bluuebunny/crossref_metadata_2025_split huggingface dataset:
90. Incidence and Risk Factors for Inappropriate Use of Non-culture Based Fungal Assays: Implication for Diagnostic Stewardship
Authors: Ito Hiroshi , Okamoto Koh , Yamashita Marie , Yamamoto Shinya , Kanno Yoshiaki , Jubishi Daisuke , Ikeda Mahoko , Harada Sohei , Okugawa Shu , Moriya Kyoji 
Published: January 2021

Abstract

Background
Culture-based diagnostic tests are the gold standard for diagnosing invasive fungal diseases (IFDs). Because these tests have low sensitivity, non-culture-based fungal assays (NCBFAs) have been used increasingly to help diagnose IFDs. However, little is known about inappropriate use of NCBFAs. We aimed to investigate inappropriate use of NCBFAs in a tertiary academic hospital in Tokyo, Japan.

Methods
This retrospective cohort study included all patients who underwent testing with beta-D glucan (BDG) between January and March 2018, or galactomannan antigen (GMA) or cryptococcal antigen (CRAG) between January and June 2018. Patients who had received hematopoietic stem cell or solid organ transplantations were excluded. Appropriateness was assessed according to the previously published study. We compared patients with appropriate and inappropriate use of NCBFAs. Risk factors for inappropriate use were evaluated using multivariate logistic regression analysis.

Results
Of 1,140 patients (BDG, 1,009; GMA 273; CRAG, 310) who underwent tests, 470 patients (BDG, 394; GMA, 138; CRAG, 164) were included in this study. Four hundred thirty-eight patients (93.2%) were aged 18 or older. About 80% of NCBFAs (BDG, 334 patients [74.8%]; GMA, 117 patients [74.8%]; CRAG, 146 patients [89.0%]) were deemed inappropriate. The factors associated with inappropriate NCBFAs use included specialties of ordering physicians, risk factors for fungal infections, and recommendation from infectious disease physicians (Table). Sixty-four patients (13.6%) underwent three inappropriate NCBFAs simultaneously. Furthermore, during the study period, 408 patients (35.8%) with inappropriate NCBFAs underwent the same assays repeatedly during the study period; 643 times for BDG, 163 times for GMA, and 192 times for CRAG.
The Factors Associated with Inappropriate Use of Non-Culture Based Fungal Assays

Conclusion
We found a large proportion of NCBFAs were deemed inappropriate and it was mostly driven by ordering physicians who generally care for transplant patients. Because inappropriate use of NCBFAs could lead to additional inappropriate tests and treatment with substantial costs to patients and health systems, diagnostic stewardship targeting NCBFAs is urgently needed.

Disclosures
All Authors: No reported disclosures
91. Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Otitis Media
Authors: Lautenbach Ebbing , Gerber Jeffrey , Grundmeier Robert , Hamilton Keith W , Hicks Lauri , Neuhauser Melinda M , Frager Nicole , Menon Muida , Kratz Ellen , Jaskowiak Anne , Cressman Leigh , James Tony , Omorogbe Jacqueline 
Published: January 2021

Abstract

Background
Antibiotic stewardship (AS) interventions have primarily focused on acute care settings. The majority of antibiotic use, however, occurs in outpatients. The electronic health record (EHR) might provide an effective and efficient tool for outpatient AS. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with acute otitis media (AOM).

Methods
Within the Children’s Hospital of Philadelphia (CHOP) Care Network, we used ICD-10 diagnostic codes to identify patient encounters for AOM at any CHOP practice between 3/15/17 – 3/14/18. Exclusion criteria included underlying immunocompromising condition, comorbidities, and concurrent infections that might influence antibiotic use. We randomly selected 450 eligible subjects (150 each from academic practices, non-academic practices, and urgent care). Inappropriate antibiotic use based on CHOP and professional society guidelines were assessed via chart review and served as the basis for assessment of the electronic algorithm which was constructed using only data in the electronic health record (EHR). Criteria for appropriateness focused on the decision to prescribe, the choice of antibiotic, and duration of therapy.

Results
Of 450 subjects, median age was 2, 46% were female, and 88% were evaluated by a physician (vs. advanced practice provider). On chart review, the prescribing decision was correct in 438 (97%), of which 25 appropriately received no antibiotics. Of the 413 subjects who were appropriately prescribed an antibiotic, the choice of antibiotic was appropriate in 37 (9%). Finally, of the 413 patients who were appropriately treated, 412 (99.7%) received the correct duration. Test characteristics of the EHR algorithm (compared to chart review) are noted in the Table.

Conclusion
For children with AOM, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. This algorithm can also highlight for which elements of prescribing the impact of an intervention might be greatest (i.e., choice of agent). Future work should validate this approach in other health systems and geographic regions and evaluate the impact of an audit and feedback intervention based on this tool.
Table. Test Characteristics of Electronic Algorithm for Inappropriate Prescribing, Agent, and Duration

Disclosures
All Authors: No reported disclosures
92. Successful Scale-up of an Intervention to Decrease Unnecessary Urine Cultures Led to Improvements in Antibiotic Use
Authors: Grigoryan Larissa , Van John , Ramsey David J , Goebel Melanie , Walder Annette , Kramer Jennifer , Chou Andrew , Patel Payal K , Graber Christopher J , Lichtenberger Paola , Wiseman Steven , Shukla Bhavarth , Drekonja Dimitri , Calub Feliza , Naik Aanand , Trautner Barbara 
Published: January 2021

Abstract

Background
We previously conducted a successful single-site intervention to improve compliance with antibiotic stewardship guidelines for asymptomatic bacteriuria (ASB). In this dissemination project we explored whether we could facilitate antibiotic stewardship for ASB at a distance, in four distant VA medical centers.

Methods
Each site champion received a decision-aid algorithm, interactive teaching based on actual cases, and support with data collection. The focus of the intervention was on teaching providers in acute and long-term care to avoid ordering unnecessary urine cultures. We measured DOT (days of antibiotic therapy), LOT (length of antibiotic therapy) and urine cultures ordered per 1,000 bed-days monthly in the intervention sites and four matched control sites. Both DOT and LOT captured all systemic antibiotics initiated on day -1 to +2 of a urine culture order. We conducted segmented regression analyses for the three outcomes for the intervention and control sites separately, and difference in differences analysis for urine cultures.

Results
Over the baseline and intervention years, 12,260 urine cultures were ordered in 6823 unique patients in the acute and long-term care wards at the 8 sites. During the baseline year, the average urine-culture related DOT was 45.1 and LOT was 34.7, per 1000 bed-days. Both DOT and LOT decreased significantly over the intervention period in the intervention sites (p &lt; 0.05 for both); a significant decrease was not seen in the control sites (Figures 1 and 2). For urine cultures, at baseline the average number of cultures ordered per month per 1000 bed-days was 13.6. Both intervention and control sites saw a significant decrease in urine cultures over the baseline year. In the intervention year, urine cultures continued to decrease in the intervention sites (p=0.001) but increased in the control sites (Figure 3).
Figure 1. Days of Therapy (DOT) per 1,000 bed-days, for antibiotics started within -1 to +2 days of a urine culture

Figure 2. Length of Therapy (LOT) per 1,000 bed-days, for antibiotics started within -1 to +2 days of a urine culture

Figure 3. Urine Cultures per 1,000 bed-days

Conclusion
Our externally-facilitated intervention significantly decreased local antibiotic use (both DOT and LOT) and urine cultures. Unnecessary urine cultures are a major driver of unnecessary antibiotic use for ASB, and our focus on diagnostic stewardship for urine cultures led to antibiotic stewardship. Our next step will be to further disseminate our intervention to other VA facilities.

Disclosures
All Authors: No reported disclosures
93. Enhanced Oral Care as Prevention for Non-ventilator Hospital Acquired Pneumonia
Authors: Giuliano Karen K , Penoyer Daleen , Middleton Aurea , Baker Dian 
Published: January 2021

Abstract

Background
Non ventilator hospital-acquired pneumonia (NVHAP) is now the most common HAI. The purpose was to test primary source control through reduction of germs in the mouth as a modifiable risk factor for in NVHAP prevention.

Methods
The 12-month study (10/1/18–9/31/19) was conducted at an 800-bed tertiary medical center. 1 medical and 1 surgical unit were randomized to enhanced oral care (intervention) and matched with 1 medical and 1 surgical unit providing usual oral care (control). An American Dental Association oral care protocol was delivered by nurses/nursing assistants (Intervention) vs. usual care. Frequency of oral care was tracked. Pneumonia cases were identified using ICD-10 codes and confirmed using CDC criteria.

Results
For medical control (n=2059) v. intervention (n=2706), oral care/day increased from .96 to 2.2; there was an 85% reduction in NVHAP (1.41 to 0.21)/1000 patient days which was significant by Chi-square (p&lt; 0.001), and Cramer’s V effect size of 0.52. Using logistic regression, the odds of NVHAP were 7.1 times higher on the on the control unit v. intervention (OR:7.1 [CI 2.01:24.1] p=.002). For surgical control (n=2075) v. intervention (n=1830), oral care frequency/day increased from 1.2 to 2.1. There was a 56% reduction in NVHAP which was NS by Chi-square (p=.289), Cramer’s V effect size of 0.02, and this group was underpowered to detect a difference (post hoc actual power=.61).
NVHAP demographics

NVHAP incidence

NVHAP secondary outcomes

Conclusion
These findings add to the growing body of evidence that oral care as primary source control is likely to have a role in NVHAP prevention.

Disclosures
Karen K. Giuliano, PhD, Medline (Grant/Research Support) Daleen Penoyer, PhD, RN, Medline (Grant/Research Support) Aurea Middleton, MS, RN, Medline (Grant/Research Support) Dian Baker, PhD, RN, Medline (Grant/Research Support)
94. Clinical Correlates of Cdc’s Hospital-onset Adult Sepsis Event Surveillance Definition and Association with Reportable Healthcare-associated Infections
Authors: Page Brady , Klompas Michael , Chan Christina , Filbin Michael , Dutta Sayon , McEvoy Dustin , Rhee Chanu 
Published: January 2021

Abstract

Background
Hospital-onset (HO) sepsis is associated with substantial mortality but is not tracked or reported by most hospitals. CDC’s Adult Sepsis Event (ASE) definition may facilitate standardized surveillance but little is known about the clinical correlates of HO-ASEs and their association with currently reportable healthcare-associated infections (HAIs).

Methods
In this retrospective study of all adult patients admitted to an academic medical center between June 2015–2018, we assessed the overlap between HO-ASEs and HAIs reported to the National Healthcare Safety Network (NHSN) and reviewed a random subset of 110 HO-ASE cases to determine their clinical correlates.

Results
The cohort included 168,249 hospitalized patients, including 2,139 (1.3%) with HO-ASE and 2,133 (1.3%) with NHSN HAIs. Amongst the 2,139 HO-ASE patients, 480 (22.4%) had ≥1 HAI: 8.1% VAE, 6.2% CLABSI, 6.1% C.difficile, 3.1% CAUTI, 1.3% MRSA bacteremia, and 0.8% SSI. HO-ASE was associated with higher in-hospital mortality rates than HAIs (28.6% vs 14.6%, p&lt; 0.001). HO-ASE associated mortality was high even when NHSN-reportable HAIs were absent (26.5%) whereas NHSN-reportable HAI mortality was relatively low when HO-ASE was absent (8.4%). Amongst the 110 reviewed HO-ASE cases, 102 (93%) were possible or confirmed infections, most commonly pneumonia (39%, of which 35% were ventilator-associated), non-C.difficile intra-abdominal infections (15%), febrile neutropenia (14%), urinary tract infection (7%, of which 88% were catheter-associated), and skin/soft tissue infection (7%). Most (86%) infections flagged by HO-ASEs were acquired in the hospital rather than the community. The most common non-infectious events flagged by HO-ASE were pulmonary edema and periprocedural blood loss associated with blood cultures and empiric antibiotics.

Conclusion
CDC’s hospital-onset ASE definition accurately identifies patients with nosocomial sepsis who have very high mortality rates and are generally not captured by currently reportable HAI metrics. Routine hospital-onset ASE surveillance could provide a broader window into serious nosocomial infections, identify new targets for prevention, and further improve outcomes for hospitalized patients.

Disclosures
All Authors: No reported disclosures
95. CAUTI and CLABSI in Hospitalized COVID-19 Patients
Authors: Knepper Bryan C , Wallace Kristin , Young Heather 
Published: January 2021

Abstract

Background
Patients hospitalized for suspected or confirmed COVID-19 often require high levels of support, including supplemental oxygen or ventilation, intravenous fluids and pressors, prone positioning, and strict input/output monitoring. Increased utilization of invasive devices such as indwelling urinary catheters and central venous catheters may be needed in this population. Staff minimize contact time with COVID-19 patients. We hypothesized higher rates of device infection in patients with COVID-19.
Table 1

Methods
This is a retrospective cohort study at a 555-bed safety net hospital. 4 units (125 beds) primarily cared for patients with confirmed infection. Other units did not accept patients until COVID status was deemed negative, except Labor & Delivery and a designated mixed unit. Indwelling urinary catheter and central venous catheter (CVC) device days are tracked in all inpatient areas. CLABSI and CAUTI surveillance is performed using NHSN definitions. The first hospitalized COVID-19 case at our hospital occurred late March 2020. April - May 2020 was considered the initial pandemic phase for our institution. Device utilization for the 6 months prior (October 2019 – March 2020) was compared to initial pandemic phase. Device infection rates were also compared. Within the initial pandemic phase, utilization and infection rates were stratified by COVID-19 vs non-COVID-19 areas.

Results
Median indwelling urinary catheter usage increased during the initial pandemic period by 36% (998 to 1355 catheter days, p=0.13); CVC usage increased 25% (997 to 1246 CVC days, p=0.13). Hospital-wide, median CAUTI rates remained constant (2.9 and 2.7 infections/1000 catheter days, p=1.00). CLABSI rates increased significantly (0.0 and 1.6 infections/1000 CVC days, p=0.008). CAUTI rates were 83% higher, and CLABSI rates were 65% higher in COVID-19 areas compared to non-COVID-19 areas (Table 1). Urine culture and blood culture ordering were 69% higher and 73% higher in COVID-19 areas, respectively.

Conclusion
Utilization of both indwelling urinary catheters and CVC increased during the initial phase of the pandemic. Hospitalized COVID-19 patients appear to be at higher risk of both CAUTI and CLABSI. Patient care protocols, device utilization and culture ordering all require further investigation.

Disclosures
All Authors: No reported disclosures
96. Surgical Site Infection Prophylaxis Selection and Postoperative Clinical Outcomes in Patients with Reported Penicillin Allergy
Authors: Dare Ryan K 
Published: January 2021

Abstract

Background
Administration of preoperative antibiotics are known decrease risk of postoperative surgical site infections (SSI) and deviation from first line prophylaxis increases this risk. Patients who report penicillin (PCN) allergy are less likely to receive cefazolin preoperatively despite being the preferred antibiotic for SSI prevention in the majority of surgical procedures.

Methods
A single center retrospective descriptive study was performed during the 2018–2019 academic year. Perioperative antimicrobial administration practice was evaluated for all types of surgical procedures. Patient demographics, PCN allergy history, development of Clostridioides difficile infection (CDI) within 90 days of procedure, and total hip and knee arthroplasty SSIs were assessed.

Results
During the study period, 16,376 procedures were performed with perioperative antibiotic administration. Cefazolin (12,756; 77.9%) was most frequently administered followed by clindamycin (1,396; 8.5%), and vancomycin (735, 4.5%). PCN allergy was reported in 2,051 (12.5%) patients, of which 1,180 (57.5%) had record of previously receiving a cephalosporin. Interestingly, 694 (33.8%) and 11,799 (82%) patients with and without a reported PCN allergy respectively received cefazolin perioperatively (P&lt; 0.001). The incidence of joint replacement SSI was higher in patients with a reported PCN allergy (6 of 97; 6.2%) compared to those without (12 of 671; 1.8%) (P=0.018). CDI occurred in 44 (1.1%) of 3,883 and 70 (0.5%) of 12,493 patients who received a non-cefazolin or cefazolin respectively for prophylaxis (OR 2.1; 95% CI 1.5–2.9). In multivariate analysis controlling for surgery type, age, weight, and renal function, receipt of a non-cefazolin antibiotic was independently associated with developing CDI (OR 1.6; 95% CI 1.1–2.4).

Conclusion
Patients with a reported PCN allergy were more likely to receive a non-cefazolin antibiotic perioperatively and were more likely to develop a SSI following hip or knee replacement. Administration of a non-cefazolin antibiotic was independently associated with increased risk of CDI. Efforts should be made to minimize inappropriate avoidance of first line perioperative prophylaxis due to reported PCN allergies.

Disclosures
Ryan K. Dare, MD, MS, Accelerate Diagnostics, Inc (Research Grant or Support)
98. Antibiotic Stewardship Interventions Significantly Improve Preferred Antibiotic Prophylaxis in Total Joint Arthroplasty
Authors: Quartuccio Katelyn , Roberts Raquel , Pillinger Kelly E , Heintz Eric , Stern Jessica , Myers Thomas 
Published: January 2021

Abstract

Background
Most patients reporting a penicillin (PCN) allergy can tolerate cefazolin, the preferred prophylaxis in a total joint arthroplasty (TJA). The purpose of this study was to evaluate surgical prophylaxis in patients with a reported PCN allergy undergoing a TJA following a stewardship intervention that included updates to institutional guidelines, reclassification of severe PCN allergy, standardization of ordering processes, and participation of a physician champion.

Methods
This was a single center, retrospective study of adult orthopedic patients greater than 18 years old who underwent a primary elective TJA at a 261-bed community hospital from March 1, 2017 to August 30, 2017 (pre-intervention) and from March 1, 2019 to August 30, 2019 (post-intervention). The primary outcome was the difference in the composite rate of the following: 1) Patients with a reported non-severe PCN allergy without MRSA risk factors who received cefazolin; 2) Patients with a non-severe PCN allergy with MRSA risks factors who received cefazolin plus vancomycin; and 3) Patients with a severe PCN allergy who received vancomycin prior to a primary elective TJA.

Results
A total of 180 patients with a documented PCN allergy were evaluated (90 patients in the pre-intervention group and 90 patients in the post-intervention group). Rash and hives were the most commonly reported allergies in both groups (71% vs 61%, P=0.2076). Post-intervention revealed a significant increase in the primary outcome of appropriate perioperative antibiotic (55% vs 91%, P&lt; 0.001), largely driven by patients with non-severe allergy [47% (36/76) vs 96% (73/76), P&lt; 0.001]. No patients had signs of an allergic reaction thought to be due to cefazolin, including 8 patients with severe PCN allergy. No patients in either group developed a surgical site infection or C. difficile infection within 90 days post-procedure.

Conclusion
A multifaceted antibiotic stewardship intervention increased preferred prophylaxis in elective primary TJA. Patients with non-severe PCN allergies, even those reporting hives or local swelling, can tolerate cefazolin without issue. Patients with severe PCN allergy should undergo further evaluation as cefazolin may be a safe option.

Disclosures
Katelyn Quartuccio, PharmD, BCPS, AstraZeneca (Consultant) Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker)
99. Effectiveness of Antibiotic Prophylaxis Among Patients Undergoing Elective Transurethral Resection of the Prostate in the Era of Antibiotic Resistance
Authors: Khawcharoenporn Thana , Kanoktipakorn Pimjira 
Published: January 2021

Abstract

Background
Data existing on effectiveness of antibiotic prophylaxis (AP) for transurethral resection of the prostate (TURP) are limited in the era of antibiotic resistance.

Methods
A 4-year prospective observational cohort study was conducted among patients undergoing TURP in an academic tertiary-care hospital during 2016–2019. Patients were excluded if pre-operative (pre-op) urine cultures were not sent or grew mixed (&gt;2) organisms, or they had pre-op urinary tract infection (UTI) or lost follow-up after TURP. Appropriateness of AP was defined as 1) correct dosing and duration and narrowest spectrum according to the hospital AP guidelines and local epidemiology and 2) being active against uropathogens isolated from the pre-op culture. Primary outcome was the rate of UTI within 30 days post TURP compared between appropriate antibiotic prophylaxis (AAP) and inappropriate antibiotic prophylaxis (IAP) groups.

Results
342 patients were screened and 61 were excluded. Of the 281 patients included, 139 (49%) received AAP and 142 (51%) received IAP. The reasons for IAP were prescribing too broad-spectrum antibiotics (57%), inactive antibiotics (41%) and incorrect dosing (2%). Pre-op urine cultures were no growth in 148 patients (53%). Among the 133 positive urine cultures with 144 isolates, Escherichia coli (52%) was the most commonly isolated. Thirty-one percent of these 144 isolates produced extended-spectrum beta-lactamase (ESBL) and 23 (16%) isolates were multidrug-resistant. The resistant rates of Enterobacteriaceae were 73% for ciprofloxacin, 65% for TMP-SMX and 46% for ceftriaxone. The two most commonly prescribed prophylactic antibiotics were ceftriaxone (51%) and ciprofloxacin (34%). The rate of UTI within 30 days post-TURP was significantly higher in IAP group compared to AAP group (47% vs 27%; P&lt; 0.001). Prescribing inactive prophylactic antibiotics was the independent factor associated with 30-day post-TURP UTI (adjusted odds ratio 2.88; P=0.001).

Conclusion
Appropriate antibiotic prophylaxis significantly reduced UTI within 30 days of elective TURP. Obtaining pre-op urine culture and prescribing an active prophylactic agent are critical for preventing post-TURP UTI in the era of antibiotic resistance.

Disclosures
All Authors: No reported disclosures