bluuebunny/crossref_metadata_2025_split huggingface dataset:
160. A Pre- and Post-intervention Study to Implement a Successful Antimicrobial Stewardship Program in Palliative Care
Authors: McCracken James A , Nakeshbandi Mohamed , Sainvil Carline , Porosnicu Eduard , Sharma Roopali 
Published: January 2021

Abstract

Background
In patients receiving palliative care, medical interventions are transitioned away from aggressive and curative attempts to less invasive and more comfort measures. Antimicrobial usage remains a challenging subject in palliative care decisions, where many physicians focus interventions on reduction of patient pain and discomfort, without consideration for adverse effects such as the development of antimicrobial resistance or patient-specific adverse drug events. With limited data on the comfort benefit, we aimed to assess antimicrobial use in patients at the end of life in our institution as well as the success of targeted stewardship interventions in palliative care patients.

Methods
Patients who expired between November 2018 and August 2019 were assessed retrospectively for antimicrobial use during their last 14 days of life. In January 2020, a prospective stewardship initiative began in collaboration with our institution’s palliative care team to focus antimicrobial interventions on patients involved in goals of care discussions.

Results
In our retrospective review of 200 patients, 139 (69.5%) of patients received antimicrobials in their last two weeks of life, with 50% having formal palliative care consultations. The most commonly used antimicrobials were piperacillin-tazobactam (64.7%) and vancomycin (60.4%), with primary indications being pneumonia (34.5%) and empiric coverage/sepsis (24.5%). Of note, 46% of antimicrobial regimens were eligible for optimization through stewardship initiatives.
From January through February 2020, sixteen stewardship interventions were made on thirteen palliative care patients, with an 81.3% acceptance rate. Duration of therapy based on indication and discontinuation of antibiotics following transition to comfort measures only were the most frequent interventions made.
Table 1. Baseline Characteristics

Table 2. Antimicrobial Usage - Pre-intervention

Table 3. Prospective Intervention Data

Conclusion
Close of half of patients receiving antimicrobials at the end of life are eligible for interventions to improve antibiotic regimens. These patients are often overlooked in antimicrobial stewardship, and, despite small sample size, our study shows the benefit of targeted stewardship in palliative care populations with an intervention acceptance rate of over 80%.

Disclosures
All Authors: No reported disclosures
161. Assessing Antimicrobial Stewardship Engagement among Frontline Oncology Nurses and Chartering a Path Forward
Authors: McCort Margaret E , Bartash Rachel , Cowman Kelsie , Sakalian Susan , Sheridan Carol , Wright Karen , Hopkins Una T , Nori Priya , Nori Priya 
Published: January 2021

Abstract

Background
Developing robust, multidisciplinary antimicrobial stewardship programs to combat drug resistance is a priority of healthcare institutions, in accordance with Joint Commission standards and national legislature. However, the involvement of nurses in stewardship programs has trailed behind that of physicians and pharmacists, despite their unique position as frontline providers. In particular, oncology nursing staff can play a key role in extending stewardship to their high acuity patients, who frequently require antimicrobials. We sought to conduct a survey study of oncology nursing providers on their understanding, perceptions, and attitudes about antimicrobial stewardship.

Methods
A voluntary and anonymous survey was emailed to oncology nursing staff on adult and pediatric oncology wards and clinics throughout our hospital system. We used an adapted 28-item Likert scale-based survey to assess understanding of antimicrobial stewardship attitudes and perceived barriers to greater involvement in stewardship programs. A survey reminder was emailed weekly for 8 weeks and completion was encouraged by nursing leadership in unit staff meetings.

Results
The survey was emailed to 281 nurses, of whom 39% (n=109) responded. 54.1% of nurses believed that an antibiotic stewardship program was very important in their healthcare setting. However, 56% of respondents were unfamiliar with the meaning of antibiotic stewardship, and 83.5% were not aware of how to contact the antimicrobial stewardship team with questions. More than 75% felt that nurses could help with antibiotic use, though 76% indicated wanting to know more about which antibiotics treat different infections and 74% wanted to know more about appropriate durations of antibiotics.

Conclusion
Oncology nurses have the potential to play a valuable role in antimicrobial stewardship. Barriers to nursing involvement include knowledge gaps on antibiotics and unfamiliarity with existing stewardship programs and their functions within hospital systems. Nursing education and orientation to available resources are key steps to involving nursing staff in antimicrobial stewardship programs, maximizing benefits for both patients and hospitals.

Disclosures
All Authors: No reported disclosures
178. Implementation of the Core Elements of Antibiotic Stewardship in Nursing Homes – National Healthcare Safety Network (NHSN), 2016–2018
Authors: Gouin Katryna A , Anttila Sarah Kabbani; Angela , Mak Josephine , Mungai Elisabeth , McCray Ti Tanissha , Bell Jeneita , Hicks Lauri , Stone Nimalie D 
Published: January 2021

Abstract

Background
Since 2016, nursing homes (NHs) enrolled in the Centers for Disease Control and Prevention’s NHSN Long-term Care Facility (LTCF) Component have reported on their implementation of the core elements of antibiotic stewardship. In 2016, 42% of NHs reported implementing all seven core elements. Recent regulations require antibiotic stewardship programs in NHs. The objectives of this analysis were to track national progress in implementation of the core elements and evaluate how time dedicated to infection prevention and control (IPC) is associated with the implementation of the core elements.

Methods
We used the NHSN LTCF 2016–2018 Annual Surveys to assess NH characteristics and implementation of the core elements, defined as self-reported implementation of at least one corresponding stewardship activity. We reported absolute differences in percent implementation. We used log-binomial regression models to estimate the association between weekly IPC hours and the implementation of all seven core elements, while controlling for confounding by facility characteristics.

Results
We included 7,506 surveys from 2016–2018. In 2018, 71% of NHs reported implementation of all seven core elements, a 28% increase from 2016 (Fig. 1). The greatest increases in implementation from 2016–2018 were in Education (+19%), Reporting (+18%) and Drug Expertise (+15%) (Fig. 2). Ninety-eight percent of NHs had an individual responsible for antibiotic stewardship activities (Accountability), with 30% indicating that the role was fulfilled by an infection preventionist. Furthermore, 71% of NHs reported pharmacist involvement in improving antibiotic use, an increase of 27% since 2016. NHs that reported at least 20 hours of IPC activity per week were 14% more likely to implement all seven core elements, when controlling for facility ownership and affiliation, 95% CI: (1.07, 1.20).

Conclusion
NHs reported substantial progress in antibiotic stewardship implementation from 2016–2018. Improvements in accessing drug expertise, providing education and reporting antibiotic use may reflect increased stewardship awareness and use of resources among NH providers under new regulatory requirements. NHs with at least 20 hours dedicated to IPC per week may have greater capacity to implement all core elements.

Disclosures
All Authors: No reported disclosures
191. The impact of antibiotic use on clinical outcomes in cancer patients treated with immune checkpoint inhibitors: a systematic review and meta-analysis
Authors: Vafea Maria Tsikala , Belani Neel , Vieira Kendra , Farmakiotis Dimitrios 
Published: January 2021

Abstract

Background
Observational studies and experimental models suggest that use of antibiotics close to the administration of immune checkpoint inhibitors (ICI) can negatively affect tumor response and patient survival. This observation may be attributed to microbiome dysbiosis and the resultant suppression of host immune response against neoplastic cells.

Methods
We conducted a systematic search of PUBMED and EMBASE databases and references of articles retrieved. We included studies published between 1/1/17 and 2/1/20, which evaluated the association between antibiotic use and clinical outcomes in cancer patients treated with ICI. Primary endpoints were overall survival (OS), progression free survival (PFS), response rate (RR) and progressive disease (PD) rate. We performed a study-level random-effects meta-analysis with pooling of hazards ratios (HR) for OS, PFS, and odds ratios (OR) for RR and PD (PROSPERO ID: CRD42020166473).

Results
We included 41 studies with a total of 10,857 patients. The most common malignancies were lung cancer (59.7%), melanoma (23.1%), renal cell and urothelial carcinomas (8.1%). OS and PFS were shorter, RR lower, and PD higher in patients receiving antibiotics, both in univariate analyses and after adjustment for other confounders. Heterogeneity was significant for all outcomes, less so for adjusted OS and PFS (Table). To our knowledge, this is the largest meta-analysis on the association between antibiotic use and efficacy of ICI, and the only one to address RR and PD to-date.
Association between antibiotics and clinical outcomes.

Conclusion
We demonstrated a significant association between antibiotic use and unfavorable clinical outcomes in patients with cancer receiving ICI. Such patients may be an important target group for antibiotic stewardship interventions. The high heterogeneity across all outcomes underscores the need for more detailed, patient-level studies with stratification by host, antibacterial and cancer treatment factors.

Disclosures
All Authors: No reported disclosures
192. A Hematology/Oncology Unit-Specific Antibiogram Emphasizes the Need for Intensified Local Stewardship
Authors: Bartash Rachel , McCort Margaret E , Cowman Kelsie , Orner Erika , Szymczak Wendy , Nori Priya , Nori Priya 
Published: January 2021

Abstract

Background
Antibiograms are important stewardship tools for empiric antibiotic prescribing. Appropriate therapy is particularly important in patients with hematologic malignancies and bone marrow transplants being treated for febrile neutropenia. These patients are at high risk for multi-drug resistance based on extensive prior antibiotic and hospital exposures, and therefore, hospital-wide antibiograms may not reliably reflect resistance patterns for this population. We created a unit-specific antibiogram for a closed hematology/oncology unit and hypothesized there would be decreased antibiotic susceptibilities compared to the hospital-wide antibiogram.

Methods
All positive cultures with antimicrobial susceptibilities on a closed 32-bed hematology-oncology unit from 7/2016-6/2019 were obtained from the microbiology laboratory. Based on recommendations by the Clinical and Laboratory Standards Institute (CLSI), only organisms with &gt; 30 isolates were included in antibiogram analysis. Susceptibilities were compared to those reported in our hospital-wide antibiograms from the same time period using Fisher’s exact test.

Results
Two organisms met CLSI criteria: Escherichia coli (n=83) and Klebsiella pneumoniae (n=31). Unit Escherichia coli isolates were significantly more resistant to almost all commonly tested antibiotics (Table 1). Klebsiella pneumoniae unit susceptibilities were significantly lower for many antibiotics, including aztreonam, ceftriaxone, cefepime, levofloxacin, piperacillin-tazobactam and tobramycin (Table 1).
Table 1: Percentage of Escherichia coli and Klebsiella pneumoniae isolates susceptible to reported antibiotic agents

Conclusion
Our hematology-oncology antibiogram showed significantly lower antibiotic susceptibilities in Escherichia Coli and Klebsiella pneumoniae compared with the hospital-wide antibiogram. These findings can help guide prescribers toward appropriate broad-spectrum empiric therapy. Additionally, results suggest a need for intensified stewardship measures to prevent multi-drug resistance in this population.

Disclosures
All Authors: No reported disclosures
204. Post-Liver Transplant Antimicrobial Use after the Expansion of a Pharmacist-Lead Antimicrobial Stewardship Program
Authors: Gales Kee , Wrin Justin E , Pennington Catherine 
Published: January 2021

Abstract

Background
Antimicrobial stewardship programs (ASPs) allow for infectious diseases (ID)-trained practitioners to focus on timely and appropriate antimicrobial use. In December 2016, the ASP at Indiana University (IU) Health expanded from one ID pharmacist to three. The purpose of this study was to assess the impact of an expanding ASP on broad-spectrum antimicrobial use within post-liver transplant patients.

Methods
This was a retrospective, cross-sectional study. Data were collected from patients aged at least 18 years old that received a liver transplant either before or after the ASP expansion. Patients were excluded if they survived less than 72 hours after transplant, if they received a multivisceral transplant, or if there was an active infection prior to transplantation. The hypothesis of this study was that an expanded ASP leads to a reduction in days of therapy (DOT) per 1000 patient-days for a composite of broad-spectrum antimicrobial agents within this patient population.

Results
A total of 268 patients were included in this study. Of the patients that received at least one dose of the studied antimicrobial agents, the median (IQR) DOT per 1000 patient-days in the pre- and post-ASP expansion cohort was 174.4 (117.6 – 333.3) and 142.9 (62.5 – 257.5), respectively. This was statistically significant (difference 48.6, 95% CI 7.5 – 83.3). Specifically, the post-ASP expansion cohort used less meropenem (difference 197.8, 95% CI 66.3 – 451.6) and vancomycin (difference 57.6, 95% CI 2.2 – 132.2). The post-ASP expansion cohort also consulted ID for more patients (2 vs. 12 consults in the pre- and post-expansion group, respectively; p=0.011). Patient and graft survival one year after transplantation were similar between the two cohorts (p=0.540 and p=0.255, respectively).

Conclusion
An expanded ASP contributed to a reduction in broad-spectrum antimicrobial use in post-liver transplant patients without negatively impacting patient and graft survival one year post-transplantation. These data provide further evidence of ASP benefits within immunocompromised populations.

Disclosures
All Authors: No reported disclosures
218. Changes in Dental Antibiotic Prescribing in the United States, 2012–2017
Authors: Ramanathan Swetha , Yan Connie H , Hubbard Colin , Calip Gregory , Sharp Lisa K , Rowan Susan A , McGregor Jessina C , Gross Alan E , Campbell Allen , Evans Charlesnika T , Hershow Ronald , Suda Katie J 
Published: January 2021

Abstract

Background
Data suggest dental antibiotic prescribing is increasing with relatively less documented about prescribing trends in adults and children. Therefore, the aim was to evaluate trends in antibiotic prescribing by US dentists from 2012–2017.

Methods
This was a cross-sectional study of US dental prescribing using IQVIA Longitudinal Prescription Data from 2012 to 2017. Prescribing rates (prescriptions [Rx] per 100,000 dentists), mean days’ supply, and mean quantity dispensed were calculated monthly across eight oral antibiotic groups: amoxicillin, clindamycin, cephalexin, azithromycin, penicillin, doxycycline, fluoroquinolone, and other antibiotics. Descriptive frequencies and multiple linear regressions were performed to obtain trends overall and stratified by adults (≥ 18) and children (&lt; 18).

Results
220, 325 dentists prescribed 135 million Rx (94.0% in adults). 61.0% were amoxicillin, 14.4% clindamycin, 11.7% penicillin, 4.4% azithromycin, 4.3% cephalexin, 2.0% other antibiotics, 1.4% doxycycline, and 0.7% fluoroquinolones. Prescribing increased by 33 Rx/100,000 dentists (p&lt; 0.0001) each month for all antibiotics. Amoxicillin (p&lt; 0.0001) and clindamycin (p=0.02) prescribing rate increased by 73 and 5 Rx/100,000 dentists, respectively. Prescribing decreased by 8, 12, and 2 Rx/100,000 dentists for cephalexin (p&lt; 0.0001), doxycycline (p&lt; 0.0001), and fluoroquinolones (p=0.008), respectively. Mean days’ supply increased for amoxicillin, penicillin, and clindamycin (p&lt; 0.0001), and decreased for cephalexin (p&lt; 0.0001).Mean quantity dispensed decreased (p&lt; 0.0001) for all groups except azithromycin and doxycycline. Among adults, cephalexin prescribing rates (7 Rx/100,000 dentist; p&lt; 0.0001) and other antibiotics days’ supply (p&lt; 0.0001) decreased. Among children, azithromycin prescribing rates (1 Rx/100,000 dentists, p=0.02), and fluoroquinolone and other antibiotics days’ supply (p&lt; 0.0001) decreased.

Conclusion
These findings support dental antibiotic prescribing is increasing, specifically for amoxicillin and clindamycin. Further, trends differed between adults and children. Understanding what is driving these trends is important to target dental antibiotic stewardship efforts.

Disclosures
All Authors: No reported disclosures
219. Characteristics Associated with Inappropriate Antibiotic Prescribing in Patients with Asymptomatic Bacteriuria (ASB)
Authors: Bixby Morgan L , Raux Brian R , Bhalla Aakansha , McCoy Christopher , Hirsch Elizabeth B 
Published: January 2021

Abstract

Background
Antibiotic treatment of asymptomatic bacteriuria (ASB) is considered inappropriate, does not improve patient outcomes, and may lead to adverse events such as antibiotic resistance and Clostridioides difficile infection. Previous stewardship interventions have focused on reducing unnecessary urine culture collection in individuals without urinary symptoms; however, further interventions to reduce inappropriate prescribing in ASB are warranted. This study sought to identify characteristics associated with treatment of ASB in order to implement future stewardship interventions.

Methods
This two-center, retrospective cohort study included unique emergency department or inpatient adults with consecutive non-duplicate monomicrobial urine isolates of Enterobacterales or Pseudomonas aeruginosa collected between 8/2013 and 1/2014 from two academic hospitals in Boston, Massachusetts. Patients with ASB (without chart-documented urinary-specific symptoms) were identified through chart review and stratified into two groups: those treated with empiric urinary tract infection (UTI) antibiotics and those untreated. Logistic regression analyses were performed to identify variables independently associated with antibiotic treatment of ASB.

Results
During the study, 255 patients were determined to have ASB and a majority (80.8%) were treated with empiric UTI antibiotics. Most patients were female (71.4%) and elderly (mean age 70 years). The most common organisms isolated were Escherichia coli (59.2%), Klebsiella spp. (23.1%), and P. aeruginosa (9.8%). The presence of isolated fever (OR, 7.83 [95% confidence interval, 1.51, 144.20]); p = 0.05), urinalysis positive for pyuria (&gt;10 white blood cells) (OR, 2.52 [95% CI, 1.15, 5.54]; p = 0.02), and Klebsiella spp. urine isolate (OR, 2.99 [95% CI, 1.19, 8.60]; p = 0.02) were independently associated with treatment.

Conclusion
A large proportion of ASB patients were treated with antibiotics despite clinical practice guidelines recommending against this practice. Isolated fever, pyuria, and Klebsiella spp. culture were all significantly associated with the treatment of ASB; targeted review of these patients by stewardship programs may help to reduce inappropriate ASB treatment within these institutions.

Disclosures
Elizabeth B. Hirsch, PharmD, Merck (Grant/Research Support) Nabriva Therapeutics (Advisor or Review Panel member)
231. Impact of DRIP Score Documentation at Time of Physician Order Entry on Combination Antimicrobials in Treatment of Community Acquired Pneumonia
Authors: Herbin Shelbye R , Scipione Marco R , Yost Raymond 
Published: January 2021

Abstract

Background
The Drug Resistance in Pneumonia (DRIP) score is a predictive model for identifying drug-resistant pathogens in community-acquired pneumonia (CAP). The Detroit Medical Center adopted DRIP documentation at time of antimicrobial order entry for CAP in 2017. The purpose of this study was to identify the difference in overall consumption of antibiotics used for the treatment of CAP after the implementation of DRIP documentation.

Methods
A retrospective analysis of adult patients with an antimicrobial order with a documented indication of pneumonia between Jun 1-Oct 31, 2017 and Jun 1-Oct 31, 2018, was conducted. Days of antimicrobial therapy per 1000 adjusted patient days (DOT/1000 pt days) was assessed in patients before and after implementation of DRIP documentation at time of order entry. The percent concordance with institutional guidelines for empiric CAP treatment post-implementation of DRIP documentation was also evaluated.

Results
The DOT/1000 pt days increased in the post-DRIP group for ceftriaxone (36.5 vs. 76.3), doxycycline (22.3 vs. 44.5), and azithromycin (29.5 vs. 53.4). The DOT/1000 pt days decreased for carbapenems in the post-DRIP group (14.0 vs. 8.5). There was no change in vancomycin or linezolid use. Empiric therapy after implementation of DRIP documentation was concordant with institutional guidelines in 34.7% and 11.2% of patients with documented DRIP&lt; 4 and DRIP≥4, respectively. Overall, the most common reason for non-concordance was lack of atypical coverage. Use of expanded Gram-negative coverage (i.e. cefepime) for documented DRIP&lt; 4, and lack of expanded Gram-negative coverage with aminoglycosides in ICU patients with documented DRIP≥4 were also common

Conclusion
An increase in guideline-directed therapy and a decrease in use of carbapenems were seen after implementation of DRIP score documentation at time of order entry. Overall concordance with guidelines was low, and additional review is needed to identify if providers are accurately documenting the DRIP score. Future directions should focus on education of clinicians on the importance of accurate DRIP documentation in order to improve compliance with institutional guidelines.

Disclosures
All Authors: No reported disclosures