bluuebunny/crossref_metadata_2025_split huggingface dataset:
156. Evaluation of Trends in Antimicrobial Use and Proportion of Culture Positive Gram-Negative/Gram-Positive Pathogens Comparing Prior to and During the SARS-CoV-2 Pandemic: A Multicenter Evaluation
Authors: Puzniak Laura A , Bauer Karri A , Yu Kalvin , Gupta Vikas 
Published: December 2021

Abstract

Background
Increased risk for bacterial co-infections has been described in the pathogenesis of primary viral infections. We evaluated trends in incidence of antibiotic use (abx) and culture positive Gram negative/Gram positive (GN/GP) pathogens in US hospitalized patients prior to and quarterly during the SARS-CoV-2 pandemic.
Table. Trends in antimicrobial use, duration, and positive GN/GP pathogen results.

Methods
We conducted a multi-center, retrospective cohort analysis of all hospitalized patients from 241 US acute care facilities with &gt;1-day inpatient admission between 7/1/19-5/15/21 in the BD Insights Research Database (Franklin Lakes, NJ USA). SARS-CoV-2 infection was defined as a positive PCR during or ≤7 days prior to hospitalization. Admissions with abx prescribed ≥24 hrs and a GN/GP non-contaminant, positive culture were evaluated.

Results
During the pre-pandemic period (7/19 – 2/20) 30% (600,116/2,001,793) admissions were prescribed abx ≥ 24 hrs and 5.3% were positive for a GN/GP pathogen (Table 1). During the SARS-CoV-2 pandemic, abx use ≥ 24 hrs (66.2%) and positive GN/GP culture (8.4%) was highest in SARS-CoV-2 positive patients followed by patients negative for SARS-CoV-2 (abx ≥ 24 hrs 36.7%; GN/GP pathogens 6.8%), and SARS-CoV-2 not tested (abx ≥ 24 hrs 27.5%; GN/GP pathogens 4.5%). GN/GP positive culture was consistent by quarter during the pandemic for SARS-CoV-2 positive patients, whereas SARS-CoV-2 negative and not tested patients had the highest proportion of antibiotics received and positive pathogens in the first three months of pandemic. SARS-CoV-2 positive patients with positive GN/GP culture had the longest median abx duration. (Table 1) The prevalence of abx usage was highest in all groups for all abx during the early pandemic and then declined over time with the largest declines in SARS-CoV-2 positive patients. (Table 2)

Conclusion
This study highlights the impact of viral infections on both prescribing practices and prevalence of bacterial pathogens. Approximately two-thirds of SARS-CoV-2 positive patients received an antibiotic despite a low percentage of positive cultures, however aggregate antimicrobial use overall was similar prior to compared to during the SARS-CoV-2 pandemic. These data may inform opportunities for stewardship programs and antibiotic prescribing in the current and future viral pandemics.

Disclosures
Laura A. Puzniak, PhD, Merck & Co., Inc. (Employee) Karri A. Bauer, PharmD, Merck & Co., Inc. (Employee, Shareholder) Kalvin Yu, MD, BD (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)
158. National Cross-Sectional Study of Factors Influencing the Decision of Prescribing Penicillin as First Choice among Dentists in Japan
Authors: Koizumi Ryuji , Ishikane Masahiro , Kusama Yoshiki , Tsuzuki Shinya , Asai Yusuke , Shimada Yasuyuki , Tanaka Chika , ono Akane , Kaneko Akihiro , Ohmagari Norio 
Published: December 2021

Abstract

Background
Antimicrobial stewardship programs are needed to improve antimicrobial use among not only physicians but also dentists. This study aimed to investigate the factors influencing the decision of prescribing penicillin as first choice among dentists at clinics in Japan.

Methods
We conducted a nationwide cross-sectional study of dental clinics in Japan between July and September 2020. Data on the following were collected using questionnaires: basic information, types of antimicrobials stocked, first-choice antimicrobials, and knowledge and practice of antimicrobial resistance and infectious endocarditis. Using logistic regression, odds ratios (ORs) and 95% confidence intervals (CIs) were estimated to assess the factors influencing penicillin prescription.

Results
Among the 1700 participating dental clinics, 342 dental clinics responded. The median age of the study cohort was 57 (49–65) years, and there were 298 (87.1%) men. The first choice of antimicrobials was third-generation cephalosporin (169 [49.4%]), followed by penicillin (103 [30.1%]) and macrolide (19 [5.6%]). In multivariate analysis, clinics with stocked penicillin (OR = 27.30 [95% CI: 12.04–63.00]) and with more than two dentists (OR = 0.48 [95% CI: 0.24–0.92]) were associated with penicillin use as first choice.

Conclusion
This is the first study investigating the factors influencing the decision of prescribing penicillin as first choice among dentists in Japan. Further studies evaluating the relationships between penicillin use as first choice and stocked penicillin in the clinic and the number of working dentists are needed.

Disclosures
All Authors: No reported disclosures
159. Characterization of Suboptimal Discharge Antimicrobial Prescriptions and Effect of Inpatient Audit and Feedback on Quality of Antimicrobial Prescribing
Authors: Puckett Lauren M , Bio Laura , Cornell Sean , Joerger Torsten , Schwenk Hayden T , Schwenk Hayden T 
Published: December 2021

Abstract

Background
Approximately 30% of children are discharged from the hospital with an antimicrobial prescription; nearly a third of these prescriptions are suboptimal. Although the best approach to antimicrobial stewardship of discharge prescriptions remains uncertain, prospective audit and feedback (PAF) has improved inpatient antimicrobial use. We aimed to identify and characterize suboptimal discharge antimicrobial prescribing and assess the impact of inpatient PAF on the quality of discharge antimicrobial prescribing at a free-standing children’s hospital.

Methods
A retrospective review of enteral discharge antimicrobial prescriptions between 12/1/20-5/31/21 and parenteral antimicrobial prescriptions sent to our hospital’s infusion pharmacy between 3/1/21-5/31/21 was performed to determine if suboptimal or not. A prescription was determined to be suboptimal if the antimicrobial choice, dose, frequency, duration, formulation, or indication was not consistent with institutional and/or national guidelines. Data collection included the antimicrobial, indication, and prescribing medical service. Prescriptions were evaluated for a corresponding inpatient PAF for the same drug and indication and then stratified based on inpatient PAF completion.

Results
A total of 1192 discharge prescriptions for 698 unique patients over 834 hospital encounters were reviewed. Overall, 243 (20%) prescriptions were identified as suboptimal; reasons were duration (16%), dose (8%), frequency (5%), or antimicrobial choice, formulation, or route (≤1%). Prescriptions for cephalexin had the highest rate of suboptimal prescribing (80/167, 48%), followed by amoxicillin-clavulanate (89/203, 44%). A corresponding inpatient PAF was identified for 675 (57%) of discharge antimicrobial prescriptions. Inpatient PAF prior to discharge resulted in fewer suboptimal discharge prescriptions for the same antimicrobial (8% vs. 36%, p &lt; 0.001).

Conclusion
Antimicrobial prescribing at inpatient discharge was suboptimal in 1 of every 5 prescriptions. Inpatient PAF was associated with improved antimicrobial prescribing at hospital discharge. Antimicrobial stewardship programs should continue to explore ways to capture and intervene on antimicrobials prescribed at discharge.

Disclosures
Hayden T. Schwenk, MD, MPH, Nothing to disclose
160. Urgent Care Prescriber Perspectives on Antibiotic Prescribing During the COVID-19 Pandemic
Authors: Betts Brooke , Ha David R , Holubar Marisa , Holubar Marisa , Artandi Maja , Onguti Sharon , Nelligan Ian 
Published: December 2021

Abstract

Background
Urgent care practices were significantly impacted by the COVID-19 pandemic. Studies conducted early in the pandemic demonstrated dramatic decreases in outpatient antibiotic prescribing, particularly amongst agents typically used for respiratory infections. We observed a 33% decline in urgent care antibiotics prescribing during the COVID-19 pandemic in our urgent care clinics. We investigated the prescriber experience to elucidate factors influencing antibiotic use for respiratory conditions during the COVID-19 pandemic at two academic urgent care clinics.

Methods
We employed a mix method approach, first distributing a survey to all full-time prescribers. We then followed up with qualitative interviews (12 of 22 prescribers) which was conducted by a single, trained interviewer using a standardized guide. Interviews were recorded and transcribed verbatim. Each transcription was independently reviewed and coded by two blinded investigators using standardized themes and adjudicated by a third investigator for stability, robustness, and interrater reliability. Individually, researchers identified and coded key themes and statements. These themes were then discussed as a group and combined where they shared meaning. This project was reviewed and deemed to be non-human subjects research by the Stanford University School of Medicine Panel on Human Subjects in Medical Research.

Results
A total of 20 of the 22 prescribers (13 MDs and 9 APPs) completed the survey (91% response rate). Notably, only 25% of prescribers agreed that COVID-19 had changed their antibiotic prescribing practices for patients with respiratory infections despite objective data that all prescribed less. In the qualitative interviews, we identified four major themes impacting the appropriateness of antibiotic prescribing practices as shown in Table 1.

Conclusion
Urgent care prescribers attributed a decrease in antibiotic prescribing during COVID-19 to changes in patient expectations and knowledge base, a switch to telemedicine-based encounters, and changing epidemiology. These shifts could be utilized by outpatient antimicrobial stewardship efforts to sustain low prescribing rates for conditions in which antibiotics are generally not indicated.

Disclosures
Marisa Holubar, MD, MS, Nothing to disclose
161. Flucytosine Utilization and Dosing Practices at an Academic Medical Center
Authors: Miller Molly M , Kreikemeier Emily , Stohs Erica J , Van Schooneveld Trevor C , Van Schooneveld Trevor C , Alexander Bryan , Bergman Scott J , Bergman Scott J 
Published: December 2021

Abstract

Background
The typical dose of flucytosine is 25 mg/kg/dose every 6 hours for severe infections due to Candida and Cryptococcus. Many hospital protocols use ideal body weight (IBW) for initial dosing to achieve a goal peak serum concentration of 30-80 mcg/mL, but this is supported by very limited data. Our objective was to evaluate flucytosine dosing strategies, describe safety concerns, and explore financial benefits associated with using IBW.

Methods
All inpatient flucytosine orders for adults from 1/1/2015 through 10/31/2020 were retrospectively evaluated. Doses, weight used, flucytosine levels, adverse events, and potential cost savings associated with IBW dosing were characterized.

Results
During this period, 35 patients received flucytosine. The most common indications were cryptococcal meningitis (73%), pulmonary cryptococcosis (14%), and candidiasis (11%). Most patients were receiving concurrent liposomal amphotericin B (92%). Based on body mass index, most patients were overweight or obese (60%). Actual body weight was used for initial dosing in most cases (81%). Flucytosine peak monitoring was performed in 51% of cases. Initial peak levels were supratherapeutic in 10/19 cases (53%). Of those 10 patients, 70% were overweight/obese, and 60% would have received a lower initial dose if IBW had been used with dose rounding to the nearest 500mg capsule. Adverse events for all patients included new onset cytopenias, hepatic and renal dysfunction, occurring in 20%, 11%, and 60% respectively. Those with supratherapeutic levels had higher rates of new onset hepatic and renal dysfunction, 30% and 90% respectively. In 32% of cases, using IBW would have resulted in a lower daily dose, with an average dose reduction of 1888 mg, resulting in a mean cost savings per patient of &640/day using average wholesale price.

Conclusion
Most flucytosine orders were not dosed using IBW, which may have led to supratherapeutic levels. Using IBW for dosing in overweight patients may lead to reduced toxicity and potential cost savings. The default dosing weight for flucytosine in our electronic medical record will be set to IBW to encourage change.

Disclosures
Trevor C. Van Schooneveld, MD, FACP, BioFire (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Insmed (Individual(s) Involved: Self): Scientific Research Study Investigator; Merck (Individual(s) Involved: Self): Scientific Research Study Investigator; Rebiotix (Individual(s) Involved: Self): Scientific Research Study Investigator Bryan Alexander, PharmD, Astellas Pharma (Advisor or Review Panel member) Scott J. Bergman, PharmD, FCCP, FIDSA, BCPS, BCIDP, Merck & Co., Inc (Grant/Research Support) Scott J. Bergman, PharmD, FCCP, FIDSA, BCPS, BCIDP, Merck & Co., Inc (Individual(s) Involved: Self): Research Grant or Support
163. MIC Shifts in Response to Increased Antibiotic Utilization During COVID-19 Pandemic
Authors: Byrd Jonathan , Thomas-Gosain Neena , Eason Jane V , Bennett Jessica , Bowden Jarred 
Published: December 2021

Abstract

Background
Multiple studies have shown that antibiotic utilization increased during the COVID-19 pandemic. However, the impact of this increased utilization has not been well established. The aim of this study is to describe the trends in minimum inhibitory concentrations for various antibiotics against common gram-negative pathogens observed since the start of the COVID-19 pandemic as compared to previous years.

Methods
This retrospective study was conducted at the Memphis VA. All respiratory, urine, and blood culture MicroScan results run from October 2017-March 2021 were analyzed. Only inpatient and emergency department data was included. The MIC50 and MIC90 of seven antibiotics for four of the most common pathogens were trended by quarterly intervals.

Results
MIC50 and MIC90 were compared using standardized breakpoints. As compared to previous years, Pseudomonas aeruginosa was noted to have the most sustained increase in MIC90 across various antibiotics. In the last 3 quarters of the study time frame, piperacillin-tazobactam mean MIC90 increased from 32 to 64, cefepime from 8 to &gt; 16, and meropenem from 4 to &gt; 8. Escherichia coli had a sustained increase in ceftriaxone MIC90 from &lt; 1 to &gt; 8 in the final quarter of 2020 and beginning of 2021. Klebsiella pneumonia was also found to have a sustained increase in cefepime mean MIC90 from &lt; 1 to &gt; 16 during the year of 2020, with return to previous MIC90 the following quarters.

Conclusion
Previous studies have clearly demonstrated a widespread increase in antibiotic utilization during the COVID era. Our study demonstrates how even short-term increases in antibiotic use can lead to shifts in MIC, if not outright resistance. This was demonstrated across multiple common gram-negative pathogens and to various broad-spectrum antibiotics which were commonly used more frequently during COVID-19. Further analysis will be needed to determine whether these trends continue or whether the decrease in antibiotic utilization in the recent months will lead to similar decrease in MIC.

Disclosures
All Authors: No reported disclosures
165. Decreased Antimicrobial Consumption and Decreased Rates of Multi-drug Resistant Organisms Following Onset of the COVID-19 Pandemic: Experience from an Australian Tertiary Hospital
Authors: Moso Michael , Cairns Kelly , Peel Trisha , Macesic Nenad 
Published: December 2021

Abstract

Background
Current guidelines recommend empiric antibiotics be used only for severe cases of coronavirus disease 2019 (COVID-19) or in cases where there is high clinical suspicion for bacterial co-infection. Level of adherence to guideline-recommended prescribing is unknown and high rates of antimicrobial prescribing may lead to increased development of resistance.

Methods
We reviewed antimicrobial prescribing patterns for patients with COVID-19 managed at The Alfred Hospital in Melbourne, Australia in 2020. Adherence to World Health Organization (WHO) guideline-based prescribing was assessed by manual review of case notes. Monthly hospital-wide antibacterial consumption April-Dec 2020 (post-pandemic period) was compared to Jan 2019-Mar 2020 (pre-pandemic period), measured as days of therapy (DOT) per 1000 patient-days. Rates of multi-drug resistant organisms (MRO) (including MRSA, VRE, CPE, ESBL) were compared between months in 2019 and 2020 after pandemic onset (April 2020) and expressed as isolates per 1000 patient-days.

Results
147 patients were managed for COVID-19 in 2020 at our centre. 101 patients required hospital admission and 58 (39%) were classified as either severe or critical in severity. 80 (54%) patients received empiric antimicrobial treatment, including 78/101 (77%) of hospital inpatients and 24/26 (92%) of ICU-admitted patients. 59 (73%) of antimicrobial prescriptions were adherent to WHO guidelines. Monthly antibacterial consumption was significantly lower post-pandemic than in the pre-pandemic period (mean 853 vs 902 DOT/1000 patient-days, P=0.0065). Antimicrobial use patterns varied, with significant decreases in commonly used antibiotics such as ceftriaxone, piperacillin-tazobactam, azithromycin and ciprofloxacin but no change in vancomycin or meropenem (Figure 1). There was a mean decrease of 0.77 MRO isolates/1000 patient-days (P=0.026) when each month in 2020 was compared with the corresponding month in 2019 (Figure 2).

Antibacterial consumption in 2019 and 2020 by month, expressed as days of therapy/1000 patient-days.

Rates of isolated multi-drug resistant organisms in 2019 and 2020 by month, expressed as isolates/1000 patient-days.

Conclusion
A high proportion of admitted patients with COVID-19 received empiric antibiotics. In spite of this, we observed a significant reduction in total antimicrobial consumption and reduced rates of MRO isolation in the post-pandemic period.

Disclosures
All Authors: No reported disclosures
166. Evaluation of Daptomycin Prescribing Practices Based on Microbiologic Susceptibility Determination of “Susceptible-Dose Dependent” (SDD)
Authors: Rowley Amy , Marx Ashley H , Weber David J , Weber David J 
Published: December 2021

Abstract

Background
Recent changes in CLSI microbiologic interpretations of daptomycin and enterococci include the “susceptible-dose dependent” (SDD) category. The effectiveness of SDD for directing clinicians to employ higher dosing of daptomycin is unknown. The study objective was to determine if implementation of SDD paired with a comment recommending higher doses of daptomycin (8-12mg/kg) and ID consultation in 2019 was associated with changes in rates of daptomycin use and prescribed doses for enterococcal bloodstream infections (BSI).

Methods
Single-center, retrospective cohort study of adult inpatients with enterococcal BSI and daptomycin susceptibility results reported from Aug 2016-Jul 2020. Chart review was performed to collect demographics, source of infection, and clinical management strategy. Rate of daptomycin use for definitive therapy (antimicrobial on day 4 after final susceptibilities) and median prescribed dose were compared for BSI caused by S and SDD isolates. Annual (Aug 1-Jul 31) trends in infections and daptomycin use were tabulated.

Results
189 blood cultures were reviewed, yielding 56 unique episodes of enterococcal BSI. Patients had a mean age of 59 years and majority had an immunocompromising disease or medication. Of the cases in which it was a clinically appropriate option, clinicians selected daptomycin for definitive treatment in 81% of S and 71% of SDD cases (p = 0.46, Chi-square). Median daptomycin dose prescribed was 10mg/kg for both interpretations; dose range was 6-12mg/kg for S and 9.5-12mg/kg for SDD isolates. No temporal trend in prescribed dose noted over the 4-year study period. Repeat blood cultures performed in 50/56 (89%). Within 90 days, rates of relapse were low but mortality was 26/56 (46%).
Table 1. Infection and Treatment Characteristics

Chart 1. Frequency of prescribed daptomycin dose (mg/kg) for susceptible (A) and SDD (B) enterococci BSI isolates.

Conclusion
No difference detected in rate of daptomycin use nor median prescribed dose based on microbiologic interpretation. While the majority of doses were adequate (10mg/kg) based on current guidance for enterococcal BSI, the use of a directive comment to guide dosing and ID consultation may have recused outliers. Additional data is needed to characterize the impact of specific microbiologic interpretations on clinician prescribing and determine the most effective messaging strategies.

Disclosures
David J. Weber, MD, MPH, PDI (Consultant)
167. Incidence of Acute Kidney Injury with Aminoglycoside Impregnated Foreign Body Implantation
Authors: Royster Kelly , Chan Dominic 
Published: December 2021

Abstract

Background
During orthopedic surgeries, antibiotic impregnated cement is sometimes used to prevent infection. Elution from these cements can lead to systemically detectable levels of aminoglycosides, a known adverse effect of which is nephrotoxicity. The purpose of this study is to determine if the implantation of aminoglycoside impregnated cement is associated with subsequent development of Acute Kidney Injury (AKI).

Methods
A retrospective chart review from 1/1/2018-1/1/2021 was conducted to identify a relationship between aminoglycoside impregnated cement and subsequent development of AKI. Data were extracted from Electronic Health Records (Epic) and SAP Business Objects WebI. All patients with knee or hip arthroplasty or hardware removal procedures conducted at a Legacy Health facility during the specified time frame were included. Patients were excluded from the study if &lt; 2 serum creatinine levels were drawn during that hospitalization, AKI occurred prior to the procedure, or dialysis was required at baseline. The primary outcome was development of AKI, a &gt; 150% increase from baseline serum creatinine according to the Acute Kidney Injury Network (AKIN) criteria. The power level was set to 80% with an alpha level of 0.05. A multiple regression analysis was conducted to control for confounding variables

Results
A total of 2229 patients were included (591 received aminoglycoside cement,1638 did not). Aminoglycoside impregnated cement implantation was not associated with an increased incidence of AKI (1.5% versus 2.3%, P = 0.25). After controlling for covariates, aminoglycoside cement was not associated with development of AKI (adjusted OR 0.68, P = 0.32).

Conclusion
The results of this study suggest aminoglycoside impregnated foreign body implantation was not associated with a greater incidence of AKI development compared to implantation of foreign bodies lacking aminoglycosides. It is possible that development of AKI post-discharge was not identified in patients with uncomplicated procedures due to omission of lab draws once discharged. Patients admitted for longer durations were more likely to have multiple serum creatinine labs drawn during hospitalization, and likely had multiple comorbid conditions or complications, innately biasing and predisposing AKI development.

Disclosures
All Authors: No reported disclosures