bluuebunny/crossref_metadata_2025_split huggingface dataset:
1673. Epidemiology of Complicated Urinary Tract Infections (cUTIs) Presenting in Emergency Departments Across the United States (US)
Authors: Lodise Thomas , Chopra Teena , Nathanson Brian , Sulham Katherine 
Published: January 2021

Abstract

Background
Complicated urinary tract infection (cUTI) is a common emergency department (ED) diagnosis. Results of urine culture and antimicrobial susceptibility testing are usually not available for up to 48 hours after an ED visit; therefore, diagnosis and treatment decisions are empiric and based on symptoms, physical findings, and underlying risk of resistance. We sought to understand the epidemiology and incidence of resistance to commonly used oral antibiotics among patients presenting to US EDs with cUTI.

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. We examined rates of resistance to the following drugs/classes: 3rd generation cephalosporins, fluoroquinolones, trimethoprim-sulfamethoxazole, fosfomycin, and nitrofurantoin in patients presenting to the ED, stratified by those who were ultimately admitted as inpatients vs. not. Regional variation by US Census Division was examined.

Results
187,789 patients met inclusion criteria; 119,668 (63.7%) were admitted to the hospital. 4.6% had positive cultures only with gram-positive bacteria; the remainder had at least one gram-negative pathogen. E. coli was the most common infecting pathogen, present in 72.1% of ED-only infections and 51.4% of those admitted. 44.7% and 58.4% of ED-only and admitted patients, respectively, were resistant to at least 1 of the 5 drugs/classes examined (see table). We saw substantial regional variation; resistance to at least 3 of 5 drugs/classes across all patients ranged from 5.0% in West North Central region to 11.1% in East South Central region (national average: 9.1%).
Resistance Rates by Drug/Drug Class and Hospital Admission Status

Conclusion
Patients with cUTI infections presenting to EDs in the US are frequently resistant to many commonly used oral antibiotics, even in patients not admitted to the hospital. Local epidemiology and resistance should be considered when making empiric treatment decisions in the ED. New oral options for cUTI patients are needed to address the growing challenge of resistance.

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)
1677. Evaluation of Optimal Treatment for Urinary Tract Infections in Outpatient Clinics at an Academic Medical Center
Authors: Walters Jennifer , Kim Jihye , Stevens Michael 
Published: January 2021

Abstract

Background
Inappropriate prescribing of antibiotics is an important modifiable risk factor for antibiotic resistance. The Joint Commission has identified the need for outpatient antimicrobial stewardship efforts. The purpose of this study was to assess the incidence of optimal empiric antibiotic therapy for urinary tract infections (UTIs) in outpatient clinics at VCU Health.

Methods
This was a retrospective study of patients seen in internal medicine (IM) and urology clinics between July 1, 2018 and June 30, 2019. Patients were included if they were ≥ 18 years old, had a diagnosis of UTI per ICD-10 code, and received a prescription to treat a UTI at the visit. Patients were excluded if they had a concurrent infection, currently prescribed antibiotics, or pregnant. The primary outcome was to evaluate the incidence of optimal empiric treatment for UTIs. Appropriateness of antibiotic therapy was assessed based on prior culture data along with our institutional UTI treatment guideline.

Results
Two hundred and twenty-six patients were included: 136 in IM clinics and 90 in urology clinics. Patients in the IM clinics were significantly older (mean age 64.8 vs. 60.5, p= 0.033) and more were female (88% vs. 38%, p&lt; 0.001). More patients in the urology clinics had a history of a UTI within 24 months (72% vs. 57%, p= 0.016), history of fluoroquinolone-resistant Gram-Negative UTIs (35% vs. 13%, p= 0.007), and history of genitourinary cancer (28% vs. 1%, p&lt; 0.001). Overall, 61% of patients were treated with optimal empiric antibiotics. Incidence of optimal prescribing in the IM clinics was significantly higher compared to urology clinics (69% vs 49%, p= 0.002). See table 1 for additional results.
Table 1. Optimal UTI Treatment in Internal Medicine Clinics vs Urology Clinics

Conclusion
IM clinics more frequently prescribed optimal empiric antibiotics for UTIs compared to urology clinics. Resident prescribers were more likely to prescribe optimal empiric therapy. Presence of a beta-lactam allergy was not predictive of optimal prescribing. These data highlight opportunities for antibiotic therapy optimization for UTIs at our health system.

Disclosures
All Authors: No reported disclosures
1684. Hospital Costs and Reimbursement in Patients with Resistant Enterobacteriaceae (ENT) Urinary Tract Infection (UTI) in the United States (US): A Multicenter Analysis
Authors: Melnick David , Jain Akash , Gupta Vikas , Sulham Katherine 
Published: January 2021

Abstract

Background
Rates of fluoroquinolone resistance (FQ-R) and third-generation cephalosporin resistance/extended-spectrum beta-lactamases (ESBL+) are rising. These pathogens generally retain susceptibility to intravenous (IV) carbapenems; however, the loss of susceptibility to commonly used oral (PO) antibiotics limits the opportunity to transition these patients home, leading to increased length of stay (LOS) and higher costs. Here, we evaluate the hospital LOS, costs and reimbursement for UTI hospitalizations.

Methods
We analyzed the first positive enterobacteriaceae (ENT) urine culture ≤ 3 days from hospital admission in patients with a primary or secondary UTI ICD10 discharge diagnosis from 68 US hospitals admitted October 1, 2015-2017. Patient characteristics and outcomes were categorized by ESBL+ and FQ-R status. IV to PO was identified as PO therapy after 24 hours of IV. Outcomes were stratified by resistance and PO conversion status.

Results
16,022 patients were eligible for analysis; 5,017 (31.3%) were FQ-R, 1,763 (11.0%) were ESBL+, and 1,433 (8.9%) were both FQ-R and ESBL+; 2,367 (14.8%) were converted to PO antibiotics during their hospitalization. Overall, mean LOS, costs, and reimbursement were 5.2 days, $9,303 and $8,501 (mean difference between cost and reimbursement: -$878). Mean LOS was shorter and mean difference between cost and reimbursement was lower overall for patients converted to PO therapy vs. those who did not (4.7 vs. 5.3 days, -$532 vs. -$938). Drug resistance was associated with higher LOS and a larger difference between cost and reimbursement; patients who were FQ-R and ESBL+ and did not convert to PO had a mean LOS of 6.0 days, costs of $11,482, and reimbursement of $9,243 (difference: -$2,446). Mean LOS, costs, and reimbursement for patients who were neither FQ-R nor ESBL+ and who did convert to PO therapy were 4.6 days, $7,904, and $7,496 (difference: -$527), respectively.

Conclusion
Reduced LOS and substantial cost savings could be recognized by efficiently converting patients receiving IV antimicrobials to PO and discharging them from the hospital. Lack of PO therapies with activity against resistant pathogens has made this challenging; new PO options may help reduce hospital costs and resources required to treat these UTI patients.

Disclosures
David Melnick, MD, Spero Therapeutics (Employee)Spero Therapeutics (Employee) Akash Jain, PhD, Spero Therapeutics (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Katherine Sulham, MPH, Spero Therapeutics (Independent Contractor)
1689. Oral Beta-lactam Step Down in Bacteremic E. coli Urinary Tract Infections
Authors: Saad Stephan , Mina Neil , Lee Colin , Afra Kevin 
Published: January 2021

Abstract

Background
Literature is scarce regarding oral step down to beta-lactams in bacteremic urinary tract infections. Oral fluoroquinolones are an accepted and common step down for bacteremic urinary tract infections; however, their use is associated with mounting safety concerns. We compared clinical cure in patients with E. coli bacteremic urinary tract infections who were stepped down to oral beta-lactams compared to oral fluoroquinolones.

Methods
This multicentre retrospective cohort study included patients with first positive concurrent urine and blood cultures from January 2016 to December 2016. Patients were included if they received empiric intravenous beta-lactam therapy with step down to either oral beta-lactam or fluoroquinolone for treatment completion. The primary outcome was clinical cure. Secondary outcomes were length of hospitalization, all-cause mortality and C. difficile infection. Multivariate analysis and propensity score were used to control for confounding.

Results
A total of 207 patients were identified with bacteremic E.coli urinary tract infections. Clinical cure was achieved in 72/77 (94%) in the oral beta-lactam group versus 127/130 (98%) in the oral fluoroquinolone group (absolute difference -4.2%, 95% confidence interval [CI] -10.3% to 1.9%, p=0.13). The adjusted odds ratio (OR) for clinical cure with oral beta-lactams was 0.31 (95% CI 0.05 – 1.90, p=0.21); propensity score adjusted analysis showed a similar result. There was no statistically significant difference in secondary outcomes.
Table 2

Table 3

Table 4

Conclusion
Oral beta-lactams appear to be a safe and effective step down option in bacteremic E. coli urinary tract infections compared to oral fluoroquinolones.

Disclosures
All Authors: No reported disclosures
1691. Pre- and Post-Hospitalization Resource Utilization and Costs Associated with Urinary Tract Infection (UTI) in both Commercial and Medicare Populations
Authors: Melnick David , Baljian Nayiri , Jain Akash , Sulham Katherine 
Published: January 2021

Abstract

Background
In the United States, urinary tract infections (UTIs) result in an estimated 7 million office visits, 1 million emergency department visits, and over 500,000 hospitalizations with an associated annual cost of $1.6 billion. Little is known regarding pre- and post-hospitalization resource use. Here, we quantify resource utilization and costs associated with both commercially insured and Medicare patients hospitalized for UTI.

Methods
A retrospective multi-center study using data from the MarketScan® Commercial and Medicare Supplemental Databases was performed. Inclusion criteria: (1) inpatient hospital admission with a primary ICD-10 diagnosis for UTI between October 1, 2015 and December 31, 2017 (index hospitalization), (2) at least 6 months of continuous enrollment and pharmacy benefits prior to the index date, (3) at least 12 months of continuous enrollment and pharmacy benefits after the index date, (4) patient age &lt; 64 (Commercial) or ≥65 (Medicare) on the index date. Demographics, hospitalization characteristics, antibiotic use, and resource utilization/costs in the pre- and post-index periods were examined.

Results
5,248 Commercial and 7,791 Medicare patients were eligible for analysis. 29.7% and 24.1% of Medicare and Commercial patients, respectively, were male. 5.9% of Medicare patients had a claim for skilled nursing facilities (SNF) in the 14 days pre-index admission (1.0% Commercial), 9.1% had emergency department claims (13.1% Commercial), and 39.8% had office visit claims (49.9% Commercial). Post-hospitalization, 20.3% (1.3% Commercial) were discharged to SNF and 15.4% (4.7%) were discharged to home health services. Mean insurer UTI-related costs were $8,677 (Commercial) and $5,358 (Medicare) in the 6 months pre-index hospitalization. Similarly, costs were $21,135 (Commercial) and $22,342 (Medicare) in the 12 months post hospitalization ($3,944 and $2,988 in the first 30 days post-discharge, respectively).

Conclusion
UTI is associated with substantial costs and resource utilization to insurers in both pre- and post-hospitalization settings. Understanding total costs of care and location of service may aid in cost-reduction strategies for treating UTI.

Disclosures
David Melnick, MD, Spero Therapeutics (Employee)Spero Therapeutics (Employee) Nayiri Baljian, n/a, Spero Therapeutics (Employee) Akash Jain, PhD, Spero Therapeutics (Employee) Katherine Sulham, MPH, Spero Therapeutics (Independent Contractor)
1692. Retrospective Review on the Safety and Efficacy of Nitrofurantoin for the Treatment of Cystitis in the Veteran Population With or Without Renal Insufficiency
Authors: Welch Elwyn W , Sheth Shaila , Ashong Chester , Pham Caroline 
Published: January 2021

Abstract

Background
Nitrofurantoin has been used to treat cystitis in women; however, data supporting its use in men is lacking. In addition, recent retrospective studies have challenged the manufacturer’s recommendation to avoid nitrofurantoin with creatinine clearances (CrCl) less than 60 mL/min. The purpose of this study is to compare the efficacy and safety of nitrofurantoin for the treatment of acute cystitis in male and female veterans with variable degrees of renal dysfunction.

Methods
A retrospective chart review was conducted in adult patients who received nitrofurantoin for acute cystitis in the outpatient setting between May 1, 2018 and May 1, 2019. The primary outcomes were rates of clinical cure as compared between males and females, and across various renal function groups (CrCl greater than 60 mL/min, 30 to 60 mL/min, and less than 30 mL/min) following treatment with nitrofurantoin. The secondary outcome was adverse event rates.

Results
A total of 446 patients were included with 278 females and 168 males. Overall clinical cure rate was 86.5% (n=386). Clinical cure rate did not vary between genders (p=0.0851) or CrCl ranges (p=1.0) as shown in the tables. Benign prostatic hyperplasia (BPH) was associated with decreased odds of clinical cure (OR 0.50 [95% CI 0.26-0.97], p=0.0404) in addition to cirrhosis (OR 0.22 [95% CI 0.06-0.91], p=0.0357). Adverse events occurred in 2% of patients and did not vary based on gender or renal function.
RATES OF CLINICAL CURE

Conclusion
There was no statistically significant difference in clinical cure with nitrofurantoin between genders and various renal impairments. However, history of BPH and cirrhosis were associated with decreased efficacy. Subgroup analysis also revealed lower efficacy in males with CrCl greater than 60 mL/min versus females with similar renal function. This study adds to the growing body of literature suggesting that renal dysfunction with CrCl of 30 to 60 mL/min may not carry the risk of treatment failure and adverse effects previously associated with nitrofurantoin, but large randomized trials are needed to confirm these results.

Disclosures
All Authors: No reported disclosures
1700. What Is Specific With Bacterial Escherichia Coli Urinary Tract Infection
Authors: Hammami Fatma , Koubaa Makram , Chakroun Amal , Rekik Khaoula , Smaoui Fatma , Elleuch Emna , Marrakchi Chakib , Jemaa Mounir Ben 
Published: January 2021

Abstract

Background
Bacterial urinary tract infections continue to be a major health problem, responsible for a significant morbidity and mortality. Its prognosis is more severe than non-bacterial forms. The aim of this work was to study the clinical and evolutionary features of bacterial urinary tract infections caused by Escherichia coli (E.coli).

Methods
We conducted a retrospective study including all patients hospitalized in infectious diseases department for urinary tract infection (UTI) caused by E.coli between 2010 and 2017.

Results
During the study period, we enrolled 613 cases of UTI caused by E.coli, among whom 75 cases (12.2%) were bacterial. There were 47 females (62.7%). The mean age was 59 ±17 years. Thirty-three patients were aged ≥ 65 years (44%). Diabetes was noted in 38 cases (50.7%) and renal lithiasis in 14 cases (18.7%). A history of UTI was reported in 13 cases (17.3%). The most common clinical presentation was acute pyelonephritis (59 cases; 78.7%) and followed by prostatitis (8 cases; 10.6%). Renal abscess was noted in 5 cases (6.7%) and prostatic abscess in 3 cases (4%). There were 36 cases of multidrug-resistant bacteria (48%). Community-acquired UTI were noted in 70 cases (93.3%). The mean duration of treatment was 18 ± 6 days. Surgery and radiological drainage were indicated in 4 (5.3%) and 2 cases (2.7%), respectively. The outcome was favourable in 58 cases (77.3%). Complications were noted in 10 cases (13.3%) represented mainly by acute renal failure in 4 cases (5.3%). Relapse was noted in 9 cases (12%) and reinfection in 6 cases (8%). Two patients died (2.7%).

Conclusion
Bacterial urinary tract infections were associated to complications such as renal and prostatic abscess, requiring surgery and long duration of treatment.

Disclosures
All Authors: No reported disclosures
143. Initial Impact of COVID-19 on Ambulatory Antibiotic Prescribing for Respiratory Viral Infections
Authors: Escobar Zahra Kassamali , Bouchard Todd , Lansang Jose Mari , Thomassen Scott , Huang Joanne , Lynch John B , May Larissa , Kvak Staci , D’Angeli Marisa A , Bryson-Cahn Chloe 
Published: January 2021

Abstract

Background
Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one third of this usage is considered unnecessary. In 2019, our institution implemented the MITIGATE Toolkit, endorsed by the Centers for Disease Control and Prevention to reduce inappropriate antibiotic prescribing for viral respiratory infections in emergency and urgent care settings. In February 2020 we identified our first hospitalized patient with SARS-CoV(2). In March, efforts to limit person-to-person contact led to shelter in place orders and substantial reorganization of our healthcare system. During this time we continued to track rates of unnecessary antibiotic prescribing.

Methods
This was a single center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. We provided monthly individual feedback to urgent care prescribers, (Sep 2019-Mar 2020), primary care, and ED providers (Jan 2020 – Mar 2020) notifying them of their specific rate of unnecessary antibiotic prescribing and labeling them as a top performer or not a top performer compared to their peers. The primary outcome was rate of inappropriate antibiotic prescribing.

Results
Pre toolkit intervention, 14,398 patient visits met MITIGATE inclusion criteria and 12% received an antibiotic unnecessarily in Jan-April 2019. Post-toolkit intervention, 12,328 patient visits met inclusion criteria and 7% received an antibiotic unnecessarily in Jan-April 2020. In April 2020, patient visits dropped to 10–50% of what they were in March 2020 and April 2019. During this time the unnecessary antibiotic prescribing rate doubled in urgent care to 7.8% from 3.6% the previous month and stayed stable in primary care and the ED at 3.2% and 11.8% respectively in April compared to 4.6% and 10.4% in the previous month.

Conclusion
Rates of inappropriate antibiotic prescribing were reduced nearly in half from 2019 to 2020 across 3 ambulatory care settings. The increase in prescribing in April seen in urgent care and after providers stopped receiving their monthly feedback is concerning. Many factors may have contributed to this increase, but it raises concerns for increased inappropriate antibacterial usage as a side effect of the SARS-CoV(2) pandemic.

Disclosures
All Authors: No reported disclosures
1702. Assessing the Safety and Efficacy of Valganciclovir Dosing for Cytomegalovirus Prophylaxis in Solid Organ Transplant Recipients on Hemodialysis
Authors: Yee Jason , Saunders-Hao Patricia , Miko Leandra , Rana Meenakshi 
Published: January 2021

Abstract

Background
Valganciclovir is the standard of care used for the prevention of Cytomegalovirus (CMV) infections among solid organ transplant (SOT) recipients. Currently there is minimal guidance for prophylaxis in SOT recipients undergoing intermittent hemodialysis (IHD). At Mount Sinai Hospital (MSH), the current practice for CMV prophylaxis in SOT recipients on IHD is valganciclovir 450 mg every other day (Q48H) or three-times weekly (TIW). This study aims to evaluate the safety and effectiveness of these dosing regimens in SOT recipients on IHD.

Methods
A single-center, retrospective chart review study was conducted among all MSH SOT recipients on valganciclovir 450 mg Q48H or TIW for CMV prophylaxis and undergoing IHD for at least 30 days. The primary study outcome was the safety of using these valganciclovir doses determined by the incidence of leukopenia, thrombocytopenia, and the administration of growth colony stimulating factor (GCSF). The secondary outcome were the incidences of CMV viremia and CMV disease while on prophylaxis.

Results
Eighteen transplant encounters satisfied the inclusion and exclusion criteria. The majority were liver (7, 38.9%) and kidney (5, 27.8%) transplants. Thirteen (72.2%) recipients were on valganciclovir 450 mg Q48H dosing, while 5 (27.8%) were on valganciclovir 450 mg TIW dosing. Both the mean platelet count nadir (131 ± 93 vs 161 ± 115) and mean white blood cell count nadir (3.4 ± 2.5 vs 5.1 ± 3.8) were lower in the Q48H regimen. Four patients (22.2%) in the Q48H regimen group required GCSF vs none (0.0%) in the TIW regimen. No patient had a detectable CMV viral load while on either prophylactic dose. Two (11.1%) CMV high risk patients on the every other day dosing regimen and one (5.6%) CMV moderate risk patient on the three times weekly regimen developed CMV viremia about 2-3 months after their prophylaxis was stopped.
Table 1. Baseline Demographics.

Table 2. Primary Outcomes

Table 3. Secondary Outcomes

Conclusion
Valganciclovir 450 mg TIW may be safer than and as efficacious as Q48H dosing for prophylaxis in SOT recipients on chronic IHD. This data supports the use of three times weekly dosing as standardized practice at MSH, however more data is necessary to determine a conclusive result.

Disclosures
All Authors: No reported disclosures