bluuebunny/crossref_metadata_2025_split huggingface dataset:
1676. Evaluation of Antibiotic Overuse for Asymptomatic Bacteriuria in a Hospital with Low Baseline Antibiotic Use
Authors: Kernan Bailey , Shihadeh Katherine C , Jenkins Timothy C 
Published: January 2021

Abstract

Background
In 2019, the Infectious Diseases Society of America published guidelines for the management of asymptomatic bacteriuria (ASB) with recommendations to avoid antimicrobial therapy in most patients. Denver Health has existing guidance for the management of patients with a urinary tract infection (UTI) and in August of 2019, implemented specific guidance for the management of ASB. As an institution, Denver Health has a Standardized Antimicrobial Administration Ratio (SAAR) of 0.8-0.9, suggesting a strong antimicrobial stewardship program with a ratio of &lt; 1. The purpose of this study is to assess if signs and symptoms were present in patients prescribed an antibiotic for UTI.

Methods
We retrospectively identified hospitalized patients at least 18 years old who were prescribed an antibiotic with “UTI” as the indication from March 1st to August 31st, 2019. Patients with catheter-associated UTIs were excluded. A random sample of 50 cases was manually reviewed for signs and symptoms of infection. Signs were considered fever, defined as at least 38oC or leukocytosis, defined as at least 10 k/uL WBC. Symptoms collected were based on documentation of patient reported dysuria, frequency, or urgency, or findings of hematuria. The primary outcome was proportion of patients prescribed an antibiotic for UTI in the absence of signs or symptoms. Prescribing patterns for choice and duration of antimicrobials were also surveyed.

Results
A total of 382 antibiotics were prescribed for UTI during the study period. Of the 50 cases reviewed, median age was 65.8 years, with 11% being male. Overall, 29 patients (58%) had no documented symptoms while being treated for UTI. Additionally, 22 patients (44%) had no documented fever, leukocytosis, or urinary symptoms. The most commonly prescribed antibiotics were cefdinir, fosfomycin, and nitrofurantoin. Tables 1 and 2 include additional findings.
Table 1 Symptomology and Type of UTI

Table 2 Antimicrobial Choice and Duration

Conclusion
Despite a well established stewardship program, nearly half of patients prescribed an antibiotic for UTI did not have signs or symptoms consistent with infection. This suggests many patients were treated for ASB, without necessity. Among hospitals with comparatively low antibiotic use, ASB may be a high-yield opportunity to reduce unnecessary antibiotic use.

Disclosures
All Authors: No reported disclosures
1679. Evaluation of the Treatment of Urinalyses and Urine Cultures in Multiple Sclerosis Patients
Authors: Griffith Nicole C , Hill Brandon , Tingen S Ross , Crowe J Cameron 
Published: January 2021

Abstract

Background
Patients with Multiple Sclerosis (MS) experience lower urinary tract dysfunction (LUTD) that in some cases, may necessitate catheterization. Discerning asymptomatic bacteriuria (ASB) from urinary tract infection (UTI) in MS patients is complicated by LUTD, leading to potentially inappropriate antimicrobial use. The purpose of this study was to evaluate the antimicrobial treatment practices of positive urine cultures in patients with MS.
Methods: A single-center, retrospective study. Positive cultures in patients with diagnosed MS (ICD10: G35) were included. The primary outcome was the proportion of patients that were appropriately treated with or without antimicrobial therapy. Secondary endpoints included antimicrobial selection and urinalysis obtainment and positivity.

Results
236 cultures from 139 patients were evaluated. Frequency, nocturia, dysuria, and foul-smelling urine were reported by patients in 54 (23%), 10 (4%), 25 (11%), and 14 (6%) of cases, respectively. Treatment was inappropriate in 81/201 (40%) of treated cultures. The agent selected was considered too broad in 35/201 (17%) instances. Of those, fluoroquinolones were the agents utilized in 33/35 (94%) cases. A urinalysis was sent in 200 (85%) cases, with 197/200 (99%) positive for at least one of four pre-defined positivity criteria.

Conclusion
Urinalyses and urine cultures are obtained frequently in patients with MS, often independent of patient symptomatology. Multiple sclerosis patients may be treated for ASB at higher rates than the general population, and traditional urinary symptoms may not be appropriate indicators of infection. Empiric therapy for UTI is frequently utilized in this population, often resulting in too broad of antimicrobial therapy.

Disclosures
All Authors: No reported disclosures
1681. Female Urinary Metagenomic Analysis and Natural Language Processing Enhances the Infectious Diagnostic Yield in Precision Medicine
Authors: Valencia C Alexander , Baugher David , Larsen Alexander , Chen Alvin , Icenhour Crystal 
Published: January 2021

Abstract

Background
In this study, we assessed the diagnostic yield of metagenomics urine sample testing in patients with urological symptoms.

Methods
We conducted metagenomic analysis on 69 consecutive unbiased female patients, by sequencing their DNA using the KAPA HyperPlus library construction with next-generation sequencing (Nextseq500, Illumina) and reads were analyzed using Xplore-Patho®, an analytical system that permits the detection of 37,000+ microorganisms, including over 12,000 known pathogens, and examined report summaries written by infectious disease experts to obtain a diagnostic yield. In addition, infectious disease expert analysis was contrasted with a natural language (NLP) pathogen detection system to investigate its accuracy.

Results
In the expert data summaries, a total of 95% of the patients tested had at least one pathogen identified by metagenomics as a potential explanation of their urological symptoms and these results were binned into four categories: 1) 51% of infection likely, 2) 4% of infection possible, 3) 26% of low-grade infection likely and 4) 14% of low-grade infection possible. Data from healthy controls was used in conjunction with an NLP pathogen detection pipeline and compared to infectious disease expert summaries. The NLP pathogen algorithm detected that at least 97% of samples had one pathogen which was more than 5 standard deviations from the abundance of that pathogen in healthy controls, and least 84% had 2 or more pathogens. These diagnostic percentages were consistent with the infectious disease expert summaries. The NLP algorithm had access to a large database derived from PubMed articles and it was found that several relevant uropathogens were not mentioned in report summaries. For example, one well-documented uropathogen was present in 13 samples, but was not mentioned in any report summaries.

Conclusion
In conclusion, this study demonstrated the high diagnostic yield in females with urological symptoms following metagenomic analysis and the ability of NLP to enhance the sensitivity of reportable pathogens.

Disclosures
All Authors: No reported disclosures
141. Implementation of Veterans Affairs Outpatient Antimicrobial Stewardship Interventions for Asymptomatic Bacteriuria and Acute Respiratory Infections, a Stepped Wedge Randomized Study
Authors: Mortrude Grace , Rehs Mary , Sherman Katherine , Gundacker Nathan , Dysart Claire 
Published: January 2021

Abstract

Background
Outpatient antimicrobial prescribing is an important target for antimicrobial stewardship (AMS) interventions to decrease antimicrobial resistance in the United States. The objective of this study was to design, implement and evaluate the impact of AMS interventions focused on asymptomatic bacteriuria (ASB) and acute respiratory infections (ARIs) in the outpatient setting.

Methods
This randomized, stepped-wedge trial evaluated the impact of educational interventions to providers on adult patients presenting to primary care (PC) clinics for ARIs and ASB from 10/1/19 to 1/31/20. Data was collected by retrospective chart review. An antibiotic prescribing report card was provided to PC providers, then an educational session was delivered at each PC clinic. Patient education materials were distributed to PC clinics. Interventions were made in a step-wise (figure 1) fashion. The primary outcome was percentage of overall antibiotic prescriptions as a composite of prescriptions for ASB, acute bronchitis, upper-respiratory infection otherwise unspecified, uncomplicated sinusitis, and uncomplicated pharyngitis. Secondary outcomes included individual components of the primary outcome, a composite safety endpoint of related hospital, emergency department or primary care visit within 4 weeks, antibiotic appropriateness, and patient satisfaction surveys.
Figure 1

Results
There were 887 patients included for analysis (405 pre-intervention, 482 post-intervention). Baseline characteristics are summarized in table 1. After controlling for type 1 error using a Bonferroni correction the primary outcome was not significantly different between groups (56% vs 49%). There was a statistically significant decrease in prescriptions for bronchitis (20.99% vs 12.66%; p=0.0003). Appropriateness of prescriptions for sinusitis (OR 4.96; CI 1.79–13.75; p=0.0021) and pharyngitis (OR 5.36; CI 1.93 – 14.90; p=0.0013) was improved in the post-intervention group. The composite safety outcome and patient satisfaction survey ratings did not differ between groups.
Table 1

Conclusion
Multifaceted educational interventions targeting providers can improve antibiotic prescribing for indications rarely requiring antimicrobials without increasing re-visit or patient satisfaction surveys.

Disclosures
All Authors: No reported disclosures
1683. Hospital Admission Patterns in Adult Patients with Complicated Urinary Tract Infections (cUTIs): Identification of Potentially Avoidable Hospital Admissions Across United States (US) Hospitals
Authors: Lodise Thomas , Chopra Teena , Nathanson Brian , Sulham Katherine 
Published: January 2021

Abstract

Background
There is an increase in hospital admissions for cUTI in the US despite apparent reductions in the severity of admissions. However, there are scant data on cUTI hospital admission rates from the emergency department (ED) stratified by age, infection severity, and presence of comorbidities. This study described US hospitalization patterns among adults who present to the ED with a cUTI. We sought to quantify the proportion of admissions that were potentially avoidable based on presence of sepsis and associated symtpoms as well as Charlston Comorbidity Index (CCI) scores.

Methods
A retrospective multi-center study using data from the Premier Healthcare Database (2013-18) was performed. Inclusion criteria: (1) age ≥ 18 years, (2) primary cUTI ED/inpatient discharge diagnosis, (3) positive blood or urine culture between index ED service days -5 to +2. Transfers from acute care facilities were excluded. Based on ICD-9/10 diagnosis codes present on admission, incidence of hospital admissions were stratified by age (≥ 65 years vs. &lt; 65 years), presence of sepsis (S), sepsis symptoms but no sepsis codes (SS) (e.g., fever, tachycardia, tachypnea, leukocytosis, etc.), and CCI.

Results
187,789 patients met inclusion criteria. The mean (SD) age was 59.7 (21.9), 40.4% were male, 29.4% had sepsis, 16.7% had at least 1 SS symptom (but no S), and 53.9% had no evidence of S or SS. The median [IQR] CCI was 1 [0, 3]. 119,668 out of 187,789 (63.7%) were admitted to hospital. Among inpatients, median [IQR] length of stay (LOS) and total costs were 5 [3, 7] days and $7,956 [$4,834, $13,960] USD. Incidence of hospital admissions by age, presence of S/SS, and CCI score are shown in the Table. 18.9% of admissions (22,644/119,668) occurred in patients with no S/SS and a CCI ≤ 2. Their median [IQR] LOS and total costs were 3 [2, 5] days and $5,575 [$3,607, $9,133].
Incidence of Hospital Admission by Age, Charlson comorbidity index (CCI), Presence of Sepsis (S), and Presence of Sepsis Symptoms (SS)

Conclusion
Nearly 1 in 5 cUTI hospital admissions may be avoidable. Given the resources associated with the management of inpatients with cUTIs, these findings highlight the critical need for healthcare systems to develop well-defined criteria for hospital admission based on presence of comorbid conditions and infection severity. Preventing avoidable hospital admissions has the potential to save the healthcare system substantial costs.

Disclosures
Thomas Lodise, PharmD, PhD, Paratek Pharmaceuticals, Inc. (Consultant) Teena Chopra, MD, MPH, Spero Therapeutics (Consultant, Advisor or Review Panel member) Brian Nathanson, PhD, Spero Therapeutics (Independent Contractor) Katherine Sulham, MPH, Spero Therapeutics (Independent Contractor)
1685. Inappropriate Treatment of Asymptomatic Bacteriuria in Elderly Patients: A Quality Improvement Study
Authors: Cornelius Tuhina , Patel Kiran K , Rubinson Michael , Aslam Nadia , Rana Ashish , Abandeh Foad 
Published: January 2021

Abstract

Background
Asymptomatic bacteriuria is often misdiagnosed as Urinary Tract Infection (UTI) in elderly patients. Studies suggest that 15-30% of males and 25-50% of females have asymptomatic bacteriuria. We wanted to estimate the percentage of elderly patients who are treated for UTI at our facility and if treatment was appropriate. The goal was to provide the staff with an educational opportunity and help decide if more antibiotic restriction policies would be beneficial.

Methods
A retrospective study of patients &gt; 65 years of age who were started on antibiotics for presumed UTI at a single medical center between 7/2018 and 12/2018. Reviewed data included demographics, admitting diagnosis, presence or absence of symptoms of UTI and urine culture results. The data was presented at educational conferences and at antimicrobial stewardship meetings in our facility.
Results: 234 patients were started on antibiotics on the basis of pyuria on admission. Of these, only 47% (n=110/234) had symptoms suggestive of UTI. Positive urine cultures were more common in symptomatic patients (n=93/110) compared with asymptomatic patients (n=47/80).
In addition, ninety patients had a change in mental status on presentation and were started on antibiotics for suspected UTI. Approximately one third of these patients had eventual negative urine cultures.
Conclusion: Elderly patients with pyuria and asymptomatic bacteriuria represent a diagnostic challenge due to their inability to vocalize signs or symptoms of UTI. In addition, a percentage of patients who are asymptomatic and admitted for another reason were often started on antibiotics inappropriately on the basis of pyuria alone. Studies have shown that treating asymptomatic bacteriuria does not add a mortality benefit or lower risk of infection. The CDC emphasizes the importance of assessing for clinical symptoms of UTI before treatment is considered.
Our study highlights the importance of provider education in the management of asymptomatic bacteriuria in elderly patients. We also feel that antibiotic restriction policies may limit use of antibiotics for asymptomatic bacteriuria. This would in turn improve patient outcomes and decrease incidence of clostridium difficile associated colitis.

Disclosures
All Authors: No reported disclosures
1686. Microbiology of Community-Onset Urinary Tract Infections in the United States, 2012-2017
Authors: Preston Leigh Ellyn , McDonald Clifford , Olubajo Babatunde , McCarthy Natalie , Reddy Sujan , Wolford Hannah , Hatfield Kelly M , Sheriff Edward , Jernigan John A , Kourtis Athena P , Baggs James 
Published: January 2021

Abstract

Background
Community-onset urinary tract infections (coUTIs) are one of the most common indications for antibiotic prescribing. It is important to understand patient demographic factors associated with microorganisms causing coUTI and their antibiotic resistance profiles, to tailor antibiotic prescribing practices. We analyzed microbiology data to understand factors associated with coUTI in the United States (US).

Methods
CoUTIs were identified in the Premier Healthcare Database and Cerner Health Facts among patients treated at participating healthcare facilities in the US between 2012-2017. Cases were defined by urine cultures yielding a bacterial organism and were collected in outpatient settings or within three days of hospitalization. Only the first specimen for each encounter was included in the analysis. Data on the organisms isolated, patient’s age, sex, and US census regions of the submitting facilities were described and compared using chi-square tests for associations. Encounters were classified as inpatient (INPT), observation (OBS), emergency department (ED), and outpatient (OTPT) based on the setting in which the culture was submitted.

Results
Using data from 637 acute care hospitals, urine samples from 3,291,561 encounters were included, with 776,653 (25.7%) INPT, 1,063,219 (34.8%) ED, 107,760 (3.5%) OBS, and 1,092,658 (35.8%) OTPT. The pathogens most frequently associated with coUTIs were Escherichia coli (57.3%), Klebsiella pneumoniae (9.7%), Enterococcus faecalis (5.1%), Proteus mirabilis (4.9%), and Pseudomonas aeruginosa (2.9%). Female sex, age &lt; 65y and OTPT and ED settings were associated with higher relative frequency of E. coli (all p &lt; 0.0001). Male sex, INPT setting and age &gt;65 y were associated with higher relative frequency of P. aeruginosa, P. mirabilis and E. faecalis (all p &lt; 0.0001, Figure). K. pneumoniae was found at higher relative frequency in those &gt;45y, and in INPT and OBS settings (all p &lt; 0.0001).
Figure. Distribution of pathogens most frequently associated with community onset urinary tract infections

Conclusion
Understanding patient factors associated with the microbiology of coUTIs is an important step in developing treatment recommendations and antibiotic stewardship efforts. Further analyses will include assessing the impact of major antibiotic resistance phenotypes, geographic and healthcare settings.

Disclosures
All Authors: No reported disclosures
1690. Oral Fosfomycin for the Treatment of Bacterial Prostatitis
Authors: Kamath Meghan , Johns Scott T , Ma Ariel , Mehta Sanjay 
Published: January 2021

Abstract

Background
Bacterial prostatitis (BP) is notoriously difficult to treat. Few antibiotics penetrate the prostate well, and antibiotic resistance can further restrict options. A small body of recent literature suggests fosfomycin, a bactericidal antibiotic that can treat multidrug resistant (MDR) organisms and has little cross-resistance, may both effectively penetrate the prostate and treat BP. This study sought to add to the limited literature on the efficacy and safety of fosfomycin for BP.

Methods
Patients treated for BP with fosfomycin between November 2009 and May 2019 at the San Diego VAMC were retrospectively examined. Patients were excluded if they died within 6 months of completion of fosfomycin or if fosfomycin was used for less than half of the treatment course. If fosfomycin was used to treat a urinary tract infection (UTI), an infectious disease physician determined if the UTI may have been undiagnosed BP. Outcomes were clinical and microbiological cure at 6 months and adverse events to fosfomycin reported during the trial period.

Results
The study included 29 patient cases. All but one had chronic BP. Most initially presented outpatient (66%). Almost all had prior occurrences of BP treated with antibiotics (90%). The most common pathogen was E. coli (73%), and 87% of all pathogens were MDR. The most common fosfomycin dosing regimen was 3g PO q48h (66%), with 3g PO q24h as the next most common (21%). Less than half of patient cases received fosfomycin courses &gt; 28 days (38%), while the remaining received courses &lt; 14 days (62%). At 6 months, 48% achieved clinical cure and 44% achieved microbiological cure. When comparing those who received courses &gt; 28 days vs. courses &lt; 14 days, clinical cure was achieved in 55% vs. 44% and microbiological cure in 56% vs. 39%, respectively. Adverse events were reported in 6 unique patients (27%), mostly diarrhea with one instance of nausea.

Conclusion
Fosfomycin may be a safe and effective alternative for the treatment of chronic BP. Treatment courses longer than 4 weeks may be more effective than courses shorter than 2 weeks with a similar rate of adverse events. This study also highlights inpatients as a relevant BP population and a need for provider education on identifying BP and prescribing optimal durations of therapy.

Disclosures
All Authors: No reported disclosures
142. Implementing an Antimicrobial Stewardship Program in the Outpatient Setting
Authors: Nielsen Travis B , Santarossa Maressa , Probst Beatrice D , Labuszewski Laurie , Lopez Jenna , Barsanti-Sekhar Mary C , Albarillo Fritzie S 
Published: January 2021

Abstract

Background
Antimicrobial-resistant infections lead to increased morbidity, mortality, and healthcare costs. Among the most facile modifiable risk factors for developing resistance is inappropriate prescribing. The CDC estimates that 47 million (or ≥30% of) outpatient antibiotic prescriptions in the United States are unnecessary. This has provided impetus for expanding our antimicrobial stewardship program (ASP) into the outpatient setting. Initial goals included the following: continuous evaluation and reporting of antibiotic prescribing compliance; minimize underuse of antibiotics from delayed diagnoses and misdiagnoses; ensure proper drug, dose, and duration; improve the percentage of appropriate prescriptions.

Methods
To achieve these goals, we first sent a baseline survey to outpatient prescribers, assessing their understanding of stewardship and antimicrobial resistance. Questions were modeled from the Illinois Department of Public Health (IDPH) Precious Drugs & Scary Bugs Campaign. The survey was sent to prescribers at 19 primary care and three immediate/urgent care clinics. Compliance rates for prescribing habits were subsequently tracked via electronic health records and reported to prescribers in accordance with IRB approval.

Results
Prescribers were highly knowledgeable about what constitutes appropriate prescribing, with verified compliance rates highly concordant with self-reported rates. However, 74% of respondents reported intense pressure from patients to inappropriately prescribe antimicrobials. Compliance rates have been tracked since December 2018 and comparing pre- with post-intervention rates shows improvement in primary care since reporting rates to prescribers in August 2019.

Conclusion
Reporting compliance rates has been helpful in avoiding inappropriate antimicrobial therapy. However, the survey data reinforce the importance of behavioral interventions to bolster ASP efficacy in the outpatient setting. Going forward, posters modeled off of the IDPH template will be conspicuously exhibited in exam rooms, indicating institutional commitment to the enumerated ASP guidelines. Future studies will allow for comparison of pre- and post-intervention knowledge and prescriber compliance.

Disclosures
All Authors: No reported disclosures