bluuebunny/crossref_metadata_2025_split huggingface dataset:
155. Development of antibiotic classification for measuring antibiotic usage in Korean hospitals using a modified Delphi method
Authors: Kim Bongyoung , Yoon Young Kyung , Kim Dong-Sook , Jeong Su Jin , ahn Song Vogue , Park Sun Hee , Kwon Ki Tae , Kim Hong Bin , Park Yoon Soo , kim Shin-Woo , Kiem Sungmin , Choi Jun yong 
Published: January 2021

Abstract

Background
In 2019, the project about developing a system for measure and benchmark antibiotic usage in each hospital was launched. As the basic work for the project, we developed ‘antibiotic classification for measuring antibiotic usage in Korean hospitals’ using a modified Delphi method.
Consensual definition of antibiotic components according to the antibiotic classification in Korean hospitals.

Methods
The study consisted of two series of modified Delphi studies and was performed from July to August 2019. The study ‘antibiotic classification in Korean hospitals’ was performed first and followed by the study ‘antibiotic components according to the antibiotic classification in Korean hospitals’. Each Delphi study included two rounds of surveys in order to gather opinions and refine the information related to each study. We recruited a total of 12 panels including infectious diseases physicians (10), professor of preventive medicine (1), and the researcher of Health Insurance Review & Assessment Service (1). The questions for the Round 1 survey in each study were adopted from the antibiotic classification of the NHSN.

Results
As for the first study, the response rate of each round was 58.3% (7/12) and 75.0% (9/12), respectively. Most of the subjects of the NHSN’s antibiotic classification for adults were accepted except ‘antibacterial agents posing the highest risk for Clostridioides difficile infection’ (CVR = -1.000). On the contrary, all subjects for children were rejected. Finally, a total of 6 classifications were accepted. They were i) broad-spectrum antibacterial agents predominantly for hospital-onset infections, for adult (CVR = 1.000), ii) broad-spectrum antibacterial agents predominantly used for community-acquired infections, for adult (CVR = 1.000), iii) antibacterial agents predominantly used for resistant gram-positive infections, for adult (CVR =1.000), iv) narrow-spectrum beta-lactam agents, for adult (CVR = 1.000), v) antibacterial agents predominantly used for extensive antibiotic resistant gram-negative bacteria, for adult (CVR = 1.000), and vi) total antibacterial agent (CVR = 1.000).

Conclusion
this study provides antibiotic classification for measuring antibiotic usage in Korean hospitals. This classification may guide to develop a system for measuring of antibiotic usage in each Korean hospital.

Disclosures
All Authors: No reported disclosures
156. Evaluating Antibiotic Use and Developing a Tool to Optimize Prescribing in a Pediatric HIV Clinic in Eswatini
Authors: Streatfield Ashish E , Ness Tara , Simelane Tandzile T , Guffey Danielle , Lukhele Bhekemusa , Kay Alexander 
Published: January 2021

Abstract

Background
Antibiotic resistance is an emerging global health issue, fueled by inadequate surveillance systems and the absence of antimicrobial stewardship. In resource-limited settings, antimicrobial use is often based on clinical evaluation rather than microbiologic evidence, making treatment guidelines and the education of healthcare providers paramount to ensuring appropriate antimicrobial prescribing. In a human immunodeficiency virus (HIV) clinic for children and their families in Eswatini, we sought to understand the use of antibiotics and identify specific areas for improvement.

Methods
We performed a retrospective patient chart review as part of a quality improvement (QI) initiative to assess antimicrobial use before and after implementation of a standardized antimicrobial guide. For each prescribing period, 100 random patient encounters were selected for review to observe if the indication for antibiotics, duration, and dose were consistent with World Health Organization (WHO) guidelines. Two physicians reviewed each encounter to determine the appropriateness of antibiotic use using a structured abstraction tool, with a third resolving discrepancies. Results were analyzed using a chi-square test of proportions and a structured survey was performed to assess perceptions of the guide.

Results
After the implementation of an antimicrobial guide, there was a significant decrease in the proportion of clinic visits with an antibiotic prescribed (p &lt; 0.001). Incorrect indication for antimicrobial use decreased from 20.4% in the initial period, to 10.31% and 10.2% but did not reach significance (p=.0621) in the subsequent periods after implementation. Incorrect dose/duration decreased from 10.47% in the initial period to 7.37% and 3.1% in the subsequent periods, but this was also was not significant (p = 0.139). All prescribers who completed the survey used the antimicrobial guide and felt that it positively impacted their prescribing patterns.

Conclusion
Our study found that an antibiotic guide reduced and improved the prescription of antimicrobials. Antimicrobial stewardship is a global problem and this data demonstrates that practical solutions can have a lasting impact on antimicrobial prescribing in low resource settings.

Disclosures
All Authors: No reported disclosures
158. A multi-site, prospective study of antimicrobial prescribing practices in three low- or middle-income country hospitals
Authors: Rolfe Robert J , Muro Florida , Lyamuya Furaha , Kwobah Charles M , Sheng Tianchen , Piyasiri Dammalage Lasanthi Bhagya , Bodinayake Champica K , Nagahawatte Ajith , Yarrington Michael E , Drew Richard H , Kussin Peter S , Watt Melissa H , Anderson Deverick J , Woods Christopher W , Mmbaga Blandina T , Tillekeratne L Gayani 
Published: January 2021

Abstract

Background
Antimicrobial stewardship programs (ASPs) are being developed internationally to mitigate the misuse of antimicrobials. An understanding of current practices and prescribing patterns is necessary to determine targets to develop context-specific ASPs in low- and middle-income country (LMIC) hospitals.

Methods
We conducted a prospective study of patients admitted to the adult medical wards at three LMIC tertiary care centers in 2018- 2019: a 1,800-bed public hospital in Galle, Sri Lanka; a 991-bed public hospital in Eldoret, Kenya; and a 630-bed private hospital in Moshi, Tanzania. Information regarding antimicrobial therapy received during hospitalization, indications for antimicrobial therapy, and duration of antimicrobial use were extracted from the medical record.

Results
In total, 3150 patients were enrolled: 1297 in Sri Lanka, 750 in Kenya, and 1103 in Tanzania. Antimicrobial use prevalence varied between the three sites, with 56.0% of patients receiving antimicrobials during hospitalization in Sri Lanka, 56.5% in Kenya, and 35.4% in Tanzania. Third-generation cephalosporins were used most frequently in Kenya (70.0%) and Tanzania (73.1%), whereas amoxicillin/ clavulanic acid was used most frequently in Sri Lanka (48.4%). Lower respiratory tract infection was the most common indication for antimicrobial use in all three locations: 37.4% in Sri Lanka, 27.8% in Kenya, and 49.2% in Tanzania. No clear indication for antimicrobial use was documented among 11.6% patients receiving antimicrobials in Sri Lanka, 32.8% in Kenya, and 10.5% in Tanzania. In Tanzania, 8.6% of the patients had documentation of input from the microbiology or infectious diseases teams compared to less than 1% in either Sri Lanka or Kenya. Pertinent culture data related to the primary indication for antimicrobials was present in 16.1% (Sri Lanka), 6.1% (Kenya), and 7.4% (Tanzania).

Conclusion
Unclear documentation for antimicrobial use was common in all three sites and most patients on antimicrobial therapy did not have pertinent culture data. Improving documentation and the capacity of the local microbiology laboratories could be initial targets for ASPs in these LMIC hospitals.

Disclosures
All Authors: No reported disclosures
163. Automation of an Inpatient Provider Specific Antimicrobial Use Report
Authors: Weslander Erin , Shovlin Brandon , Green Michael D 
Published: January 2021

Abstract

Background
The use of individual prescriber report cards has shown to be an effective strategy in optimizing antimicrobial use in the pediatric outpatient setting. This is more difficult in an inpatient setting with prescribing often being done by a resident, but the decisions regarding antimicrobials are often made by the attending physician. This concept was tackled at a tertiary children’s hospital but was a manual and time-consuming process. The purpose of this review is to compare provider specific antimicrobial use between a manual chart review and an automated report.

Methods
An automatic report was developed that calculates antimicrobial days of therapy per 1000 patient days for each Pediatric Intensive Care Unit (PICU) attending provider. The software used was Business Objects that interfaces with the Electronic Medical Record. The provider is attached to daily antimicrobial use based on the attending to write a note that day. The provider was attached to patient days based on the number of days per patient they wrote notes.

Results
One week including 96 patients was chart reviewed and compared to the automated report prospectively. The automatic report days of therapy and patient days per PICU provider were within 10% of the chart review. Two months of the previous manual chart review was compared to the same two months with the automated report, which was also within 10%. Average quarterly hospital PICU antimicrobial days of therapy per 1000 patient days during the calendar year of 2019 in the Pediatric Health Information System (PHIS) were compared quarterly to the automated report, which was also within 10%.

Conclusion
An automated report that connects the attending to antimicrobial orders by attaching it to the note writer was found to be comparable to manual chart review as well as an average of use for the PICU compared to the national database PHIS. This automation can help decrease workload and optimize efforts for specific interventions and education that can be distributed with the PICU attending antimicrobial use report.

Disclosures
All Authors: No reported disclosures
166. Barriers to implementing antimicrobial stewardship programs in low- or middle-income country settings: findings from a multi-site qualitative study
Authors: Rolfe Robert J , Kwobah Charles M , Muro Florida , Ruwanpathirana Anushka S , Lyamuya Furaha , Bodinayake Champica K , Nagahawatte Ajith , Piyasiri Dammalage Lasanthi Bhagya , Sheng Tianchen , Bollinger John W , Zhang Chi , Drew Richard H , Kussin Peter S , Anderson Deverick J , Woods Christopher W , Watt Melissa H , Mmbaga Blandina T , Tillekeratne L Gayani 
Published: January 2021

Abstract

Background
Antimicrobial resistance has been named as one of the top ten threats to health in the world. The World Health Organization has endorsed the implementation of hosptial-based antimicrobial stewardship programs (ASPs) to reduce antimicrobial resistance. We conducted a qualitative study to determine perceived barriers to the development and implementation of ASPs in low- and middle-income countries (LMICs).

Methods
We conducted 46 interviews with medical doctors at tertiary care hospitals in Sri Lanka (22 doctors), Kenya (12), and Tanzania (12). Interviews assessed knowledge and receptiveness to ASPs and barriers to implementing ASP protocols. Interviews were conducted in English, audio recorded, and transcribed. The interviews discussed knowledge of antimicrobial resistance and ASPs, current antimicrobial prescribing practices, access to diagnostics, receptiveness to ASPs, and perceived barriers to implementing ASPs. Data analysis followed procedures of applied thematic analysis, and used NVivo software. A codebook included structural themes based on the interview questions and emerging inductive themes. Two independent reviewers coded the interviews, and the coding was combined and reviewed for consensus. Themes were synthesized, with comparisons made across the three sites.

Results
Medical doctors from all three sites discussed multiple barriers to improving antimicrobial prescribing: prohibitively expensive antimicrobials, limited antimicrobial availability, resistance to change current practices regarding antimicrobial prescribing, and limited diagnostic data. The most frequent of these barriers discussed in all three locations was limited drug availability, mentioned by 12/22 physicians in Sri Lanka, 5/12 in Tanzania and 8/12 in Kenya. Improved education was a suggested component of ASPs in all three sites: 7/22 in Sri Lanka, 6/12 in Tanzania, and 6/12 in Kenya.

Conclusion
The study highlighted several important issues in determining the next steps for the implementation of ASPs in these LMIC hospitals. Improving drug availability and improving education to change physicians’ antimicrobial prescribing practices are important targets that could be addressed by ASPs in these facilities.

Disclosures
All Authors: No reported disclosures
167. Communication is Key: A Multifaceted Approach to Improving Essential ASP Metrics in Surgical Services
Authors: Britt Rachel S , Reynoso David , Keiser Philip H , Ferren R Scott 
Published: January 2021

Abstract

Background
Despite widespread antimicrobial resistance, suboptimal antimicrobial use is common, particularly among surgical services. Studies show that antimicrobial stewardship programs (ASPs) effectively improve antimicrobial use and decrease adverse events. However, evidence for optimal ASP intervention in surgical departments is lacking, and some surgical services perceive ASPs negatively. This study aimed to evaluate the effect of several collaborative ASP interventions and workflow changes on the non-acceptance rate (NAR) of ASP recommendations and antimicrobial use among surgical services.

Methods
This was a retrospective, pre-post study of services in the department of surgery at a 681-bed, academic medical center between 12/01/2018 and 5/31/2020. Throughout 10/2019 and 11/2019, the core ASP, which consists of two infectious diseases physicians and two infectious diseases pharmacists, performed several interventions with surgical services. These included meetings with the chairman, vice chairs, and division chiefs of the surgery department, a grand rounds presentation to surgical house staff, and monthly surgeon NAR reporting to the chairman. Also, per feedback from surgeons, the ASP began to communicate recommendations directly to attending surgeons instead of residents or via ASP notes in the medical record. Data for the pre-period was collected from 12/2018 to 9/2019; data for the post-period was collected from 12/2019 to 5/2020. Wilcoxson rank sum, chi-square, and Fisher’s exact tests were used to compare outcomes.

Results
The ASP communicated 353 recommendations to surgical services in the pre-period, and 181 in the post-period. ASP offered most recommendations to trauma (n=244), cardiothoracic (n=60), and plastic surgery (n=54) during the study periods. NAR decreased post-intervention overall (43% vs 29%, p=0.0013) and in trauma surgery (63% vs 47%, p=0.03). Mean monthly days of therapy per 1000 patient days trended towards a decrease post-intervention (1105 vs 1044, p=0.26). Cost per 1000 patient days decreased post-intervention ($27,677.91 vs $19,766.31, p =0.0075).

Conclusion
A communicative and adaptive approach to ASP in surgical services improved NAR and antimicrobial costs and trended towards a reduction in antimicrobial use.

Disclosures
All Authors: No reported disclosures
168. Creation and Internal Validation of a Clinical Predictive Model for Fluconazole Resistance in Patients with Candida Bloodstream Infection
Authors: Rauseo Adriana M , Olsen Margaret A , Larson Lindsey , Stwalley Dustin , Hsueh Kevin , Powderly William , Spec Andrej 
Published: January 2021

Abstract

Background
IDSA guidelines on candidemia recommend fluconazole as first-line therapy in patients considered low risk for fluconazole resistant infections. However, there is currently no mechanism to determine risk of resistance, and most community hospitals cannot perform rapid sensitivity testing, leading to prolonged use of echinocandin therapy. This study aims to develop a clinical predictive model to identify patients at low risk for fluconazole resistance where first-line use of fluconazole therapy would be acceptable without requiring resistance testing.

Methods
We performed a retrospective cohort analysis of all hospitalized adult patients with a positive blood culture for Candida spp. from 2013 to 2018. Fluconazole resistance was determined using Sensititre™ YeastOne™ YO9 AST Plate, with cutoffs defined for each Candida species based on Clinical and Laboratory Standards Institute performance standards for antifungal testing (M60) in all patients. Using backwards stepwise regression, we developed a multivariable logistic regression model to identify factors associated with fluconazole resistance in patients in Candida bloodstream infection, including only variables with clinical plausibility and p &lt; 0.1 in bivariable analysis. Stepwise regression was performed on bootstrapped samples to test individual variable stability and estimate confidence intervals. We used graphs of observed vs expected values to assess model performance across the probability spectrum.

Results
We identified 539 patients with Candida bloodstream infection from 2013–2018, of which 13.4% (72/539) were fluconazole resistant. Increased risk of fluconazole resistance was associated with age (1.12 [1.01, 1.24]), bacterial septicemia (2.14 [1.20, 3.79]), receipt of previous azole therapy (5.47 [2.92, 10.26]), bone marrow transplant (2.63 [1.31, 5.29]), and myelodysplastic syndrome (3.13 [1.14, 8.60]). The model predicted fluconazole sensitivity well (c-statistic 0.788) and all the variables were stable (Figure 1).
Figure 1. Graph comparing observed versus expected probability of fluconazole resistance. Bars included on the top parameter of the graph indicate the number of individuals, illustrating the distribution of the sample.

Conclusion
The presented model provides a potential tool for identifying the 80% of patients at low enough risk for fluconazole resistance to receive empiric therapy with azoles and reduce use of echinocandins.

Disclosures
Margaret A. Olsen, PhD, MPH, Merck (Grant/Research Support)Pfizer (Consultant, Grant/Research Support) Dustin Stwalley, MA, AbbVie Inc (Shareholder)Bristol-Myers Squibb (Shareholder) Andrej Spec, MD, MSCI, Astellas (Grant/Research Support)Mayne (Consultant)Scynexis (Consultant)
169. Development of a Real Time Electronic Algorithm to Identify Hospitalized Patients with Community-Acquired Pneumonia
Authors: Fabre Valeria , Fabre Valeria , Jones George , Amoah Joe , Klein Eili , Leeman Hannah , Milstone Aaron , Milstone Aaron , Smith Aria , Levin Scott , Cosgrove Sara E 
Published: January 2021

Abstract

Background
Syndrome-based antibiotic stewardship can be limited by difficulty in finding cases for evaluation. We developed an electronic extraction algorithm to prospectively identify CAP patients.

Methods
We included non-oncology patients ≥18 years old admitted to The Johns Hopkins Hospital from 12/2018 to 3/2019 who 1) received common CAP antibiotics for ≥48 hours after admission and 2) had a bacterial urinary antigen and chest imaging ordered within 48 hours of admission that was not for assessment of endotracheal tube or central line placement. Charts of patients meeting these criteria were reviewed by 2 authors to identify true cases of CAP based on IDSA guidelines. Cases identified in 12/2018 (n=111) were used to explore potential indicators of CAP, and cases identified 1–3/2019 (n=173) were used to evaluate combinations of indicators that could identify patients treated for CAP who did have CAP (true CAP) and did not have CAP (false CAP). This cohort was divided into a training and a validation set (2/3 and 1/3, respectively). Potential indicators included vitals signs, laboratory data and free text extracted via natural language processing (NLP). Predictive performance of composite indicators for true CAP were assessed using receiver-operating characteristics (ROC) curves. The Hosmer-Lemeshow goodness fit test was used to test model fit and the Akaike Information Criteria was used to determine model selection.

Results
True CAP was observed in 41% (71/173) of cases and 14 potential individual indicators were identified (Table). These were combined to make 45 potential composite indicators. ROC curves for selected composite indicators are shown in the Figure. Models without use of NLP-derived variables had poor discriminative ability. The best model included fever, hypoxemia, leukocytosis, and “consolidation” on imaging with a sensitivity and positive predictive value 78.7% and specificity and negative predictive value of 85.7%.
Table. Indicators evaluated to identify patients with CAP

Figure. ROC curves for composite indicators

Conclusion
Patients with CAP can be identified using electronic data but use of NLP-derived radiographic criteria is required. These data can be linked with data on antibiotic use and duration to develop reports for clinicians regarding appropriate CAP diagnosis and treatment.

Disclosures
All Authors: No reported disclosures