bluuebunny/crossref_metadata_2025_split huggingface dataset:
224. Effect of Easing Overnight Restrictions on Antimicrobial Starts
Authors: Yarrington Michael E , Wrenn Rebekah , Spivey Justin , Shoff Christopher , Spires Steven S , Turner Nicholas A , Smith Michael J , Diez Anthony , Anderson Deverick J , Moehring Rebekah W 
Published: January 2021

Abstract

Background
Some institutions allow administration of restricted antibiotics overnight until evaluation the following day (i.e. first dose free) to adapt to limitations in personnel resources. Whether this method results in higher number of overnight requests compared to strict 24/7 preauthorization has not been fully described.

Methods
In October 2019, Duke University Hospital (DUH) changed from strict preauthorization to allow initiation of two restricted agents (meropenem and micafungin) between the hours of 11pm to 7am. We performed an interrupted time series (ITS) analysis to evaluate the phase shift and change in trend in the number of new meropenem and micafungin orders per week before (Jan 2019-Oct 2019) and after (Oct 2019- Mar 2020) the process change. First antimicrobial orders for meropenem and micafungin were counted for unique patient encounters. We fit a Gaussian distribution function to the number of orders per hour of day to estimate the percent of orders initiated overnight (11p-7a) and during day/evening hours (7a-11p) before and after the process change.

Results
Hospital data included 1728 new meropenem and micafungin orders over a 61-week period (~28 per week). The total number of meropenem and micafungin orders was constant between Jan 2019 and October 2019 (+0.07 orders/week, 95% CI -0.13 to 0.27, Figure 1) and the phase shift during the first week of October was non-significant (-4.38 orders, 95% CI -12.34 to 3.58). The number of orders increased after October 2019 (+0.70 orders/week, 95% CI 0.13 to 1.25), however a sensitivity analysis removing the largest outlier eliminates significance. The percent of total orders between 11am to 7pm increased from 13.3% to 17.2% after the intervention (Figure 2). Overall antibiotic use remained similar through the study period.
Figure 1. Estimated Approvals per Week

Figure 2. Approvals by Hour of Day

Conclusion
There was no significant immediate change in overnight prescribing of meropenem and micafungin, however a trend towards increased number of orders appeared after removing overnight restriction requirements. Instead of “stealth dosing”, where providers wait to enter restricted antibiotic orders until evening hours, we observed a small increase in starts in early morning hours (1am-6am). Preauthorization approaches must adapt to personnel resources and quality of life for antimicrobial stewards.

Disclosures
Michael J. Smith, MD, MSC.E, Kentucky Medicaid (Grant/Research Support)Merck (Grant/Research Support) Rebekah W. Moehring, MD, MPH, Agency for Healthcare Quality and Research (Grant/Research Support)Centers for Disease Control and Prevention (Grant/Research Support)
226. Evaluating the Unnecessary Use of Intravenous Broad-Spectrum Antibiotics in Patients Based on Systemic Inflammatory Response Syndrome Criteria in the Emergency Department (ED)
Authors: Bae Esther Y , Monogue Marguerite , Smith Tiffeny T 
Published: January 2021

Abstract

Background
Recognition of sepsis frequently occurs in the ED. To demonstrate the need to optimize antibiotic use for suspected sepsis and evaluate the reliability of systemic inflammatory response syndrome (SIRS) criteria in predicting bacterial infection, we quantified the rate of unnecessary intravenous (IV) broad-spectrum antibiotic use for suspected sepsis in the ED at an academic medical center.

Methods
Adult patients who were admitted to the ED between January 2018 and June 2018 with suspected sepsis (≥ 2 SIRS) and received ≥ 1 dose of IV broad-spectrum antibiotic were included in this retrospective study. The presence of bacterial infection was determined using Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) definitions, microbiologic, radiographic, and laboratory findings. Suspected infections lacked microbiologic data. The primary outcome was the percentage of confirmed and suspected infections. Secondary outcomes included 90-day Clostridioides difficile infection (CDI) and 90-day drug-resistant organism (DRO) infections.

Results
A total of 218 patients were included. The percentages of confirmed/suspected and absence of bacterial infections were 63.8% and 36.2%, respectively. Elevated SIRS (≥ 2) and Quick Sequential Organ Failure Assessment (qSOFA; ≥ 2) scores were not associated with the presence of bacterial infections. 82% of patients were discharged from the ED. Antibiotic exposure in days of therapy in the ED and/or hospital admission did not significantly vary between patients with confirmed/suspected bacterial infection and those with absence of bacterial infections. Among patients who lacked evidence of bacterial infections, 44% were prescribed outpatient antibiotics after being discharged from the ED. 90-day CDI and DRO infections were identified in 7 and 6 patients, respectively, regardless of the presence of bacterial infections.
Table 1. Baseline demographics of patients admitted to the ED with suspected sepsis

Conclusion
A third of the patients with suspected sepsis received IV broad-spectrum antibiotics in the ED but ultimately lacked bacterial infection. Our findings suggest that identification of bacterial infection and patients with sepsis using SIRS or qSOFA lack specificity and can lead to the overuse of unnecessary antibiotics in the ED.

Disclosures
All Authors: No reported disclosures
227. Evaluation of Empiric Vancomycin Utilization at 72 Hours Post Admission: is De-escalation of Vancomycin Appropriate?
Authors: Naderi Mandana , Welker Kimberly , Pourshams-Manzouri Tina , Huang Vanthida , Buros Amy 
Published: January 2021

Abstract

Background
At both of our institutions in 2018, the average vancomycin days of therapy per 1,000 patient days was 112. The purpose of this study was to examine a 72-hour time-out as an effective de-escalation tool by evaluating the indication and clinical appropriateness of the continuation of empiric vancomycin therapy.

Methods
A retrospective chart review was performed from January 2018 to October 2018 at two community hospitals. Patients &gt; 18 years who received at least 3 days of empiric vancomycin therapy were included. Patients were excluded if immunocompromised, pregnant, on hemodialysis, received vancomycin for surgical prophylaxis, or expired within 72 hours of vancomycin initiation. Criteria for appropriate continuation of vancomycin at 3 days: positive culture for methicillin-resistant Staphylococcus aureus (MRSA), presence of infection with or without defined sources with systemic signs of infection (i.e. white blood cells &gt;12,000 cells/L or &lt; 5,000 cells/L and/or elevated temperature ≥ 37.5°C), or pending wound/sputum cultures after vancomycin initiation.

Results
A total of 160 adult patients initiated on vancomycin were analyzed; 118 of 160 (74%) met appropriate criteria. The most common indications for vancomycin were: skin and soft tissue infections (SSTI) 82 patients (51%); pneumonia 37 patients (23%); and positive blood culture 20 patients (13%). Risk factors for MRSA were similar between both groups. Forty-four (28%) patients had cultures pending and 23 patients (14%) had a known non-MRSA pathogen at time of assessment. American Indian race (OR 3.01 (1.21, 7.53) p-value= 0.0174) and SSTI indication (OR 2.87 (1.24, 6.80) p-value= 0.0147) were associated with not meeting appropriate criteria.

Conclusion
Approximately 25% of patients receiving empiric vancomycin therapy did not meet clinical criteria for continuation beyond 72 hours. The indication most commonly associated with continued vancomycin utilization was SSTI. These results identified indications in which empiric vancomycin prescribing can be optimized, and a 72-hour antibiotic time-out may be warranted as a stewardship intervention. Timely culture obtainment and intervention when another pathogen is identified are possible strategies to ensure success of 72-hour time-out.

Disclosures
All Authors: No reported disclosures
232. Impact of Weekend Initiation of Vancomycin or Piperacillin/Tazobactam on Days of Therapy Received upon Hospital Admission
Authors: McGregor Jessina C , McCracken Caitlin M , Hohmann Samuel F , Pakyz Amy L 
Published: January 2021

Abstract

Background
Antibiotic therapy for inpatients with suspected infections is typically empirically initiated and therapy narrowed or altered when additional diagnostic evidence becomes available. For patients whose therapy is initiated on a weekend, differences in hospital staffing may impact the timing of therapy changes. We aimed to compare the duration of therapy of vancomycin and piperacillin-tazobactam between those who had therapy initiated on a weekday versus a weekend day.

Methods
We performed a cross-sectional study among U.S. hospitals that contributed pharmacy data for inpatients to the Vizient clinical database in 2016. We identified vancomycin and piperacillin-tazobactam courses initiated within the first 48 hours of admission; courses were categorized as weekend initiation (Friday, Saturday, Sunday) versus weekday initiation. The median days of therapy were compared between weekend and weekday initiation using the Wilcoxon rank-sum test.

Results
Among the 145 hospitals representing approximately 3.7 million patient encounters there were 401,101 encounters with vancomycin and 221,751 with piperacillin/tazobactam initiated within the first 48 hours of admission. Of these courses, 33% of vancomycin and 40% of piperacillin/tazobactam were initiated on a weekend day. The median (IQR) days of therapy for vancomycin initiated on a weekend was 2 days (1–4 days) compared to 2 days (1–3 days) when initiated on a weekday (p&lt; .01). The median (IQR) days of therapy for piperacillin/tazobactam was 3 days (2–5 days) for courses initiated on either a weekend or weekday (p&lt; .01).

Conclusion
We observed a statistically significant difference in the days of therapy received by patient encounters with vancomycin or piperacillin/tazobactam initiated on weekdays versus weekends. However, because of the large sample size in this study, we had power to identify small differences as statistically significant. Still, for vancomycin the 75th percentile received at least one additional day of therapy when initiated on a weekend versus a weekday. Further exploration is needed to identify if weekend initiation is associated with extended durations of therapy in specific sub-populations of patients.

Disclosures
All Authors: No reported disclosures
233. Improved Penicillin Susceptibility of Streptococcus pneumoniae and Increased Penicillin Consumption in Japan, 2013–18
Authors: Tsuzuki Shinya , Akiyama Takayuki , Matsunaga Nobuaki , Yahara Koji , Shibayama Keigo , Sugai Motoyuki , Ohmagari Norio 
Published: January 2021

Abstract

Background
Penicillin is often recommended as the first choice for Streptococcus pneumoniae infection due to its effectiveness and narrow spectrum. However, it is not clear whether increased penicillin consumption at the population level induces penicillin resistance in S. pneumoniae. The main objective of this study was to examine the association between penicillin susceptibility of S. pneumoniae and penicillin consumption in Japan.

Methods
We used Japan Nosocomial Infection Surveillance data, which comprehensively collected all routine microbiological test results from approximately 2,000 out of 8,000 hospitals across Japan that voluntarily participated in the surveillance. on susceptibility of S. pneumoniae, and sales data obtained from IQVIA Services Japan on national penicillin and cephalosporin consumption from January 2013 to December 2018. Clinical and Laboratory Standards Institute minimum inhibitory concentration breakpoints for meningitis were used as indicators of susceptibility. We analysed both sets of data by decomposing them into seasonality components and chronological trend components. The cross-correlation function was checked using Spearman’s rank correlation coefficient to examine for correlation between susceptibility and consumption.

Results
After adjusting for the influence of seasonality, the susceptibility of S. pneumoniae to penicillin gradually improved from 0.53 in January 2013 to 0.61 in December 2018 and penicillin consumption increased in the same period from 0.67 defined daily doses per 1,000 inhabitants per day (DID) in January 2013 to 1.23 DID in December 2018, thus showing positive cross-correlation (coefficient = 0.801, p &lt; 0.001). Conversely, cephalosporin consumption decreased from 3.80 DID in January 2013 to 3.33 DID in December 2018, showing negative cross-correlation with penicillin susceptibility of S. pneumoniae (coefficient = -0.981, p &lt; 0.001).
Figure 1. Trend of penicillin-susceptibility of Streptococcus pneumoniae in Japan, 2013–2018 (based on non-meningitis MICs)

Figure 2. Sales amount of penicillins in Japan, 2013–2018

Figure 3. Sales amount of cephalosporins in Japan, 2013–2018

Conclusion
The rate of penicillin-resistant S. pneumoniae isolate was not positively correlated with penicillin consumption at the population level. Increased penicillin consumption might not induce penicillin resistance of S. pneumoniae.

Disclosures
All Authors: No reported disclosures
234. Improving Antibiotic Prophylaxis Selection for Patients Undergoing Urology Procedures
Authors: Mattappallil Arun , Magan Alyssa M , Kim Eun Hyun , Sackey Joachim D , Chew Debra 
Published: January 2021

Abstract

Background
Evidence evaluating prescribing patterns in antibiotic (ABC) prophylaxis (PPX) for urology (UGY) procedures is limited. Although national guidelines give direction on the ABC PPX for specific procedures, ABC PPX should also be based on local ABC resistance patterns, individual host factors and procedure type factors. Our institution’s urine culture antibiogram illustrates increasing resistance to Cefazolin, a national guideline preferred ABC. The purpose of this study is to assess the impact of a quality improvement intervention on prescribing practices for ABC PPX in patients undergoing UGY procedures.

Methods
This is a retrospective study evaluating all patients receiving perioperative ABC PPX for UGY procedures from 01/01/2019 to 07/31/2019. The intervention (focusing on UGY provider education for ABC PPX based on local ABC resistance patterns, host factors and UGY procedure type) occurred on multiple in-person sessions during 04/2019. Emphasis occurred with replacing Cefazolin with Ceftriaxone, given local resistance patterns. We compared patient characteristics, appropriate ABC PPX use (deemed by local ABC Stewardship Team) and postoperative infections between the “pre” (01/01/2019 – 03/31/2019) and “post” (05/01/2019 – 07/31/2019) groups.

Results
The “pre” group had 85 patients and the “post” group had 80 patients. 62% had a same day UGY procedure with the most common procedures designated as “clean-contaminated” (81.8%) and ASA physical status classification as “ASA II” (53.9%). After the intervention, appropriate ABC PPX choice improved (14.5% to 76%, P &lt; 0.001) based on local ABC resistance patterns. No significant difference is noted in urine culture collection before procedure (36.4% to 43.7%, P = 0.3), ABC PPX choice based on prior patient-specific culture results including multi-drug resistant pathogens (75% to 82.3%, P = 0.6), use of ABC PPX post-procedure (40% to 35%, P = 0.5) and postoperative infections (7% to 11.2%, P = 0.4).

Conclusion
Utilization of education sessions as a quality improvement intervention resulted in significant improvement in ABC PPX choice for UGY procedures based on local ABC resistance patterns. Further interventions are necessary to optimize additional areas related to ABC PPX use for UGY procedures.

Disclosures
All Authors: No reported disclosures
239. Outcomes Associated with Empiric Aztreonam Use Compared to Anti-Pseudomonal β-lactams in Patients with Sepsis: An Opportunity for Allergy Stewardship
Authors: Jaffa Rupal K , Pillinger Kelly E , Medaris Leigh A , Anderson William E , Heffner Alan C , Hammer John M 
Published: January 2021

Abstract

Background
Aztreonam is often given to patients with a documented β-lactam allergy in lieu of a first-line anti-pseudomonal β-lactam (APBL). However, aztreonam offers no gram positive coverage and data suggest that gram negative organisms have lower susceptibility rates to this antibiotic than to APBLs. Septic patients are especially vulnerable to poor outcomes since inappropriate initial antimicrobial therapy has been shown to be an independent predictor of increased mortality. The purpose of this study was to determine whether septic patients treated with aztreonam experience inferior outcomes compared to those treated with an APBL.

Methods
This was a retrospective, multicenter, cohort study of all adult patients in metro Charlotte Atrium Health facilities treated for sepsis or septic shock from January 2014 to October 2017. Patients receiving either aztreonam or an APBL were identified using the system-wide sepsis database and enrolled in a 1:2 ratio. Patients were excluded if there was no infection-related discharge ICD-9 or ICD-10 code, if they received both aztreonam and an APBL in the first 8 hours, or if they received fewer than 2 doses of the study antibiotic. The primary endpoint was in-hospital mortality.

Results
A total of 194 patients received aztreonam and 388 patients received an APBL. β-lactam allergies were more common in patients who received aztreonam compared to APBL (97% vs. 14.2%, p &lt; 0.01). In-hospital mortality rates were greater in the patients who received aztreonam vs. APBL (22.7% vs. 12.9%, p = 0.0025). After adjusting for APACHE II score, initial aztreonam exposure remained independently associated with hospital mortality (OR = 1.74, 95% CI: 1.0 – 2.8, p = 0.02). Additionally, we identified an increase in combination therapy with the use of aminoglycosides (28.9% vs. 12.4%, p &lt; 0.0001) and fluoroquinolones (50.5% vs. 25.8%, p &lt; 0.0001) in patients receiving aztreonam. No difference was found in overall length of stay or ICU length of stay.

Conclusion
In septic patients, the use of aztreonam as the backbone of antimicrobial therapy may result in increased mortality. This highlights the importance of stewardship interventions that obtain an accurate allergy history and encourage the use of APBL antibiotics whenever feasible.

Disclosures
Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker)
240. Reduction of antibiotic use in children admitted with viral respiratory tract infections
Authors: Dutta Ankhi , Lo Huay-Ying , Singh Amrita , Mobeen Samrah , Kulik Kelli , James Megan 
Published: January 2021

Abstract

Background
Viral respiratory tract infections (VRTI) accounts for a significant proportion of hospitalized children and contributes to a substantial use of health care resources and costs. American Academy of Pediatrics (AAP) recommends against using antibiotics in uncomplicated viral respiratory infections in children. Overuse of antibiotics ranges between 29–80%. The goal of an Antibiotic stewardship programs (ASP) is to decrease antibiotic misuse, lower costs, and prevent emergence of antibiotic resistance in the community.
Proportion of children with Viral respiratory tract infections on antibiotics

Methods
Our smart aim was to reduce antibiotic use by 25% in admitted children with VRTI between October 2019-March 2020. Our outcome measure was to reduce inappropriate antibiotic use during the 2019–20 season by 25%. Process measures included percentage of antibiotic used in viral RTI, antibiotic days of therapy and appropriate audit-feedback from the ASP team to facilitate discontinuation or de-escalation of antibiotics based on culture data. Our balance measure included readmission rates in patients in whom antibiotics were discontinued or de-escalated. Several PDSA cycles implemented with predominant emphasis on communication between ASP team and primary providers.

Results
No differences were noted in patient demographics including sex, age, ethnicity between the viral season in 2018–19 and 2019–2020. In our previous study in 2018–2019 RSV season, there was 40.7% antibiotic use in patients admitted with RSV bronchiolitis. In 2019–2020 season we included all patients admitted with viral RTI. Of the 213 patients evaluated between October 2019 through Dec 2020, 40% of the patients received antibiotics. 100% of the antibiotics were justified, based on independent review of antibiotic data by the team. Most common cause of antibiotics were community acquired pneumonia, rule out sepsis and otitis media. Antibiotic discontinuation and de-escalation were achieved in over 90% of the justified antibiotics.

Conclusion
Though antibiotic usage was still at 40% at our institution, 100% of antibiotic use was deemed appropriate and significant proportion were discontinued or deescalated by the ASP team.
The ASP team played a crucial role in communicating with the primary providers to advocate for appropriate antibiotic use in the children.

Disclosures
All Authors: No reported disclosures
241. Rural-urban differences in antibiotic prescribing for uncomplicated urinary tract infections
Authors: Clark Abbye W , Durkin Michael , Olsen Margaret A , Keller Matthew R , Ma Yinjiao , Butler Anne M 
Published: January 2021

Abstract

Background
Identification of inappropriate antibiotic prescribing patterns is critical for designing antimicrobial stewardship programs. We sought to examine whether the risk of receipt of an inappropriate outpatient antibiotic prescription varied by rural-urban status among women with an uncomplicated urinary tract infection (UTI).

Methods
Using the IBM MarketScan Commercial Database, we identified U.S. women 18–44 years diagnosed with a new uncomplicated UTI and prescribed an oral antibiotic with activity against common uropathogens from April 2011 through June 2015. We classified first-line agents (nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin) as appropriate, non-first-line agents (fluoroquinolones and β-lactams) as inappropriate, and antibiotic duration as appropriate when the days’ supply was consistent with Infectious Diseases Society of America 2011 guidelines. Rural-urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural-urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics.

Results
Of 670,450 women with uncomplicated UTI, 46.7% of antibiotic prescriptions were written for inappropriate agents and 76.1% for inappropriate durations (Figures 1 and 2). Use of inappropriate agents or durations did not change appreciably over the study period (2011–2013 vs. 2014–2015). Of 507,737 prescriptions with inappropriate duration, 501,496 (98.8%) were written for a days’ supply longer than recommended. Compared to urban women, rural women had similar risk of receipt of an inappropriate agent (adjusted risk ratio 0.99, 95% CI, 0.98–1.00) but were more likely to receive a prescription for an inappropriate duration (adjusted risk ratio 1.10, 95% CI, 1.09–1.11).
Figure 1. Distribution of antibiotic agent by rural-urban status

Figure 2. Distribution of the antibiotic prescription days’ supply by antibiotic agent and rural-urban status

Conclusion
Regardless of rural-urban status, the majority of antibiotic prescriptions for uncomplicated UTI were written for inappropriate agents and durations. Rural women were more likely to receive prescriptions with inappropriately long durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and reduce unnecessary exposure to antibiotics, particularly in rural settings.

Disclosures
Margaret A. Olsen, PhD, MPH, Merck (Grant/Research Support)Pfizer (Consultant, Grant/Research Support)