bluuebunny/crossref_metadata_2025_split huggingface dataset:
1349. Institutional Antibiograms Are Insufficient to Guide Clindamycin Use in Pediatric Skin and Soft Tissue Infections
Authors: Firmani Sarah E , Molloy Leah , Trivedi Gaurangi , Abdel-Haq Nahed M 
Published: January 2021

Abstract

Background
Clindamycin (CLN) is a common empiric antimicrobial for pediatric skin and soft tissue infections (SSTI) despite decreasing susceptibility of Staphylococcus aureus (SA) to CLN on institutional antibiograms. This study inquired whether institutional antibiograms are an accurate representation of susceptibility for these infections. It also attempted to find patient and infection characteristics associated with being clindamycin susceptible (CLN-S).

Methods
This was a retrospective chart review of children with community-acquired (CA) SA infections in 2016 and 2017. A Staphylococcus aureus antibiogram was created based on infection type. Various patient and infection characteristics were compared between CLN-S and clindamycin-resistant (CLN-R) isolates to identify predictors of being CLN-S via binary logistic regression. Characteristics with p &lt; 0.2 from a univariate analysis (chi-square or Fisher’s exact test) were included in the regression; p &lt; 0.05 after the regression was considered statistically significant.

Results
362 SA infections were included. These were 76% CLN-S, similar to the institutional antibiogram (79% CLN-S, p = 0.168). MSSA CLN susceptibility was lower than the antibiogram (71% vs. 79% CLN-S, p = 0.042). MRSA susceptibility was similar (79% vs. 80% CLN-S, p = 0.859). Infection types assessed were abscess (n = 264, 81% CLN-S), osteomyelitis (n = 40, 75% CLN-S), lymph node (n = 16, 75% CLN-S), staphylococcal scalded skin syndrome (n = 9, 56% CLN-S), eczema superinfection (n = 17, 53% CLN-S), bullous impetigo (n = 7, 40% CLN-S), and non-bullous impetigo (n = 7, 29%). Characteristics found to be associated with being CLN-S included abscess (OR 3.883, p = 0) and high white blood cell count (OR 2.482, p = 0.001). Characteristics associated with CLN-R included contact to person with abscess (OR 0.468, p = 0.035) and hypotension during infection (OR 0.312, p = 0.005).

Conclusion
The use of institutional antibiograms to guide CLN susceptibility in CA SA infections may be limited by the type of infection, patient characteristics, and the likelihood of MSSA vs. MRSA infection. In our patients, having an abscess was associated with CLN-S. Empiric therapy of CA SA infections in children should not be driven solely by institutional antibiograms.

Disclosures
All Authors: No reported disclosures
1351. Pediatric Antibioitic Use in the North Carolina Medicaid Population
Authors: Young Rebecca R , Lantos Paul , Lantos Paul , Smith Michael J 
Published: January 2021

Abstract

Background
Antimicrobial resistance is increasing in the United States, with antibiotic use as the main driver. The majority of antibiotic use occurs in the outpatient setting. 6 of the 7 highest prescribing states are located in the Appalachian region of the country. Overall, the state of North Carolina (NC) has prescribing rates that are at the national average, but the geographic, patient and provider-level characteristics associated with antibiotic prescribing within the state are unknown.

Methods
We used NC Medicaid claims from 2013-2018 to identify oral antibiotics prescribed to children, defined as individuals &lt; 21 years. Antibiotics were identified using National Drug Codes. Overall rates of antibiotic prescribing were reported as the number of prescriptions per 1000 children overall and stratified by age, sex, race/ethnicity and residence in a metropolitan area. Provider characteristics and setting type were identified using existing variables in the Medicaid dataset. A geographic information system was used to graphically depict rates of antibiotic use by county.

Results
Rates of prescribing decreased from 724/1000 children in 2013 to 578/1000 children in 2018. Across all study years there were differences in prescribing rates by sex, race/ethnicity, age and residence in a metropolitan area. (Table) Prescriptions were more common in children who were younger (0-2), white non-Hispanic, female and living in non-metropolitan areas. Prescribing rates were geographically heterogeneous, with the highest rates in the western mountain region and declining across a west to east gradient. (Figure) Most (62%) antibiotic prescriptions were written in the primary care setting. Pediatricians prescribed 48% of all antibiotic courses.
Antibiotic Prescriptions Per 1000 Children, by Demographic Group (2013-2018)

Antibiotic Prescriptions per 1000 Children, by County (2013-2018)

Conclusion
Although NC is not a high-prescribing state in general, we found notable difference in prescribing based on key demographic characteristics. These results are consistent with prior reports from other Appalachian states including Kentucky, West Virginia and Tennessee. Rates of prescription were highest in non-metropolitan areas overall but GIS mapping revealed a marked west-east gradient. These data suggest that specific Appalachian characteristics, rather than rurality alone, may be associated with excessive antibiotic prescribing.

Disclosures
Michael J. Smith, MD, MSC.E, Kentucky Medicaid (Grant/Research Support)Merck (Grant/Research Support)
1353. Pediatric Urinary Tract Infections: A Choosing Wisely Initiative to Advance Antimicrobial Stewardship and Diagnostic Accuracy in the Emergency Department
Authors: Prodanuk Michael , Foong Yen , Singh Valene , Morrissey Laura , Science Michelle , Ostrow Olivia 
Published: January 2021

Abstract

Background
Urinary tract infection (UTI) is a common diagnosis in the pediatric emergency department (ED) that often results in empiric antibiotic treatment prior to culture results. A 2016 cohort study from our centre found that 47% of children diagnosed with a UTI and prescribed antibiotics had a negative urine culture. None of these patients were notified of the misdiagnosis or told to discontinue antibiotics.
Figure 1: Choosing Wisely pediatric urinary tract infection diagnostic algorithm

Figure 2: Patients included/excluded with exclusion criteria

Methods
Institutional approval was obtained for a quality improvement project in our quaternary pediatric ED. For uncomplicated pediatric UTIs, the aim was to reduce misdiagnosis by 50% and promote antimicrobial stewardship over a 24-month period. Using the Model for Improvement, two interventions were implemented using PDSA cycles: (1) a UTI diagnostic algorithm embedded in the electronic medical record, (2) a urine culture callback system. Outcome measures included the percentage of patients with UTI misdiagnosis (urine culture negative) and antibiotic-days saved. Process measures included adherence to the UTI algorithm and callback system as well as antibiotic duration standardization. As a balancing measure, patients developing positive urine cultures without UTI diagnosis were reviewed for potential harm.
Figure 3: Run chart of urinary tract infection misdiagnosis rate

Figure 4: Callback system - Percent patients contacted and antibiotics-days saved

Results
From June 2017-April 2020, 2,183 children (0.97% of all visits) were diagnosed with a UTI in the ED. 1,381 (63.3%) met inclusion criteria for analysis. Following UTI algorithm launch, median UTI misdiagnosis decreased by 20% (52.5% vs. 32.5%), median correct antibiotic duration increased by 30% (45.2% vs. 75.1%), and algorithm adherence was 78.9%. With implementation of the callback system, 1,678 antibiotic-days were saved as mean patients contacted to discontinue antibiotics increased from 0% to 76.8%. Of 106 patients with positive urine cultures with missed UTI diagnosis over a 29-month period, 8 patients returned to the ED within 72 hours and 2 patients required admission for intravenous antibiotics.

Conclusion
Implementation of a UTI diagnostic algorithm and urine culture callback system for uncomplicated pediatric UTIs reduced UTI misdiagnosis and promoted antimicrobial and resource stewardship in the ED. Future directions include improving UTI algorithm adherence through targeted clinician audit and feedback, plus sustainability planning.

Disclosures
Olivia Ostrow, MD, Choosing Wisely Canada (Advisor or Review Panel member)
1354. Reducing vancomycin utilization rate in a level 4 NICU
Authors: Chang Millie R , Mongkolrattanothai Kanokporn , Chin Steven , Li Yijie , Orbach Regina , Stach Leslie , Nair Srikumar , Milisavljevic Vladana 
Published: January 2021

Abstract

Background
Vancomycin is frequently used empirically in suspected sepsis in neonatal intensive care unit (NICU). However, inappropriate or unnecessary use can lead to additional morbidities and emergence of drug resistant pathogens. Standardization of vancomycin use is imperative for safer and more efficient patient care.

Methods
This study was part of a QI initiative to optimize vancomycin use by revising a standardized late onset sepsis (LOS) guideline with defined indications and criteria for empiric vancomycin. The implementation was started in 9/19 after completion of providers’ education. To reduce seasonal variations, 1/19-3/19 (pre-guideline) and 12/19-2/20 (post-implementation) data was retrospectively compared, including demographics, antibiotic indications, days of therapy/1000 patient days (AUR), positive cultures, isolated pathogens and resistance profiles. Clinical outcomes and adherence to the guideline were evaluated. Wilcoxon rank sum test was applied for continuous variables and Pearson chi-square test was applied for categorical variables. p&lt; 0.05 was considered significant.

Results
There were 53 LOS antibiotic courses in 35 patients pre-guideline and 113 in 64 patients post-implementation. We found an overall increase in vancomycin AUR in the post-implementation period (66.92 vs. 70.72, respectively, p=0.79), however, largely due to appropriate use of vancomycin for documented infections with gram-positive pathogens (including CONS and MRSE). Mortality was not statistically significant between two periods (Table 1 and 2). Vancomycin was ordered significantly less empirically, as per guideline, in the post implementation period (71.43% vs 46.15%, p=0.02). Adherence to the LOS antibiotics guideline was 69%.
Table 1: Demographic characteristics of infants pre and post-guideline

Table 2: Therapy indication, medication exposure and clinical outcomes 30 days after LOS treatment pre and post-guideline

Conclusion
Development of a standardized guideline for empiric antibiotic therapy is important to reduce unnecessary and inappropriate use of vancomycin. We demonstrated that use of a guideline significantly decreased vancomycin ordering as an empiric antibiotic. Further analysis is needed in order to identify safety of the guideline’s criteria, factors contributing to unnecessary vancomycin use, as well as educational needs to ensure appropriate antibiotic use.

Disclosures
All Authors: No reported disclosures
1357. Urinary Symptom Management in Children with Neuropathic Bladder Presenting to the Emergency Department
Authors: Curley Tara , Forster Catherine , Pohl Hans G , Chamberlain James , Hamdy Rana F 
Published: January 2021

Abstract

Background
Children with neuropathic bladders are at high risk for developing urinary tract infections (UTIs). The accurate diagnosis of UTI is complicated by altered sensation and the ubiquity of bacterial colonization. As a result, overdiagnosis and overtreatment for presumed UTIs is common. The objective of this study is to estimate potential overdiagnosis and unnecessary antibiotic treatment in children with neuropathic bladder presenting to the Emergency Department (ED) with urinary symptoms.

Methods
Retrospective cohort study of patients with neuropathic bladder presenting to the Children’s National Hospital ED between October 2008 and December 2019. Chart review was used to determine presenting symptoms, urinary evaluation, and antibiotic treatment. We used the validated urinary symptoms questionnaire (USQNB-IC) to categorize ED visits as ‘evaluation warranted’ if the patient presented with at least one of the actionable symptoms on the USQNB-IC. We used the Spina Bifida Association’s (SBA) published definitions for UTI to determine which patients warranted presumptive antibiotic treatment.

Results
There were 211 visits by 82 patients (43% female), with a mean of 4.6 visits per patient (IQR 6). Mean age at ED visit was 5.2 years (SD 4.2 years). The most common presenting symptoms were fever (57%), emesis (32%), abdominal pain (24%), foul-smelling urine (11%), and cloudy urine (8%). Of the total visits, 122 (58%) had a urinary evaluation and 31% were treated with antibiotics. Sixteen ED visits (8%) resulted in a urinary evaluation that was not warranted. Of the 122 ED visits with urinary evaluation, 32 patients (26%) did not meet SBA criteria for UTI but were treated empirically with antibiotics.
Table 1: Urinary evaluation in children with neuropathic bladder seen in CNH ED between October 2008 and December 2019.

Table 2: UTI treatment in children with neuropathic bladder seen in CNH ED between October 2008 and December 2019.

Conclusion
Most children with neuropathic bladder presenting to the ED were appropriately evaluated and treated for presumed UTI. One-quarter of evaluated children received empiric antibiotics despite not meeting SBA criteria for UTI, indicating this may be a target for educational initiatives to promote antibiotic stewardship. Further research is needed to generate and validate clinical guidelines for emergency department providers to limit unnecessary testing and antibiotic therapy in this population.

Disclosures
All Authors: No reported disclosures
109. Impact of Accelerate PhenoTM System on Time to De-escalation of Antimicrobial Therapy
Authors: Powers Caroline , Moenster Ryan P , Linneman Travis W 
Published: January 2021

Abstract

Background
The Accelerate PhenoTM system yields identification (ID) and antimicrobial susceptibility testing (AST) within 7 hours of growth in blood culture. The objective of this study was to determine its impact on time to de-escalation of antimicrobial therapy.

Methods
This retrospective quasi-experimental, observational cohort study included patients hospitalized at the St. Louis VA who received intravenous antibiotics for a positive blood culture. Patients with blood cultures positive for polymicrobial growth or fungi or those requiring antibiotics for other infections were excluded. The primary endpoint was time to de-escalation of antimicrobial therapy from before and after implementation of Accelerate PhenoTM (September 2017 to August 2018 and September 2018 to August 2019, respectively). Secondary outcomes included time to ID and AST, length of hospital stay, and days of antimicrobial therapy. The variables of gram-positive infections, use of Accelerate PhenoTM, and presence of infectious diseases consult and/or pharmacist antimicrobial stewardship note were included in a univariate analysis. Variables with a p-value&lt; 0.2 were included in a multivariate regression.

Results
168 patients were included, with 92 patients in the pre-implementation and 76 in the post-implementation group. Overall, mean age was 67 years and 162 (96%) were men. Staphylococcus spp. and Escherichia coli were the most common causative organisms. Time to de-escalation did not differ significantly between the post-implementation and pre-implementation groups (65 vs. 61 hours, p=0.47). Time to organism ID was decreased by 16 hours using Accelerate PhenoTM (50 vs. 66 hours, p=0.016). However, no difference was found in time to AST or length of hospital stay. Days of antimicrobial therapy while hospitalized was also similar between groups (6.8 vs. 5.9 days, p=0.256). Only gram-positive infections and presence of antimicrobial stewardship notes were included in the multivariate regression. Neither were independently associated with de-escalation within 48 hours.

Conclusion
Accelerate PhenoTM system did not impact time to de-escalation of antimicrobial therapy.

Disclosures
All Authors: No reported disclosures
1358. Using natural language processing to optimize case ascertainment of acute otitis media in a large, state-wide pediatric practice network
Authors: Herigon Joshua C , Kimia Amir , Harper Marvin 
Published: January 2021

Abstract

Background
Antibiotics are the most commonly prescribed drugs for children and frequently inappropriately prescribed. Outpatient antimicrobial stewardship interventions aim to reduce inappropriate antibiotic use. Previous work has relied on diagnosis coding for case identification which may be inaccurate. In this study, we sought to develop automated methods for analyzing note text to identify cases of acute otitis media (AOM) based on clinical documentation.

Methods
We conducted a cross-sectional retrospective chart review and sampled encounters from 7/1/2018 – 6/30/2019 for patients &lt; 5 years old presenting for a problem-focused visit. Complete note text and limited structured data were extracted for 12 randomly selected weekdays (one from each month during the study period). An additional weekday was randomly selected for validation. The primary outcome was correctly identifying encounters where AOM was present. Human review was considered the “gold standard” and was compared to ICD codes, a natural language processing (NLP) model, and a recursive partitioning (RP) model.

Results
A total of 2,724 encounters were included in the training cohort and 793 in the validation cohort. ICD codes and NLP had good performance overall with sensitivity 91.2% and 93.1% respectively in the training cohort. However, NLP had a significant drop-off in performance in the validation cohort (sensitivity: 83.4%). The RP model had the highest sensitivity (97.2% training cohort; 94.1% validation cohort) out of the 3 methods.
Figure 1. Details of encounters included in the training and validation cohorts.

Table 1. Performance of ICD coding, a natural language processing (NLP) model, and a recursive partitioning (RP) model for identifying cases of acute otitis media (AOM)

Conclusion
Natural language processing of outpatient pediatric visit documentation can be used successfully to create models accurately identifying cases of AOM based on clinical documentation. Combining NLP and structured data can improve automated case detection, leading to more accurate assessment of antibiotic prescribing practices. These techniques may be valuable in optimizing outpatient antimicrobial stewardship efforts.

Disclosures
All Authors: No reported disclosures
1360. Variation in Duration of Antibiotic Therapy for Central-line Associated Blood Stream Infections Caused by Gram Negative Bacilli in Hospitalized Children
Authors: Whitmer Grant R , Scardina Tonya , Sun Shan , Zheng Xiaotian , Patel Sameer 
Published: January 2021

Abstract

Background
Central-line associated bloodstream infections (CLABSIs) are associated with increased morbidity, mortality, and duration of hospitalization in children. Existing guidelines recommend a broad range (7-14 days) for duration of antibiotic therapy. Unnecessarily prolonged therapy may be associated with emergence of antibiotic resistance and adverse events.

Methods
We performed a retrospective review of all patients diagnosed with CLABSIs caused by Gram negative bacilli (GNB) at our institution from August 2009 to April 2019. CLABSI was defined as isolation of a GNB from the blood &gt;48 hours after hospital admission with presence of a central venous catheter. Children who died before completion of treatment were excluded. Data collection variables included severe neutropenia (defined as absolute neutrophil count &lt; 500), immunocompromised status (defined as receipt of bone marrow transplant, solid organ transplant, or immunosuppressive medication), and catheter removal. The duration of effective antibiotic therapy was calculated from the date of last positive culture to discontinuation. Effective therapy was defined as use of an agent to which the isolated organism was susceptible by antimicrobial susceptibility testing. The primary outcome was microbiological recurrence of the same organism and/or all-cause mortality within 30 days of discontinuation.

Results
Overall, 95 CLABSIs were included. Of 92 patients, 46 (50%) were immunocompromised. For patients with catheters removed prior to the end of therapy (n=48), the median duration of effective therapy was 13.5 days (IQR: 8.75-16 days). For patients who retained catheters throughout treatment (n=47), the median duration of effective therapy was 13 days (IQR: 9-15 days). Of these 95 CLABSIs, one patient (retained catheter) had microbiological recurrence within 30 days. Seven patients died (without microbiological recurrence), with range of duration of therapy of 6-14 days.

Conclusion
There was a wide variation in length of therapy for CLABSIs caused by GNB in children. Microbiological recurrence was rare, and mortality was unrelated to microbiological recurrence. Future studies should evaluate standardization of shorter duration therapy to avoid unnecessarily prolonged antibiotic exposure.

Disclosures
Sameer Patel, MD MPH, Merck (Grant/Research Support)Nexogen (Consultant)
1363. Assessment and Quantification of Nasopharyngeal Streptococcus pneumoniae Colonization Does Not Discriminate Between Children with Viral and Bacterial Respiratory Infection
Authors: Pernica Jeffrey , Inch Kristin , Alfaraidi Haifa , Van Meer Ania , Carciumaru Redjana , Luinstra Kathy , Smieja Marek 
Published: January 2021

Abstract

Background
Pediatric uncomplicated pneumonia can be caused by viruses, bacteria, and atypical pathogens. Unfortunately, readily-available diagnostics do not reliably identify which cases of uncomplicated pneumonia have a bacterial etiology. It has been suggested that measuring pneumococcal nasopharyngeal carriage can discriminate between viral and bacterial disease. The objective of this study was to determine if nasopharyngeal pneumococcal carriage differed between children with definite viral disease, definite bacterial disease, and respiratory disease of indeterminate etiology.

Methods
Three cohorts were recruited. Cohort 1 consisted of children with acute respiratory illness admitted to the pediatric intensive care unit; Cohort 2 consisted of previously healthy children with acute respiratory illness admitted to the general pediatric ward; and Cohort 3 consisted of previously healthy children diagnosed with non-severe community-acquired pneumonia in the emergency department. Children were categorized into the following disease categories: a) viral infection syndrome, b) pneumonia complicated by effusion/empyema, or c) ‘indeterminate’ pneumonia. Study subjects’ nasopharyngeal swabs (NPS) underwent quantitative PCR testing for S. pneumoniae.

Results
There were 206 children in Cohort 1, 122 children in Cohort 2, and 179 children in Cohort 3. The median subject age was 2.5 y (25-75%ile 1.3-4.9 y). Only a minority (227/507, 45%) had pneumococcal carriage detected; in those participants, there was no association of quantitative genomic load with age, cohort, or disease category. In multivariate logistic regression, NPS pneumococcal carriage (positivity &gt;3 log copies/mL) was associated with younger age and cohort of recruitment, but not with disease category (all those with indeterminate non-severe pneumonia were from Cohort 3).
Table 1. Comparison of subjects in different cohorts

Table 2. Comparison of subjects in different disease categories

Table 3. Associations with nasopharyngeal pneumococcal colonization &gt;3 log copies/mL.

Conclusion
The nasopharyngeal S. pneumoniae carriage patterns of subjects with definite viral infection were very similar to those with definite bacterial infection and to those with indeterminate pneumonia. It would therefore appear that assessment and quantification of nasopharyngeal pneumococcal colonization is not useful to discriminate between acute viral and bacterial respiratory disease in children in North America.

Disclosures
All Authors: No reported disclosures