bluuebunny/crossref_metadata_2025_split huggingface dataset:
1040. Effects of An Antimicrobial Stewardship Team-led Staphylococcus aureus Bacteremia Management Bundle: A Quasi-Experimental Study
Authors: Marx Ashley H , Chundi Vahini , Zaccardelli Jill , Angle Timothy , Oriet Jonathan , Swartwood Michael J , Boyce Ross , Daniels Lindsay M , Juliano Jonathan J 
Published: October 2019

Abstract

Background
Mortality associated with Staphylococcus aureus bacteremia (SAB) has prompted the development of “bundle”-based approaches to improve outcomes. Components of bundled strategies include appropriate antibiotic selection, early source control, documenting negative cultures, echocardiogram, and adequate treatment duration. In 7/2016, the UNC Antimicrobial Stewardship Program (ASP) began prospective monitoring of SAB patients. Here we describe the impact of these ASP efforts.

Methods
Quasi-experimental study of patients ≥16 years with SAB 9/2015-3/2016 (pre-intervention) and 9/201/2017 (post-intervention). Patients were excluded if the bloodstream infection was polymicrobial, therapy began at an outside hospital, or the patient was discharged or died within 72 hours of positive blood culture. Minimum adequate treatment duration was defined as 14 days for uncomplicated SAB; 28 days for complicated SAB; 42 days if endovascular disease or osteomyelitis present. Categorical variables were compared using the chi-squared test, significance level of P < 0.05. The study was approved by the UNC IRB.

Results
217 treatment courses were included; 114 pre- and 103 post-intervention. Rates of adequate empirical antibiotics were consistently high throughout the study (Table 1). Pre-intervention, individual bundle components occurred frequently: negative culture documented (95%), echocardiogram (80%), and adequate duration of an appropriate antibiotic (71%; Table 2). After ASP intervention, echocardiography and adequate treatment duration rates increased to 92% (P < 0.05, both outcomes), as did ID consultation rates (59% to 67%; P = 0.04). Overall bundle achievement increased from 54% to 82%. ASP interventions were documented for 11 (10%) and 32 (31%) of patients during the periods. Mortality and readmission within 6 months of discharge were unchanged (12% and 11%; 41% and 42%, respectively).

Conclusion
ASP intervention was associated with increased rates of bundle achievement but did not impact mortality or 6-month readmission. Despite adequate empiric therapy and relatively high rates of adherence to best-evidenced practices, SAB continues to be associated with significant mortality and high rates of 6-month readmission.

Disclosures
All authors: No reported disclosures.
1045. Impact of an Antimicrobial Stewardship Pharmacist on Microbiology Rounds
Authors: Sapozhnikov Julia , Huang Angela , Revolinski Sara , Ledeboer Nathan A , Buchan Blake W 
Published: October 2019

Abstract

Background
Microbiology rounds is an area for antimicrobial stewardship programs (ASP) to potentially intervene on antimicrobial prescribing in both the inpatient and outpatient settings. The purpose of this study was to describe and evaluate the impact of ASP pharmacist participation in microbiology rounds.

Methods
This was a single-center retrospective descriptive study including inpatient and ambulatory adults ( ≥18 years) with a susceptibility request requiring review during microbiology rounds between October 2018 and 3/2019. During daily microbiology rounds, susceptibility or workup requests were reviewed with the multidisciplinary microbiology team. The ASP pharmacist was called for their clinical expertise in assessing complicated or nonstandard susceptibility requests. Number and types of interventions made by ASP pharmacist were recorded (e.g., approval rate, education, ASP referral, ID consult referral). Additionally, number and types of intervention outcomes (unnecessary susceptibility prevented, optimized susceptibility request, treatment recommendation, improved clinician understanding, etc.) were analyzed.

Results
There were 66 susceptibility requests reviewed by an ASP pharmacist from October 2018 to 3/2019, of which 84.8% were inpatient. An ID provider was the requestor for 35% of requests. ASP pharmacists completed chart reviews for 92.4% of patients and contacted the requester/primary team 72.7% of the time. Thirty-three (50%) susceptibility requests were approved and, notably, 65.2% of requests from an ID provider were approved. Intervention rates for education provided, ASP referral, and ID consult referral were 50%, 1%, and 7%, respectively. ASP pharmacists were able to impact multiple intervention outcomes, including preventing unnecessary susceptibility requests (45.5%) and improving clinician understanding (39.4%) (Table 1).

Conclusion
ASP pharmacists are an important part of the microbiology team and are able to use their clinical expertise to help approve or deny susceptibility requests, make potential recommendations to optimize antimicrobial therapy, and provide education to other healthcare professionals.

Disclosures
All authors: No reported disclosures.
1059. Impact of a Syndrome-Based Antimicrobial Stewardship Intervention on Anti-Pseudomonal β-Lactam Use, C. difficile Rates and Cost in an Urban Community Hospital
Authors: Mena Lora Alfredo J , Cortez Martin , Li Ella , Sanchez Lawrence , Bello Rochelle , Krill Candice , Coleman Yolanda , Takhsh Eden , Bleasdale Susan C 
Published: October 2019

Abstract

Background
The use of anti-Pseudomonal β-lactam (APBL) agents has significantly increased in the past decade, carrying higher costs and contributing to antimicrobial pressure. Antimicrobial stewardship (ASP) can promote evidence-based antimicrobial selection and mitigate excess APBL use. We implemented a comprehensive ASP with syndrome-based prospective audit and feedback (PAF) at an urban community hospital. The goal of this study is to assess the impact of syndrome-based PAF on APBL use, C. difficile rates and cost.

Methods
ASP with all CDC core elements was implemented at a 151-bed community hospital in October 2017. Syndrome-based guidelines and PAF was established and overseen via direct communication with an ID physician. Days of therapy (DOT), cost and C. difficile rates were assessed 12 months before and after ASP. DOT for APBL and non-APBL utilization was tabulated by unit and paired t-test performed.

Results
Most cases reviewed by PAF (51%) were represented in our syndrome-based treatment guidelines (Figure 1). Soft tissue (33%) and intra-abdominal (24%) infections were the most common syndromes. Change to guideline was the most common PAF intervention (62%) followed by de-escalation (30%). At 12 months, total DOT/1,000 increased (392.5 vs. 404) while the proportion of parenteral antimicrobials used decreased (71% vs. 65%). Antibiotic expenditures decreased by 23%, with a reduction in APBL of 20% and non-APBL of 10% (Table 1). Statistically significant reductions APBL use in non-ICU settings (P = 0.0139) and statistically significant increases in non-APBL in ICU settings occurred (P = 0.0001) (Figure 2 and 3). C difficile rates decreased from 21% (3.27 vs. 2.56).

Conclusion
Syndrome-based PAF was successfully implemented. A reduction in APBL use was seen in non-ICU settings, where evidence-based de-escalation may be more feasible. APBL use remained high in the ICU but was guideline consistent. A rise in non-APBL use also occurred. Certain critical illness syndromes warrant APBLs, but PAF may promote culture-directed and syndrome-specific treatments. ASP increased guideline-based therapy and contributed to decreased broad-spectrum antimicrobial use, antimicrobial expenditures and C difficile rates. Syndrome based PAF can be successfully implemented in community settings.

Disclosures
All authors: No reported disclosures.
1072. The Role of an On-site Infectious Disease Specialist in Hospital-Based Antimicrobial Stewardship Programs
Authors: Livorsi Daniel J , Nair Rajeshwari , Lund Brian , Alexander Bruce , Beck Brice , Goto Michihiko , Ohl Michael , Perencevich Eli N 
Published: October 2019

Abstract

Background
Antimicrobial stewardship programs (ASPs) are now a requirement for many hospitals, but a large proportion of US hospitals lack an on-site Infectious Disease (ID) specialist. We sought to compare the processes and outcomes of ASPs at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist.

Methods
This retrospective cohort included all acute-care patients in VHA hospitals admitted during 2016, or 2 years after a VHA mandate for hospital-based ASPs. Data from a mandatory nationwide survey were used to identify hospitals that self-reported the absence of an on-site ID specialist, including an ID physician or ID pharmacist, in 2016. Antimicrobial use was quantified at the hospital-level as days-of-therapy (DOTs) per 1,000 days present and categorized based on National Healthcare Safety Network definitions. A facility-level negative binomial regression model with risk adjustments made for aggregated case-mix and facility-level factors was used to determine the association between the presence of an on-site ID specialist and antimicrobial use.

Results
Eighteen of 122 (14.8%) hospitals lacked an on-site ID specialist. Non-ID hospitals had fewer admissions per month than ID sites (mean 107.3 vs. 425.4, P < 0.01). An ASP policy and an ASP pharmacy champion were present at ≥90% of hospitals with and without an ID specialist. Core ASP strategies were frequently used in both ID and non-ID sites, including prior authorization (90.4% vs. 83.3%, P = 0.41) and prospective audit-and-feedback (76.9% vs. 66.7%, P = 0.38). Broad-spectrum antibacterial use (263.9 vs. 317.6 DOTs per 1,000 days-present, P = 0.01) but not total antimicrobial use (600.8 vs. 634.3 DOTs per 1,000 days-present, P = 0.34) was lower at ID vs. non-ID hospitals. After facility-level risk-adjustment, broad-spectrum antibacterial use (OR = 0.81, 95% CI 0.69–0.94) but not total antimicrobial use (OR = 0.92, 95% CI 0.70–1.21) was lower at ID hospitals.

Conclusion
An on-site ID specialist was not associated with greater use of core ASP strategies, but the presence of an on-site ID specialist was associated with less frequent prescribing of broad-spectrum antibacterial agents. An on-site ID specialist may be an important part of an effective hospital-based ASP.

Disclosures
All authors: No reported disclosures.
1073. Analysis of the Antimicrobial Stewardship Program Recommendation Process in the Intensive Care Units at a Large Tertiary Community Hospital
Authors: Song Youchan , Holt Jessica , Gens Krista 
Published: October 2019

Abstract

Background
Studies suggest up to 60% of antibiotics prescribed in the intensive care units (ICUs) may not be optimized. The antimicrobial stewardship team (AST) at Abbott Northwestern consists of infectious diseases trained pharmacists, pharmacy residents, and/or advanced pharmacy practice experience (APPE) pharmacy students and provides prospective audits and feedback on all inpatients not being seen by infectious diseases specialists and currently receiving any anti-infectives. Comprehensive daily profile reviews are performed and recommendations are communicated via a physician sticky note in the electronic medical record (EMR) and/or via a direct page. Beginning January 2018, the AST started reviewing patients in the two ICU units earlier to ensure recommendations were completed prior to multidisciplinary rounds. The AST also initiated sending a message within the EMR alerting the decentral pharmacists prior to rounds.

Methods
A retrospective chart review was conducted on recommendations made by the AST between February and April 2017 (control group) and February and April 2018 (intervention group) for patients on two ICU units (ICU 1 and ICU 2). Time to acceptance and acceptance rates were calculated for the control and intervention period. A one-tailed t-test was performed for the time to acceptance analysis and a Chi-squared test was performed to compare acceptance rates. Results were deemed statistically significant when P < 0.05.

Results
Time to acceptance for the recommendations showed a significant decrease from 25.9 to 13.7 hours with the new process in ICU 1 (P = 0.038). Provider acceptance rate increased significantly from 77.8% to 88.4% in ICU 2 (P = 0.037).

Conclusion
Changing the workflow of the prospective audit and feedback process by the AST had a meaningful impact by decreasing the response time (time to acceptance) and increasing acceptance rates of the recommendations in the ICUs. The revised process improved communication between the AST, decentral pharmacist, and attending provider, which in turn may have contributed to the positive outcomes.

Disclosures
All authors: No reported disclosures.
1100. Facility Factors Are a Stronger Driver of Peri-Operative Vancomycin Use Than Patient Risk Factors
Authors: Branch-Elliman Westyn , O’Brien William , Strymish Judith , Itani Kamal , Gupta Kalpana 
Published: October 2019

Abstract

Background
Prior reports suggest that the use of vancomycin for surgical prophylaxis is common and increasing. However, rates of administration and reasons for choosing vancomycin are unknown. Thus, we sought to quantify the frequency of vancomycin as a surgical prophylaxis agent and to determine drivers of use.

Methods
All Veteran patients undergoing major cardiac, orthopedic total joint, vascular, or colorectal procedures and entered into the VA External Peer Review Program (EPRP) database during the period from October 1, 2008 to September 30, 2013 were included. EPRP includes a manual review of surgical cases to measure type of prophylaxis, and, in the case of vancomycin, clinician-documented reasons for vancomycin use (β-lactam allergy, patient at high risk of methicillin-resistant Staphylococcus aureus (MRSA), facility high rate of MRSA). Descriptive statistics were used to evaluate findings.

Results
Among 79, 058 surgical procedures at 109 different medical centers, 20,349 (25.7%) received vancomycin either alone or in combination with another agent for prophylaxis. Rates of vancomycin use were the highest for cardiac surgeries (10,455/21,396, 48.9%), followed by orthopedic total joint replacement surgeries (8,044/38,675, 20.8%), vascular surgeries (1,504/8,177, 18.4%) and colorectal surgeries (346/10,810, 3.2%). The most common reason for vancomycin use was a perceived high facility rate of MRSA (7,367, 36.2%) followed by β-lactam allergy (4,855, 23.9%) and high-risk patient (1,420/20,349, 7.0%). There was no reason documented in 5,194 (25.5%). The most common reason for vancomycin use differed by surgical type. Among cardiac and orthopedic cases, high facility rate was the most commonly reported reason, but β-lactam allergy was the most common driver among vascular and colorectal procedures.

Conclusion
Facility factors are a major driver of peri-operative vancomycin use, more so than β-lactam allergy or patient-level factors, particularly in cardiac and orthopedic surgery. These data suggest that facility-level interventions, such as implementation of specific guidelines, may be helpful for limiting vancomycin use in this population.

Disclosures
All authors: No reported disclosures.
1102. Ertapenem vs. Nonertapenem Antibiotics in Colorectal Surgery: A Stewardship Opportunity
Authors: LaDow Tiffany , Brust Karen B , Zolfaghari Kiumars , Midturi John 
Published: October 2019

Abstract

Background
The optimal regimen for antibiotic prophylaxis in colorectal surgery is not well defined. The aim of this study was to determine whether nonertapenem antibiotic prophylaxis in colorectal surgery is associated with increased rates of surgical site infections (SSI), defined by both deep and incisional infections, compared with ertapenem prophylaxis. Secondary aims were to identify differences in C. difficile infection rates at 60 days between the two groups.

Methods
This was a single-center retrospective study from November 2016 to December 2018 at a 600-bed teaching hospital equipped with a Level I Trauma Center in Central Texas. National Healthcare Safety Network (NHSN) criteria for colorectal surgical site infection (SSI) were used to identify eligible patients. Patients under 18 years or lacking pre-operative antibiotic documentation were excluded. SSI and C. difficile rates between the two prophylactic strategies were compared using Chi-squared and Fisher’s exact tests as appropriate.

Results
A total of 761 patients were included in the analysis. There were 87 patients in the ertapenem group and 674 patients in the nonertapenem group. Antibiotics included in the nonertapenem group were cefazolin (32%), ceftriaxone (22%), or ciprofloxacin (15%) plus metronidazole, and other antibiotics (31%). Baseline characteristics including age, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and number of surgical procedures were similar for both groups. The overall SSI rate was 4.7% and the 60-day C. difficile rate was 3.9%. No significant differences were found between ertapenem and nonertapenem groups in SSI rates (5.8% vs. 4.6%, P = 0.6) or 60-day incidence of C. difficile (6.9% vs. 3.6%, P = 0.1).

Conclusion
Our study, with a large sample size and a low overall incidence of SSI, did not find a significant difference in either SSI rates or 60-day C. difficile rates between ertapenem and nonertapenem prophylaxis in colorectal surgery. Given the rise of Gram-negative resistance, this study highlights an important opportunity for carbapenem stewardship.

Disclosures
All authors: No reported disclosures.
1106. Assessment of Fluoroquinolone Appropriateness for Hospitalized Patients with Asymptomatic Bacteriuria and Cystitis: A Multi-Hospital Cohort Study
Authors: Gandhi Tejal N , Petty Lindsay A , Vaughn Valerie M , Patel Twisha S , Ratz David , McLaughlin Elizabeth , Malani Anurag N , Dumkow Lisa , Pogue Jason M , Thyagarajan Rama , Hsaiky Lama , Bernstein Steven J , Flanders Scott A 
Published: October 2019

Abstract

Background
Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance, but are frequently used for hospitalized patients with bacteriuria. We assessed patterns and predictors of inappropriate fluoroquinolone (FQ) use among hospitalized patients with asymptomatic bacteriuria (ASB) and cystitis.

Methods
This is a retrospective cohort study of non-ICU medicine patients with ASB or cystitis (complicated or uncomplicated) from January 2018 to March 2019 at 43 Michigan hospitals. Patients with concomitant infections, bacteremia, or pyelonephritis were excluded. Each day of FQ (ciprofloxacin, levofloxacin) use (inpatient and post discharge) was assessed for appropriateness. FQ use was inappropriate if: (A) ASB, (B) urine culture with an FQ-resistant bacteria, (C) a safer alternative empiric or definitive antibiotic (treatment ≥2 days after urine culture collection) based on disease severity, cultures, allergies, and renal function, or (D) excess duration (>7 days complicated cystitis; >3 days uncomplicated cystitis). Hospitals were also surveyed on existing stewardship (ASP) practices targeting FQ use. ASP practices associated with inappropriate FQ use were evaluated using logistic generalized estimated equation models adjusting for patient factors and hospital clustering.

Results
Of 4849 included patients with ASB (39.7%) or cystitis (60.3%), 21.9% (n = 1,061) received an FQ and 92.7% (n = 984) received a, FQ inappropriately (Figure 1). Of 5,465 FQ days of therapy (DOT), 90.7% (n = 4,959) were inappropriate. Definitive treatment of complicated cystitis led to the greatest proportion of inappropriate FQ DOTs (50.6%), followed by ASB (36.4%) (Table 1). Hospitals varied (Figure 2), but those with cascade reporting of antibiotic susceptibilities, urinary tract infection (UTI) treatment guideline or an ASP performing prospective audit and feedback on FQ use had lower inappropriate FQ treatment rates (Table 2).

Conclusion
Hospitalized patients with ASB and cystitis often receive an FQ. Most FQ use is inappropriate due to ASB treatment or FQ use for complicated cystitis despite the option of an alternative antibiotic. Prospective audit and feedback, UTI guidelines, and cascade reporting of antibiotic susceptibilities can be used by ASP to reduce inappropriate FQ use.

Disclosures
All authors: No reported disclosures.
1120. Reliability of Parent-Reported Pediatric Antibiotic Use in a Longitudinal Birth Cohort
Authors: D’Arinzo Lauren , Patel Krisha , Carrington Tevin , Goba Miatta , Gerber Jeffrey 
Published: October 2019

Abstract

Background
Depending on the population of interest, it is not always feasible to acquire electronic health record (EHR) data for antibiotic prescribing in longitudinal outpatient studies. Even when available, EHR algorithms are limited to only capturing in-network prescriptions. Thus, there is value in learning more about the reliability of parent-reported data to see whether this approach can be validated for epidemiologic research.

Methods
We examined antibiotic prescribing in the MAGIC (Microbiome, Antibiotics, and Growth Infant Cohort) Study, a longitudinal birth cohort of healthy newborns followed through 2 years of life. An informatics algorithm within an EHR platform was developed such that the study team received a text message alert every time a study participant who sought care in the Children’s Hospital of Philadelphia (CHOP) Care Network was prescribed an antibiotic. Families were also asked every 3 months whether their child had been prescribed an antibiotic in the past 3 months. We compared parent-reported antibiotic use with antibiotic use that generated an alert in the EHR.

Results
Among the 104 EHR-documented antibiotic exposures in 3-month spans, 52 (50%) were reported by parents at the relevant time point. Of the 52 nonreported antibiotic prescriptions that generated alerts, 4 (4%) were explicitly not reported by families and the remaining 48 exposures (46%) were not reported because the family did not answer the question at the relevant time point. There were 11 total exposures that were patient-reported without documented EHR alerts.

Conclusion
In this longitudinal birth cohort, only half of in-network, EHR-generated alerts for antibiotic prescriptions were reported by parents, and parent-reported antibiotic exposures occurred outside of the pediatric network that, by definition, could not generate EHR-based alerts. These results suggest that the most effective method for quantifying antibiotic use may be using EHR data supplemented with parent-reported data.

Disclosures
All authors: No reported disclosures.