity being high and interactions valued, we need to further optimize ASP provided resources, clinical support tools, and educational offerings.

Disclosures
All Authors: No reported disclosures