bluuebunny/crossref_metadata_2025_split huggingface dataset:
46. Antimicrobial Stewardship’s Selective Antibiotic Suppression Does Not Lead to Adverse Outcomes in Neutropenic Patients with Gram-Negative Bacteremia
Authors: Witt Anna , Harper Mason G , Crescencio Juan Carlos Rico , Dare Ryan K , Burgess Mary 
Published: January 2021

Abstract

Background
An antimicrobial stewardship program (ASP) strategy to minimize the use of overly broad antimicrobials is to suppress specific antimicrobial susceptibility results when isolates are sensitive to narrow antibiotics. There is limited data on possible adverse outcomes of this method. Patients with febrile neutropenia (FN) and gram-negative bacteremia (GNB) whose culture is sensitive to non-pseudomonal antibiotics still require broader pseudomonal coverage to treat the syndrome of FN. We evaluated if ASP suppression of anti-pseudomonal antibiotics adversely affects patients with FN and GNB.

Methods
In February 2018, our institution’s ASP began suppressing cefepime and meropenem susceptibility results from E. coli, Klebsiella spp, and Proteus spp when sensitive to cefepime (MIC ≤ 2), ceftriaxone and ceftazidime. We performed a retrospective analysis of patients with FN and GNB from 2016 – 2020 to evaluate the appropriateness of antibiotic regimens before and after the ASP intervention. Antibiotic regimens were deemed inappropriate if the patient was de-escalated to a narrow-spectrum, non-pseudomonal agent while neutropenic. Of 338 inpatient encounters identified with any bacteremia and FN, 49 were due to non-Pseudomonas, non-ESBL GNB, 20 before and 29 after the intervention. Sixteen of the 29 post-intervention patients were excluded, as their isolates did not meet suppression criteria. This resulted in a total of 13 patients in the post-intervention group.

Results
After culture susceptibility reports were released, 3 out of 20 patients in the pre-intervention group (15%) and 4 out of 13 patients in the post-intervention group (30.8%) were inappropriately tailored to narrow-spectrum antibiotics (p=0.39). There was no significant difference in 30-day mortality, 10.0% pre- and 0% post-intervention (p=0.50), or amount of meropenem prescribed, 45% pre- and 38.5% post-intervention (p=0.74).

Conclusion
These data show no significant difference in inappropriate antibiotic regimens prescribed for patients with FN and GNB after ASP antibiotic suppression was implemented. 30-day mortality was also not affected. The ASP intervention did not decrease meropenem prescriptions in this patient group, which may be appropriate. Larger studies are needed to verify these findings.

Disclosures
Ryan K. Dare, MD, MS, Accelerate Diagnostics, Inc (Research Grant or Support) Mary Burgess, MD, Pfizer Inc (Grant/Research Support)
47. Assessing Viability and Outcomes following the Redistribution of Antibiotic Stewardship Tasks to the Clinical Pharmacist Team
Authors: Do Stephanie L , Shahzad Saboor , Lok Terence , An Hye Hyun , Arnone Suzanna 
Published: January 2021

Abstract

Background
Methodist Hospital and Cardinal Health determined that the TJC-mandated ASP program could be further improved. In February 2018, the program was restructured and ASP responsibilities were extended to all Clinical Pharmacists. Changing the ASP structure can improve the program efficiency via increased number of interventions/day, antibiotics’ days of therapy (DOT)/1000 patient-days, total antibiotics’ cost, and antibiotics’ cost/patient day.

Methods
A retrospective review was conducted for before and after data. The primary endpoints included number of ASP interventions/day, antibiotics DOT, and antibiotics’ cost/adjusted patient day. The secondary endpoints included effect on resistance of antibiotics for Pseudomonas aeruginosa, 48-hours antibiotic stop review, number of cultures reviewed, 7-days antibiotics review, and restricted antibiotics review.
Reports were obtained from Cardinal Health’s Drug Cost Opportunity Analytics program and Electronic Medical Record (EMR). Intervention types analyzed included: de-escalation, 48-hours review, 7-days review, cultures review, and restricted antibiotics review. Efficiency between pre and post implementation was compared via adjusted interventions/day. Resistance pattern of Pseudomonas aeruginosa, was also trended.
Interventions were trended and mean/day (SD) was calculated using Wilcox Rank Sum Test.

Results
The results showed improved efficiency with ASP interventions/day of 9.87 versus 4.73 (P≤0.0001). The DOT/1000 PD decreased from 1098 to 989 days. Antibiotics’ costs/adjusted patient day reduced from $16.62 to $9.16.
For secondary endpoints: improvement in sensitivity of different antibiotics for P.aeruginosa was noticed. Increased 48-hours antibiotic stop review (2 vs 722), increased number of cultures reviewed (380 vs 518), increased 7-days antibiotics review (24 vs 78), and increased restricted antibiotics (142 vs 432) were observed.

Conclusion
Transforming the ASP program at MHSC with Cardinal Health from resulted in improved efficiency, increased number of ASP-related interventions/day, decreased antibiotics DOT, decreased antibiotics-related cost/patient day, and increased sensitivities of drugs against Pseudomonas aeruginosa.

Disclosures
Stephanie L. Do, PharmD, Cardinal Health (Employee) Saboor Shahzad, BS. PharmD, Cardinal Health (Employee) Terence Lok, PharMD, MS, Cardinal Health (Employee) Hye Hyun An, PharMD Candidate 2022, Cardinal Health (Employee) Suzanna Arnone, PharMD, Cardinal Health (Employee)
50. Comparative Incidence of Acute Kidney Injury in Septic Patients Treated with Vancomycin in Combination with Piperacillin/Tazobactam vs. Cefepime
Authors: Deja Erin , Schmidt Monica , Frens Jeremy J , Nanavati Ankit 
Published: January 2021

Abstract

Background
Empiric antibiotic therapy for sepsis of unknown origin is typically broad spectrum and covers P. aeruginosa and methicillin-resistant S. aureus (MRSA). Nephrotoxicity is a well-known adverse event of IV vancomycin and literature suggests that combination with piperacillin/tazobactam may increase risk for acute kidney injury (AKI) as compared to combination with other beta-lactams. However, evidence is conflicting. The primary outcome of this study was to compare incidence of AKI in septic patients treated with IV vancomycin and piperacillin/tazobactam (VZ) vs. cefepime (VC). Secondary outcomes include hospital length of stay, inpatient mortality, and impact to direct variable cost.

Methods
Adult patients discharged with a sepsis diagnosis code who received VZ or VC for ≥24 hours in 2012–2019 were retrospectively identified. AKI was defined using RIFLE criteria. Patients were excluded for ESRD on HD, AKI occurring &lt; 48 hours after treatment initiation or &gt;7 days after discontinuation, pregnancy, febrile neutropenia, or meningitis. Statistical analysis controlled for many factors including age, race, gender, Elixhauser comorbidity burden, hours to first antibiotic dose, length of stay, and receipt of concomitant nephrotoxins.

Results
A total of 12,405 patients were evaluated; 7,818 received VZ and 3,096 received VC. Patients given VC had a 40% reduction in risk of AKI compared to those given VZ (IRR 0.600; 95% CI 0.46–0.78). These patients also had a 4% reduction in risk of having one additional inpatient day (IRR 0.961; 95% CI 0.937–0.985). Patients who received VZ and experienced AKI were 82.3% more likely to die inpatient compared to patients that did not (IRR 1.822; 95% CI 1.50–2.21). Patients treated with VC incurred less in average direct variable cost than those treated with VZ (p = 0.034) and those who suffered AKI also incurred more on average than those without AKI (p = 0.005).

Conclusion
Compared to septic patients treated with VZ, those treated with VC had significantly decreased risk of AKI as defined by RIFLE criteria. Patients who received VZ were at higher risk for a longer hospital stay and, if they also experienced AKI, inpatient mortality. VZ was associated with higher direct variable cost and patients with AKI incurred more dollars per encounter than those without AKI.

Disclosures
All Authors: No reported disclosures
51. Development and Assessment of a Process to Describe the Timing of Antibiotic Changes in Adult Inpatients
Authors: Livengood Spencer J , Drew Richard H , Moehring Rebekah W , Wilson Dustin , Spivey Justin 
Published: January 2021

Abstract

Background
Hospital antimicrobial stewardship programs (ASP) perform prospective audit and feedback to optimize use of antimicrobials; however, workflow inefficiency continues to be a distinct challenge. We developed a method to describe the volume and timing of antimicrobial changes to inform decisions on optimal timing of ASP review and intervention.

Methods
This retrospective study was performed at Duke University Hospital using anonymized antibiotic administration records from the DASON central database. Eligible antibiotic courses were administered to inpatients ≥ 18 years of age and had received ≥ 2 antibiotics administrations for ≥ 24 hours of treatment. A 2-month exploratory cohort (September to October 2017) was used to develop an antibiotic spectrum ranking (Table 1) and decision algorithm which was applied to a 1-year cohort (November 2017 to October 2018) for analysis of total change in antibiotic orders by day of the week. For each interval, the sum of antibiotic ranks was calculated and applied using specified definitions (Table 2) to determine the type of change occurring. The primary outcome was the number of total antibiotic changes that occurred on each day of the week. Secondary outcomes included the number and type (initiations, discontinuations, de-escalations, and escalations) of change. Descriptive statistics were used to describe the outcomes by day of the week.
Table 1: Antibiotic Spectrum Ranking

Table 2: Key Definitions

Results
The ranking and decision algorithm were applied to 16,993 unique antibiotic courses. Total changes occurred most on Wednesday (14,971, 16.2% [95% CI 15.7–17.1%]) and Friday (14,349, 15.6% [95% CI 15.0–16.2%]). Compared to intervals on weekdays (0.407 mean changes per patients on antibiotics [95% CI 0.401–0.413]), weekends had a lower number of changes (0.363 mean changes per patients on antibiotics [95% CI 0.349–0.377]). Initiations occurred most frequently on Tuesday (3,078, 18.1% [95% CI 16.3–19.9%]), and discontinuations on Wednesday (3,179, 18.7% [95% CI 17.4–20.5%]) (Figure 1).
Figure 1: Types of Changes per Day

Conclusion
We developed and applied a method to characterize antimicrobial changes. In our institution, the reductions in the number of changes observed on weekends provide an opportunity for ASP involvement to be incorporated and help facilitate appropriate antimicrobial changes.

Disclosures
Rebekah W. Moehring, MD, MPH, Agency for Healthcare Quality and Research (Grant/Research Support)Centers for Disease Control and Prevention (Grant/Research Support)
54. Effectiveness of a Venous Catheter Stewardship Intervention Targeting Parenteral Antimicrobial Therapy at Hospital Discharge
Authors: Athans Vasilios , Hamilton Keith W , Norris Anne , Dutcher Lauren , Degnan Kathleen , Gitelman Yevgeniy , Serpa Michael , Cimino Christo , Lee Tiffany , Binkley Shawn , Saw Stephen 
Published: January 2021

Abstract

Background
Peripherally inserted central catheters (PICCs) and midlines are often used in hospitalized patients who require outpatient parenteral antimicrobial therapy (OPAT) upon discharge. PICCs/midlines offer ease of insertion but still carry the risks of venous thrombosis, phlebitis, and catheter-associated infection. We report the results of a prospective audit and feedback (PAF) intervention targeting the placement of PICCs/midlines for OPAT at our institution.

Methods
We prospectively identified a cohort of patients identified by a real-time PICC/midline alert from 5/20/2019 through 5/29/2020 at two large academic medical centers. Alerts were generated by a third-party interface with the electronic health record and identified new line orders with an antimicrobial indication selected. Patients without infectious diseases (ID) consult underwent PAF by the antimicrobial stewardship team. Descriptive statistics were used to characterize patients, interventions, and outcomes.

Results
During the study period, 1267 PICC/midline alerts were identified. Most were excluded due to ID consult (85.4%). After exclusions, 113 alerts underwent full review. Median patient age was 64 years with female predominance (54.2%). Reviewable alerts most commonly originated from Pulmonary (36.5%) and Hospitalist (26.0%) services. The most frequent antimicrobial indications were pneumonia (37.5%) and bloodstream infection (28.1%), and the most frequently ordered antimicrobials were cefepime (27.1%) and piperacillin-tazobactam (17.7%). Median time from line order to insertion was 22 hours and from line insertion to discharge was 48 hours. Of 113 alerts reviewed by the stewardship team, 26 (23.0%) resulted in a recommendation to avoid line placement and 45 (39.8%) resulted in at least one specific stewardship recommendation (Table 1). Recommendations were fully or partially accepted in 58.3% of instances.
TABLE 1. Interventions Resulting from Prospective Venous Catheter Stewardship

Conclusion
Prospective audit of PICC/midline orders for OPAT identified a line-sparing opportunity in nearly 1 in 4 cases. Where line avoidance was not possible, other opportunities for antimicrobial optimization were common. This high-yield intervention should be considered for institutions that do not mandate infectious diseases consult for all OPAT discharges.

Disclosures
All Authors: No reported disclosures
55. Ertapenem for surgical prophylaxis: the impact of antimicrobial stewardship interventions on inappropriate carbapenem utilization at a community teaching hospital
Authors: Downham Gemma , Reilly Joseph , Trivedi Manish , Baptist Justin , Delfino Susan , Szymborski Shana 
Published: January 2021

Abstract

Background
Internal analysis of ertapenem utilization revealed overuse for surgical prophylaxis in intra-abdominal (IA) procedures. Our Antimicrobial Management Team (AMT) initiated a multimodal intervention to promote the appropriate use of ertapenem. The primary objective of this study is to describe and evaluate the impact of our interventions targeting ertapenem utilization for IA surgical prophylaxis.

Methods
From March to October 2019, a pre-post study was performed to evaluate ertapenem utilization for surgical prophylaxis. Our AMT interventions which were formally implemented in June 2019 included the following: targeted provider feedback, review and update of our surgical prophylactic antibiotic protocol (SPAP), policy, and order set addition of Cefoxitin to formulary, extensive provider education, and monitoring of SPAP compliance. Data was abstracted from the electronic medical record for IA cases and included antibiotics prescribed, procedure type, and prescriber information. In addition, surgical site infection (SSI) rates and Clostridium difficile infection rates were monitored throughout the study period.

Results
In total, 1,080 IA surgical cases were reviewed. The set quality measure of less than 5 percent ertapenem utilization was achieved each month after AMT interventions in June 2019, as demonstrated by monthly ertapenem use for surgical prophylaxis: 13.7 percent in March, 13.4 percent in April, 4.9 percent in May, 8.9 percent in June, 3.1 percent in July, 2.2 percent in August, 4.5 percent in September, and 3.4 percent in October. Overall, the number of ertapenem cases was 58 pre-study (March to June) versus 16 post-study (July to October), accounting for a 72.4 percent reduction in ertapenem utilization for IA surgical prophylaxis. The rate of SSI among IA surgeries and Clostridium difficile infection did not increase as a consequence of our interventions

Conclusion
Carbapenem use for surgical prophylaxis was consistently within threshold limits following the stewardship interventions. Incidence of surgical site infections and Clostridium difficile infection did not increase during the interventions suggesting that alternate antimicrobial agents in the SPAP are safe and effective for IA surgeries in our patient population.

Disclosures
All Authors: No reported disclosures
811. Utilizing IV team in Reducing the Central Line Associated Infections
Authors: Srialluri Swetha , Hassoun Ali 
Published: January 2021

Abstract

Background
Central Line-Associated Blood Stream Infections (CLABSI) are defined as the laboratory confirmed blood stream infections after 48 hours of the line placement and excluding other sources of infection. CLABSI can lead to prolonged hospital stay, increased risk of mortality and financial burden on the health care system. In our study, we aimed at evaluating the incidence of CLABSI after involving the IV team in both critically ill and non-critically ill patients.

Methods
A retrospective chart review was performed from July 2011 to August 2019 at a 971 bedded community hospital. IV team has been involved in the central line care since 2013 and started changing the scheduled central line dressings. The interventions that were introduced since then include usage of Curos, wearing masks and gloves for any contact with central lines, flushing the central lines using pulsatile method, and not drawing the routine labs. Allpoints program was introduced in July 2018 which is a retraining program to the nurses emphasizing on central line dressing changes using a sterile technique, pulsatile flushing method and medication administration. CLABSI rate was calculated per 1,000 central line days yearly and quarterly and was compared before and after the involvement of IV team.

Results
Total number of events from July 2011 to August 2019 were 275. Average central line days were 22,350. Most common organisms that were isolated are Staphylococcus aureus (13.45%) followed by Staphylococcus Epidermidis (9.8%), Candida Albicans (8.7%), E. Coli (8.72%) and Klebsiella Pneumonia (6.9%). The average CLABSI rates quarterly and yearly were 1.00 and 1.32 respectively, per 1000 central line days. Average CLABSI rates before and after the involvement of IV team were 1.32 and 1.18 respectively. CLABSI rate has decreased significantly after the involvement of the IV team in 2013. The largest impact on the CLABSI infection rate was between July 2018 to August 2019 which can be attributed to the Allpoints program. CLABSI rate in 2018 and 2019 were 0.86 and 0.6 respectively.

Conclusion
Our analysis showed that involving the IV team in the central line care and implementing the preventive strategies like usage of curos, pulsatile flush technique, wearing mask and gloves for any contact with central line helped in reducing CLABSI.

Disclosures
All Authors: No reported disclosures
819. How effective is alcohol flush and drying cycle of automatic endoscope reprocessor (AER): Stripped Endoscope (SE) model
Authors: Yassin Mohamed , Dixon Heather , Nerandzic Michelle , Donskey Curtis 
Published: January 2021

Abstract

Background
Endoscopic designs are more ergonomic and technically sophisticated than ever. Endoscope transmitted infections continues despite scrutiny and optimization of disinfection processes. Effective endoscopic dryness has been largely overlooked, even though it is paramount for prevention of water-borne pathogens accumulating after high level disinfection (HDL). Additionally, complete dryness is required to achieve sterilization. The aim of this study is to evaluate the dryness of the endoscopes after routine a routine disinfection process.

Methods
Three endoscopes were stripped from their outer sheaths to allow for visual inspection of the inside channels. SE were processed as per usual practice. After HLD in an automatic endoscope reprocessor (AER) that included an alcohol flush and drying cycle, SE were hung and observed for any water within the channels. SE were flushed with filtered compressed air. Dryness was monitored visually and by feeling for the impact of water spray at the distal tip of SE. Dryness of the channels before and after air flush was observed for the three SE for three trials each.

Results
All the SE were grossly wet after HLD despite the AER’s alcohol flush and drying cycle. Hanging vertically had no effect on the narrow diameter channels. Applying compressed air to each channel was effective for drying the channels based on visual inspection and water emission from the distal tip of the SE. The filtered compressed air had a flow rate of 20 L/minute for an average of 2 minutes to assure complete dryness. The nozzle for applying the filtered compressed air was ill-fitting to the openings of the cylinders and ports on the control handle, making it difficult to get a good seal for applying the filtered compressed air.

Conclusion
The AER’s drying cycle was not effective for drying endoscope channels. Vertical hanging had limited efficacy on endoscopic dryness. The application of filtered compressed air to individual channels was effective for drying the channels. This SE model was useful and direct for assessing the degree of moisture inside the channels. The application of filtered compressed air should be an essential step in endoscopic reprocessing regardless of the need for sterilization.

Disclosures
All Authors: No reported disclosures
824. Isolation Rounding - Enforcing Existing Isolation Policies to Conserve Personal Protective Equipment
Authors: Schaffzin Joshua K , Herber Stephanie , Kneflin Nicole , Frazier Matthew , Paolella Alyssa , Ewers Christine , Short Matthew , Huang Felicia Scaggs 
Published: January 2021

Abstract

Background
During the COVID-19 pandemic, supplies of personal protective equipment (PPE) have been limited and sold at increased cost. Prior to the pandemic, we had initiated a project to improve PPE adherence and decrease cost by removing eligible patients from transmission based precautions (TBPs). At baseline, ordering providers are responsible for TBP utilization with orders through the electronic medical record. We observed that patients were in TBP when not indicated; remained in TBP beyond the appropriate time; and a reluctance on the part of providers to discontinue the orders. We tested the effect on TBP duration and PPE utilization house-wide through frequent review of TBP by a nurse educator with communication to providers of discontinuation opportunities.

Methods
From November 2019 to February 2020, all TBP orders in the pediatric intensive care unit (PICU) were reviewed intermittently. In March 2020, review was expanded to all inpatients with daily reviews in all units. Changes recommended and completed were tracked for all reviewed patients. We estimated cost of PPE in the PICU over time based on the number of patients in isolation and type of TBP utilized to determine whether our intervention resulted in reduced PPE use.

Results
Regular rounding in the PICU increased the proportion of patients in appropriate TBP and reduced the need to communicate with providers directly (33% vs 3% requiring intervention, Figure 1). Over the same time period, less PPE was used and PPE-related costs lowered (average total PPE cost $306.18 vs $95.15 per day, Figure 2). Less of an effect was seen when analyzing house-wide data.
Figure 1 - P-chart of Percent Interventions Among Patients in TBP

Figure 2 - X-chart of Total PPE Cost in the ICU

Conclusion
Isolation rounds is an effective means to ensure proper TBP adherence and manage PPE use appropriately. Additional study is needed to confirm a return on investment, to account for variation among units, and to sustain COVID-19-influenced gains beyond the pandemic.

Disclosures
All Authors: No reported disclosures