bluuebunny/crossref_metadata_2025_split huggingface dataset:
208. Variation in Clinical Practice and Attitudes in the Management of Fever and Neutropenia in Patients With Hematologic Malignancy: A Survey of Cancer Centers Across the United States
Authors: Aitken Samuel L , Aitken Samuel L , Barreto Jason N , Nagel Jerod , Seo Susan K , Seo Susan K , Liu Catherine 
Published: January 2021

Abstract

Background
Fever and neutropenia (FN) is common in cancer patients after chemotherapy, and there are national guideline recommendations for FN prevention and treatment. We conducted a survey of practices across multiple US cancer centers to determine the extent to which these guidelines have been adapted.

Methods
US cancer centers performing 20 allogeneic hematopoietic stem cell transplantations annually were identified from the National Marrow Donor Program’s “Be the Match” directory. Antimicrobial stewardship physicians and pharmacists at each institution were identified using institutional websites, residency or fellowship program directories, and personal contacts. A survey assessing institutional practices and individual attitudes on FN management in high-risk patients was distributed via email. Duplicate responses at the hospital level were removed. Complete surveys regarding individual attitudes were assessed using a 5-point Likert scale ranging from “Strongly Agree” to “Strongly Disagree.”

Results
Thirty-four (23%) responses from 148 individuals were received, representing 31 of 86 hospitals (36%). 29 (94%) hospitals reported having guidelines for the management of FN. Of these, cefepime was the most commonly recommended agent for empiric treatment (26, 90%) and 16 (55%) provide guidance based on presumed site of infection. Eighteen (62%) hospitals recommend de-escalation of Gram negative therapy in certain situations, most often after being afebrile 48 – 72 hours or after neutrophil recovery (7 each, 39%). Twenty-seven (93%) hospitals recommended antibiotic prophylaxis, most often with levofloxacin (21, 78%). Of 34 respondents, attitudes were split regarding the statement “The benefit of antibiotic prophylaxis outweighs the harms in high-risk patients” (10 strongly agree or agree, 10 strongly disagree or disagree; 29% each); most agreed with the statement “I would use antibiotic prophylaxis in high-risk patients” (25, 78%).

Conclusion
Most cancer centers across the US have guidelines for the management of FN. While most recommend antibacterial prophylaxis, there were differences in individual perceptions regarding the risk / benefit. Significant variation exists in the approach to antibiotic de-escalation.

Disclosures
All Authors: No reported disclosures
209. Antibiotic Utilization During the COVID-19 Surge in Detroit
Authors: Shallal Anita , Kenney Rachel , Suleyman Geehan 
Published: January 2021

Abstract

Background
Antibiotic overutilization during the COVID-19 pandemic has been reported, despite relatively infrequent bacterial co-infection. We explored antibiotic utilization before, during and after the COVID-19 surge in Michigan.

Methods
Cross-sectional study at an 877-bed hospital in Detroit, Michigan from January 2019 through May 2020. Measures: Count of COVID-19 hospital admissions by day. Monthly antibiotic utilization for formulary agents used to treat pneumonia were measured using monthly days of therapy (DOT) per 1000 patient days present and the National Health Care Safety Network Standardized Antimicrobial Administration Ratio (SAAR). Descriptive analysis was utilized.

Results
The first COVID-19 case was detected March 11, 2020 and peaked in early April (Figure 1). Antibiotic utilization is demonstrated in Figure 2. The COVID-19 peak was associated with increased use of multiple antibiotics; notably, DOT per 1000 days present for ceftriaxone, cefepime and doxycycline were 85.43, 79.42 and 71.56, respectively in April. The institutional all-antibacterial SAAR was significantly reduced in May at 0.96, p=0.0022, after the COVID-19 surge.
Figure 1

Figure 2

Conclusion
We observed increased utilization of multiple antibiotics during the COVID-19 surge, and reduction in the all-antibacterial SAAR after the surge. More robust information is needed to promote optimal antibiotic use for patients with COVID-19 infections.

Disclosures
All Authors: No reported disclosures
210. Vancomycin Infusion Frequency and Intensity: Analysis of Real-World Data Generated from Automated Infusion Devices
Authors: Yamaga Cynthia , Bostick David L , Tabak Ying P , Liu-Ferrara Ann , Morel Didier , Yu Kalvin 
Published: January 2021

Abstract

Background
Automated infusion devices captures actual infused medication administration data in real-time. Vancomycin use is now recommended to be driven by AUC (area under the curve) dosing. We evaluated automated infusion device data to depict vancomycin administration practices in acute care hospitals.
Figure 1. Distribution of vancomycin infusion dosing

Figure 2. Distribution of time intervals between each vancomycin infusion session (mostly around 8 or 12 hours)

Methods
We analyzed archived vancomycin infusion data from 2,417 patients captured by automated infusion systems from 3 acute care hospitals. The infusion device informatics software recorded a variety of events during infusion – starting and stopping times, alarms and alerts, vancomycin dose, and other forms of timestamped usage information. We evaluated infusion session duration and dosing, using data-driven clustering algorithms.

Results
A total of 13,339 vancomycin infusion sessions from 2,417 unique adult patients were analyzed. Approximately 26.1% of patients had just one infusion of vancomycin. For the rest of the patients, the median number of infusion sessions per patient was 4; the interquartile range was 3 and 8. The most common dose was 1.0 gram (53.7%) or 1.5 gram (24.6%) (see Figure 1). The distribution of infusion session duration (hours) was 4.2% (≤1.0 hh); 40.1% (1.01–1.5 hh); 29.1% (1.51–2.0 hh); and 26.6% (&gt;2.0 hh). The dosing frequency was 39.5% (q8 hh), 42.9% (q12 hh), 11.1% (q24 hh), and 6.5% (&gt;q24 hh) (Figure 2), demonstrating clinical interpretability.

Conclusion
A considerable number of patients received just one vancomycin infusion during their hospital stay, suggesting a potential overuse of empiric vancomycin. The majority of infusion doses were between 1 to 1.5 grams and most infusion sessions were administered every 8 or 12 hours. The actual infusion duration for each dose often exceeds the prescribed 1- or 2-hour infusion orders, which may be due to known instances of infusion interruptions due to patient movement, procedures or IV access compromise. The data generated by infusion devices can augment insights on actual antimicrobial administration practices and duration. As vancomycin AUC dosing becomes more prevalent, real world infusion data may aid timely data-driven antimicrobial stewardship and patient safety interventions for vancomycin and other AUC dosed drugs.

Disclosures
Cynthia Yamaga, PharmD, BD (Employee) David L. Bostick, PhD, Becton, Dickinson and Co. (Employee) Ying P. Tabak, PhD, Becton, Dickinson and Co. (Employee) Ann Liu-Ferrara, PhD, Becton, Dickinson and Co. (Employee) Didier Morel, PhD, Becton, Dickinson and Co. (Employee) Kalvin Yu, MD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding)
211. A Comprehensive Assessment of Carbapenem Use across 90 Veterans Health Administration Hospitals with Defined Stewardship Strategies for Carbapenems
Authors: Suzuki Hiroyuki , Perencevich Eli N , Goto Michihiko , Alexander Bruce , Nair Rajeshwari , Puig-Asensio Mireia , Ernst Erika , Livorsi Daniel J 
Published: January 2021

Abstract

Background
Carbapenems are an important target for antimicrobial stewardship (AS) efforts. In this study, we sought to compare different hospital-based strategies for improving carbapenem use.

Methods
We analyzed a cohort of all patients hospitalized at Veterans Health Administration (VHA) acute-care hospitals during 2016 and mandatory survey data that characterized each hospital’s carbapenem-specific AS strategy into one of three types: no strategy (NS), prospective audit-and feedback (PAF), or restrictive policies (RP). Sites that could not be classified were excluded. Inpatient carbapenem use was compared across strategies using risk-adjusted generalized estimating equations that accounted for clustering within hospitals. Two Infectious Disease (ID) physicians independently performed manual chart reviews in 425 randomly-selected carbapenem-treated cases (100 for PAF/NS and 225 for RP). Auditors assessed for the presence of ID consultation and carbapenem appropriateness on day 4 of therapy. Assessments were categorized as follows: appropriate (1), acceptable (2), suboptimal (3), unnecessary (4) and inappropriate (5). Assessment scores across strategies were compared with the Kruskal-Wallis test.

Results
There were 429,602 admissions in 90 sites (8 PAF, 24 NS, 58 RP). Median carbapenem use across sites was 17.4 (IQR 8.6–28.4) days of therapy/1,000 days-present. Inpatient carbapenem use was lower at PAF than NS sites [RR 0.67 (95% CI, 0.46–0.98); p=0.04] but similar between RP and NS sites [RR 0.86 (95% CI, 0.61–1.22); p=0.41].
Carbapenem use was considered appropriate or acceptable in 215 (50.6%) of the reviewed cases. Assessment scores were higher (i.e. worse) at NS than RP sites (mean 2.7 vs 2.3; p&lt; 0.01) but did not differ significantly between NS and PAF sites (mean 2.7 vs 2.5; p=0.14).
ID consultations were more common at PAF/RP than NS sites (51% vs 29%; p&lt; 0.01). ID consultations were associated with lower (i.e. better) assessment scores (2.3 vs. 2.6; p&lt; 0.01).

Conclusion
In this VHA cohort, AS strategies and ID consultations were associated with either less or more appropriate carbapenem-prescribing. The use of AS and ID consultations may be complementary, and hospitals could leverage both to optimize carbapenem use.

Disclosures
Daniel J. Livorsi, MD, MSc, Merck and Company, Inc (Research Grant or Support)
212. Acute Kidney Injury with Piperacillin-tazobactam versus Cefepime in Combination with Vancomycin
Authors: Nguyen Phuong Khanh , Tran Thuong , Jetsupphasuk Kristy , Wang Nina , Chun Patricia , Tan Susanna , Graber Christopher J 
Published: January 2021

Abstract

Background
Drug-induced nephrotoxicity in the form of acute kidney injury (AKI) is a potential adverse effect of vancomycin, which is commonly prescribed empirically with an antipseudomonal agent. It is unclear if combinations with certain antipseudomonal agents (e.g., piperacillin-tazobactam) are associated with more AKI relative to others.

Methods
This retrospective cohort study conducted at two Veterans Affairs (VA) Medical Centers with differing preferred empiric vancomycin-antipseudomonal regimens aimed to assess the incidence of AKI in patients receiving vancomycin and piperacillin-tazobactam (VPT) at VA Greater Los Angeles Healthcare System (HCS) versus vancomycin and cefepime (VC) at VA Long Beach HCS. Patients who received VPT or VC for at least 48 hours in 2016–2018 were included. AKI definitions were derived from 2012 Kidney Disease Improving Global Outcomes guidelines. Secondary assessments included hospital length of stay, 90-day mortality, and incidence of Clostridioides difficile infection (CDI) within 90 days. Patients who developed AKI were further assessed for time-to-onset of AKI, development of chronic kidney disease (CKD) within 90 days, and hemodialysis (HD) dependence within 1 year. Statistical analysis was performed using Fisher’s exact and Mann-Whitney U tests where appropriate. Propensity score matching using logistic regression with nearest-neighbor matching was performed to control for potential confounding baseline characteristics.

Results
21/120 patients receiving VPT developed AKI vs. 4/120 receiving VC (17.5% vs. 3.3%, p=0.0005). After propensity score matching, AKI incidence remained significantly higher for VPT patients (15.2% vs. 4.0%, p=0.01). Median length of stay was significantly longer for VPT patients (10 days vs. 8 days, p=0.03). There was no significant difference in time-to-onset of AKI, 90-day mortality, or CDI. No significant difference was found in the development of CKD within 90 days nor the requirement of HD within 1 year.

Conclusion
VPT combination therapy was associated with increased incidence of AKI compared to VC, though 90-day mortality and other outcomes were similar. Advising prescribers about potentially increased risk of AKI with VPT is a viable stewardship intervention.

Disclosures
All Authors: No reported disclosures
215. Appropriateness and Accuracy of Antimicrobial Prescriptions at Pediatric Emergency Department Discharge
Authors: lau Jackelyn , Islam Shamim , Polischuk Emily 
Published: January 2021

Abstract

Background
Up to 20% of pediatric emergency department visits result in an antimicrobial prescription. The objective of this study was to evaluate the appropriateness and dosing accuracy of antimicrobial prescriptions given at discharge from an ED of a freestanding children’s hospital.

Methods
Electronic medical records of patients seen in the ED at Oishei Children’s Hospital from 12 dates (3 in each of 4 seasons) were screened. All patients discharged from the ED with a prescription for an antimicrobial were included. Diagnosis, provider type, antibiotic dose per weight, duration and frequency were recorded. Appropriateness of antibiotic choice and dosing accuracy were assessed using major medical society guidelines, pharmacy references and hospital antibiograms. Antibiotic doses were considered inaccurate if &gt;10% outside of recommended weight-based dose ranges.

Results
Of a total of 1733 screened patients, 12% (207) were discharged with a systemic antimicrobial prescription. The percentage of visits resulting in an antimicrobial prescription varied by season, and was highest during the winter at 19%. Amoxicillin (33% of all) and oseltamivir (15%) were most frequently prescribed. Overall, 98% of patients were prescribed the appropriate antimicrobial, but only 65% of systemic antimicrobial prescriptions had accurate dosing. Amoxicillin was dosed incorrectly in 32% of prescriptions, Figure 1, specifically being below the high-dose recommended range in 28% of otitis media (OM) and 29% of pneumonia cases. Despite being the most common diagnosis, OM was treated with accurate dosing only 57% of the time, Figure 2. Also, more than 40% of patients with UTI or pneumonia had inaccurate drug dosing. Nurse practitioners (NP) prescribed the most antibiotics. Appropriate prescribing did not vary by provider, but accuracy of dosing did; for example, NP dosing accuracy was 58%, vs. 73% for residents (p &lt; 0.04), Figure 3.
Dosing Accuracy of Antimicrobials

Dosing Accuracy by Diagnosis

Appropriateness and Accuracy by Prescriber Group

Conclusion
An eighth of pediatric ED visits resulted in an antimicrobial prescription. Inaccurate dosing occurred regularly for common infections; most notably underdosing of amoxicillin for OM and pneumonia. Education and audit related to specific drugs and providers promises to be of high stewardship impact in pediatric EDs.

Disclosures
All Authors: No reported disclosures
216. Are Automatic Antimicrobial Stop Orders an Effective Stewardship Tool for Urinary Tract and Intra-Abdominal Infections?
Authors: Maguire Christina , Rose Dusten T , Jaso Theresa 
Published: January 2021

Abstract

Background
Automatic antimicrobial stop orders (ASOs) are a stewardship initiative used to decrease days of therapy, prevent resistance, and reduce drug costs. Limited evidence outside of the perioperative setting exists on the effects of ASOs on broad spectrum antimicrobial use, discharge prescription duration, and effects of missed doses. This study aims to evaluate the impact of an ASO policy across a health system of adult academic and community hospitals for treatment of intra-abdominal (IAI) and urinary tract infections (UTI).
ASO Outcome Definitions

ASO Outcomes

Methods
This multicenter retrospective cohort study compared patients with IAI and UTI treated before and after implementation of an ASO. Patients over the age of 18 with a diagnosis of UTI or IAI and 48 hours of intravenous (IV) antimicrobial administration were included. Patients unable to achieve IAI source control within 48 hours or those with a concomitant infection were excluded. The primary outcome was the difference in sum length of antimicrobial therapy (LOT). Secondary endpoints include length and days of antimicrobial therapy (DOT) at multiple timepoints, all cause in hospital mortality and readmission, and adverse events such as rates of Clostridioides difficile infection. Outcomes were also evaluated by type of infection, hospital site, and presence of infectious diseases (ID) pharmacist on site.

Results
This study included 119 patients in the pre-ASO group and 121 patients in the post-ASO group. ASO shortened sum length of therapy (LOT) (12 days vs 11 days respectively; p=0.0364) and sum DOT (15 days vs 12 days respectively; p=0.022). This finding appears to be driven by a decrease in outpatient LOT (p=0.0017) and outpatient DOT (p=0.0034). Conversely, ASO extended empiric IV LOT (p=0.005). All other secondary outcomes were not significant. Ten patients missed doses of antimicrobials due to ASO. Subgroup analyses suggested that one hospital may have influenced outcomes and reduction in LOT was observed primarily in sites without an ID pharmacist on site (p=0.018).

Conclusion
While implementation of ASO decreases sum length of inpatient and outpatient therapy, it may not influence inpatient length of therapy alone. Moreover, ASOs prolong use of empiric intravenous therapy. Hospitals without an ID pharmacist may benefit most from ASO protocols.

Disclosures
All Authors: No reported disclosures
217. Broad Spectrum Antibiotic use in Outpatient Parenteral Antibiotic Therapy (OPAT): Opportunities for Antibiotic Stewardship
Authors: Brenon Jessa R , Shulder Stephanie , Munsiff Sonal , Burgoyne Colleen , Nagel Angela , Pillinger Kelly E 
Published: January 2021

Abstract

Background
Broad-spectrum antibiotics are often chosen for OPAT due to the convenience of once daily dosing. Current literature suggests that at least 20–30% of these regimens could be narrowed, but this has not been well-defined.

Methods
This was a multicenter, retrospective cohort study of adult inpatients evaluated by the infectious diseases (ID) team with culture positive infections with susceptibilities (C&S) on select intravenous (IV) antibiotics (ampicillin, ampicillin-sulbactam, cefazolin, ceftriaxone, daptomycin, ertapenem, meropenem, nafcillin, penicillin, piperacillin-tazobactam, and vancomycin) enrolled in OPAT and discharged from January 1 - June 30, 2019. Susceptibilities were not required for Actinomyces, Streptococcus spp., Haemophilus spp., anaerobes, Corynebacterium spp., or coagulase-negative Staphylococcus spp. when considered a contaminant by ID. Patients were excluded if the regimen included oral antibiotics (not including rifampin or metronidazole). Primary outcome was the percent of broad-spectrum regimens that could’ve been narrowed based on C&S (alternative available therapy or AAT group). Secondary outcomes included comparison of baseline characteristics and 30-day readmission rates between patients on narrow-spectrum IV antibiotics (NSA) vs AAT group, and the documented reason(s) for broad-spectrum antibiotic selection.

Results
113 patients met study criteria; majority were male (56%), and median age was 60 years. Sixty-four patients were discharged on a broad-spectrum regimen, and 32 (50%) met our AAT definition. Ceftriaxone was used in 75% of these cases (24/32), and mono-microbial Streptococcus spp. infection was the primary indication (54%). AAT group patients were more likely to have Enterobacterales (24.1% vs 1.9% p=&lt; 0.001) or polymicrobial infections (28.1% vs 8.2% p=0.019) compared to NSA group. Reasons for broad-spectrum antibiotic selection were largely undocumented (71%). No significant differences were seen in 30-day readmission rates.

Conclusion
At our institution, 50% of select IV broad-spectrum OPAT regimens had the potential to be narrowed based on C&S data. This rate is higher than previously reported. It warrants further investigation into the barriers to narrower-spectrum antibiotic prescribing in OPAT.

Disclosures
Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker)
223. Difference in Carbapenem Use by ASP Intervention in Japanese Healthcare Facilities
Authors: Endo Mio , Tsuzuki Shinya , Asai Yusuke , Tajima Taichi , Matsunaga Nobuaki , Hayakawa Kayoko , Ohmagari Norio 
Published: January 2021

Abstract

Background
Antimicrobial stewardship program (ASP) interventions have been reported to reduce unnecessary antimicrobial use (AMU). In this study, we investigated the difference in the use of carbapenems by ASP intervention in Japanese healthcare facilities.

Methods
Data on two components of AMU and ASP registered in Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) from January to December 2019, were used. Facilities with an infection control team in addition to an antimicrobial stewardship team responsible for the proper use of antimicrobial agents were included in the study. AMU data (such as DOT [Days of Therapy / 100 patient days]) are entered semi-automatically from medical fee statement (receipt) file at each facility. ASP intervention is divided into four categories 1) pre-authorization, 2) prospective audit and feedback (PAF), 3) PAF and required notification (RN), 4) RN. The Kruskal-Wallis test is performed to see overall difference and the Dunn test with the Bonferroni correction is done for each pair of categories.

Results
A total of 114 hospitals were included in the analysis. The median number of beds at participating facilities were 430 [IQR: 281–602], the median average hospital stay was 13.0 days [IQR: 11.4–15.2] and total number of inpatients per month was 10087 [6247–14536]. PAF and RN were the most common ASP interventions for carbapenems (62.5%), followed by RN (33.6%). The median DOT [IQR] of participating facilities were 2.1 [1.2–3.1] and 1) 0.7 [0.2–1.1], 2) 2.7 [2.1–3.4], 3) 2.1 [1.4–3.1] and 4) 2.0 [1.2–3.5] by ASP categories. There are significant differences between 1) and 2), 1) and 3), and 1) and 4) (p=0.014, p&lt; 0.01 and p&lt; 0.01, respectively) while the differences between 2) and 3), 2) and 4), and 3) and 4) are not significant (p=1.00).
Table 1. Summary statistics of healthcare facilities by ASP Interventions

Figure 1. DOT by ASP Interventions

Conclusion
Only 3.5% of ASP interventions belong to 1) pre-authorization category and this might be due to the complexity of registration process. This category was found to have the lowest DOT among all ASP interventions in Japanese healthcare facilities. The variances of DOT were especially large in categories 3) and 4), and more detailed analyses would be necessary to evaluate their efficacies accurately.

Disclosures
All Authors: No reported disclosures