bluuebunny/crossref_metadata_2025_split huggingface dataset:
104. Improving Efficiency of Antimicrobial Stewardship Reviews Using Artificial Intelligence Modelling
Authors: Tang Si Lin Sarah , Lee Winnie , Chong Yiling , Saigal Akshay , Zhou Peijun Yvonne , Hung Kai Chee , Tan Lun Yi , Chung Shimin Jasmine , Kwa Lay Hoon Andrea 
Published: December 2021

Abstract

Background
Antimicrobial stewardship programs (ASP) in hospitals improve antibiotic prescribing, slow antimicrobial resistance, reduce hospitalisation duration, mortality and readmission rates, and save costs. However, the strategy of prospective audit and feedback is laborious. In Singapore General Hospital (SGH), 10 reviews are required to identify 2 inappropriate cases. Limited manpower constraints ASP audits to only about 30% of antibiotics prescribed. This proof-of-concept study explored the feasibility of developing a predictive model to prioritise inappropriate antibiotic prescriptions for ASP review.

Methods
ASP-audited adult pneumonia patients from January 2016 to December 2018 in SGH were included. Patient data e.g., demographics, allergies, past medical history, and relevant laboratory investigations at each antibiotic use episode were extracted from electronic medical records and re-assembled through linking for analysis. Ground truth for model training was based on ASP-defined appropriateness for each encounter. The dataset was split into 80% and 20% for training and testing respectively. Three modelling techniques, XGBoost, decision tree and logistic regression, were assessed for their relative performance in terms of precision, sensitivity and specificity.

Results
There were 12471 unique patient encounters. Training was done on 10459 encounters and 39 data elements were included. When tested on 2012 encounters, the logistic regression model performed the best (86.7% sensitivity, 71.4% specificity). The model correctly classified 1377 out of 1388 (99.2%) encounters as “appropriate” (do not require ASP intervention). 624 antibiotic use encounters were classified as “inappropriate”, of which only 72 were truly inappropriate (positive predictive value for ASP intervention, PPV 11.5%). The low PPV was likely due to inadequate representation of “inappropriate” cases in the training dataset (4.1%). Applying this model would prioritise the number of immediate ASP reviews needed to identify cases for intervention by two-thirds, from 2012 to 624 (Figure 1).
Figure 1. Illustration of AI benefits in ASP

Conclusion
ASPs can leverage on machine learning capabilities to improve audit efficiency. This can increase ASP’s productivity and staff’s job satisfaction as they are freed up to perform other work.

Disclosures
All Authors: No reported disclosures
105. Fluoroquinolone Stewardship at a Community Health-System: A Decade in Review
Authors: Song Matthew , Wilde Ashley , Wilde Ashley , Moore Sarah E , Bohn Brian C , Schulz Paul S 
Published: December 2021

Abstract

Background
Fluoroquinolone stewardship is a common target for antimicrobial stewardship programs seeking to maintain or improve fluoroquinolone susceptibility rates. Additional benefits include reducing C. difficile infection rates, drug toxicities, and resistance to other antimicrobials as fluoroquinolones can co-select for resistance. The Norton Healthcare antimicrobial stewardship program was founded in 2011 and provides services at 4 adult hospitals with ~1600 beds. Main fluoroquinolone stewardship activities have included provider education, prospective audit and feedback, and guideline and order-set development. The purpose of this study was to describe the resistance and usage rates of fluoroquinolones over time.

Methods
This was a descriptive study examining individual adult hospital antibiograms from 2010 to 2020. Levofloxacin susceptibility rates to E. coli and P. aeruginosa were collated from annual antibiograms between 2010 and 2020 for outpatients and each adult hospital. Adult hospital resistance rates were aggregated and weighted accordingly to number of isolates per hospital per year. Additionally, levofloxacin and ciprofloxacin inpatient days of therapy (DOT) was collected since 2016 when DOT was first readily retrievable and was normalized per 1000 patient days to compare between different time points.

Results
Outpatient levofloxacin likelihood of activity against P. aeruginosa improved from 81% to 91%. Outpatient levofloxacin likelihood of activity against E. coli remained stable between 84 – 86% (Figure 1). Adult inpatient fluoroquinolone usage decreased by approximately 75% from 83.5 to 21.37 DOT/1000 patient days since 2016 (Figure 2). Adult inpatient levofloxacin likelihood of activity against P. aeruginosa improved from 53% to 83%. Adult inpatient levofloxacin likelihood of activity against E. coli improved from 65% to 75% (Figure 3).

Conclusion
The Norton Healthcare antimicrobial stewardship program has been effective in reducing unnecessary fluoroquinolone usage and improving inpatient fluoroquinolone susceptibility rates. Future studies should examine opportunities to translate successes to the outpatient phase of care.

Disclosures
Ashley Wilde, PharmD, BCPS-AQ ID, Nothing to disclose Paul S. Schulz, MD, Gilead (Consultant, Speaker’s Bureau)Merck (Consultant, Speaker’s Bureau)
107. Impact of Penicillin Allergy Assessment During Pre-Anesthesia Testing (PAT) on Beta-Lactam Surgical Prophylaxis in Bariatric Surgery Patients
Authors: Hitchins Maggie , Watts Amber M , Holt Shannon 
Published: December 2021

Abstract

Background
Due to utilization of alternative antibiotics, documented penicillin (PCN) allergies are associated with an increased risk of surgical site infections, cost, and infections caused by resistant organisms. In October 2019, a community hospital implemented a beta-lactam (BL) allergy assessment service in a pre-anesthesia testing (PAT) clinic without access to allergy specialists or PCN skin testing (PST). In phase 1, the surgeon was contacted to change surgical prophylaxis for BL eligible patients based on the assessment. In phase 2, an automatic protocol was implemented to allow advanced practice providers (APPs) to switch from alternative antibiotics in BL eligible patients. The objective of this study was to assess the impact of the PCN assessment service and protocol on BL surgical prophylaxis.

Methods
This retrospective cohort study included bariatric surgery patients who visited PAT clinic with a documented BL allergy between Jun 2019-Sept 2019 (control), Nov 2019-Feb 2020 (phase 1), and Nov 2020-Feb 2021 (phase 2). Patients with procedures not requiring surgical prophylaxis were excluded. Patients were determined to be eligible for BL surgical prophylaxis if: intolerance or mild-moderate reaction to PCN, previously tolerated cephalosporin, intolerance to cephalosporin, or surgeon deemed it appropriate. The primary outcome was overall utilization of BL surgical prophylaxis.

Results
This study included 38 patients in the control group, 14 in the phase 1 group, and 17 in the phase 2 group. Overall utilization of BL surgical prophylaxis significantly increased with 16% in the control group, 43% in the phase 1 group, and 65% in the phase 2 group (p=0.001). In the BL eligible patient subgroup, BL surgical prophylaxis significantly increased with 35% (n=6/17) in the control group, 50% (n=6/12) in the phase 1 group, and 92% (n=11/12) in the phase 2 group (p= 0.001). There were no reported surgical site infections or adverse drug reactions.

Conclusion
Overall utilization of BL surgical prophylaxis significantly increased after implementation of a PCN allergy assessment service with an automatic protocol for patients determined as BL eligible. This service and protocol demonstrates successful optimization of surgical prophylaxis when allergy specialists or PST is not available.

Disclosures
All Authors: No reported disclosures
108. Evaluation of the Impact of Dalbavancin Usage on Clinical Outcomes, Cost-Savings, and Adherence at a Large Safety Net Hospital
Authors: Wei Wenjing , Mang Norman , Ortwine Jessica , Meisner Jessica A , Lueking Richard 
Published: December 2021

Abstract

Background
Dalbavancin is a long-acting second-generation lipoglycopeptide antibiotic with potent activity against Gram-positive organisms. Dalbavancin is currently FDA approved for acute bacterial skin and soft tissue infections (ABSSTIs). Growing evidence suggests that patients can be successfully treated with dalbavancin for indications outside of skin and soft tissue infections which include bacteremia and osteomyelitis (OM) with significant cost savings and reduced length of stay. We developed a protocol for the use of dalbavancin in patients who required intravenous antibiotics for serious bacterial infections but did not qualify for outpatient parenteral antibiotic therapy (OPAT). During the COVID-19 pandemic, we expanded the protocol to reduce the amount of clinical contact required for all patients.

Methods
In this retrospective observational study, we reviewed all patients that received at least one dose of dalbavancin in either inpatient or outpatient setting at Parkland Hospital from July 2019 through February 2021. Patient demographics, type of infection, and rationale for dalbavancin were collected at baseline. Clinical response was measured by avoidance of Emergency Department (ED) visits or hospital readmission at 30, 60, and 90 days. In addition, a separate analysis was conducted to estimate hospital, rehabilitation, or nursing home days saved based on their diagnosis and projected length of treatment.

Results
Twenty-eight patients (24 inpatient, 4 outpatient) were included in the study. The majority were uninsured (89%), homeless (64%), or had active intravenous drug use (IDU) (60%). Indications for use included SSTI (42.9%), bacteremia (64.3%), and OM (42.6%). Clinical failure was observed in 4 (14%), 1 (3.5%), and 2 (7.1%) patients at 30, 60, or 90 days (respectively). Nonadherence to medical recommendations, lack of source control, and ongoing IDU increased risk of returning to the hospital. Dalbavancin use saved a total of 381 days of inpatient/rehab/facility stay.

Baseline Characteristics of Patients

Types of Infections and Microbiology

ED Visit or Readmissions at 30, 60, or 90 Days

Conclusion
Dalbavancin showed similar rates of success with improved length of stay and cost savings. The use of long acting lipoglycopeptides are desirable alternatives to traditional OPAT for patients that otherwise would not qualify for OPAT or desire less hospital contact.

Disclosures
All Authors: No reported disclosures
110. MRSA nasal swab as a stewardship tool to guide IV Vancomycin in diabetic foot infections
Authors: Lazo-Vasquez Alex , Piazza Michael , Cordova Leopoldo , Bjork Lauren , Zamora Gonzalez Rolando A , Lichtenberger Paola , Lichtenberger Paola , Baracco Gio 
Published: December 2021

Abstract

Background
The Infectious Disease Society of America (IDSA) guidelines suggest empiric Methicillin-Resistant Staphylococcus Aureus (MRSA) coverage for Diabetic Foot Infection (DFI) with a history of MRSA infection, if local prevalence is high, or if the infection is severe. However, data suggests that there is overutilization of vancomycin in this population and this medication is associated with toxicity. MRSA nasal screen has a high negative predictive value (NPV) for ruling out MRSA in pneumonia and other sites. We performed a medication utilization evaluation (MUE) for Vancomycin IV in DFI patients who had an MRSA nares screen to determine our own NPV of this test and feasibility to use it as an antibiotic stewardship program (ASP) tool to guide vancomycin use in this population.

Methods
We retrospectively reviewed 224 patients from January 2015 to January 2020 who had a diagnosis of DFI and an MRSA nasal screen. 139 patients had cultures done. For the NPV, we excluded patients who had any MRSA positive culture or screen up to a year from admission (Figure 1).
Figure 1. Flowchart from our medication utilization evaluation showing patient’s distribution by MRSA-screen result

Results
We found 148 (66%) patients with DFI who had received IV vancomycin empirically during the admission and 196 of them were MRSA-nares negative (Figure 2). The average days of therapy (DOT) in the MRSA-nares negative patients was 5.2 days vs 4.8 in the MRSA-nares positive patients. Out of the 139 patients with a negative MRSA nasal swab, 124 had no MRSA in cultures, yielding an NPV of 89%. If we considered only the deep cultures, the NPV increased to 90%.
Figure 2. Number of patients who received IV vancomycin grouped by MRSA-screen result

Conclusion
We identified overutilization of IV vancomycin in patients with a diagnosis of DFI in our institution. Also, our NPV of the MRSA-nasal screening to rule out MRSA infection in DFI was high at 89% similar to previous studies. Based on these findings, we plan to implement a local ASP protocol (Figure 3) using MRSA nasal swab screen to decrease the empiric use of vancomycin. The results of these efforts will be analyzed and published in future iterations with the hopes to share this knowledge to reduce the use of IV vancomycin in this population in other centers.
Figure 3. Protocol draft to be used as an ASP tool to guide IV vancomycin de-escalation based on MRSA-nasal screen for DFI patients

Disclosures
All Authors: No reported disclosures
111. Assessment of Empiric Management Practices of Common Infections in Solid Organ Transplant Recipients at a Canadian Tertiary Care Centre - A Retrospective Cohort Study
Authors: Ahmad Syed Z , Kothari Sagar , Zhao Michelle , Teixeira-Barreira Abbigayle , Richmond Mark , Husain Shahid 
Published: December 2021

Abstract

Background
Post-transplant infections remain a leading cause of morbidity and mortality in solid organ transplant recipients (SOTR). Standardized antimicrobial treatment guidelines for infectious syndromes may contribute to improved clinical care. Our study seeks to assess the rate of therapeutic compliance with local standard guidelines in the treatment of common infections in SOTR, and their associated outcomes.

Methods
Consecutive adult SOTR admitted to the transplant floor from January–May 2020 for treatment of an infectious syndrome of interest were reviewed for study inclusion. Patients were followed until discharge or for 30 days following the date of diagnosis, whichever was shorter. Data was extracted from electronic medical records.

Results
475 SOTR were admitted to the transplant floor, of which 156 patients (33%) were admitted with infectious syndromes. Guidelines were applicable to 117 patients, constituting the following 122 syndromes: 51 pneumonias; 34 urinary tract infections (UTI); 22 bacteremias and 15 intra-abdominal infections (Fig. 1). Intra-abdominal infections occurred earliest at a median time of 9 months post-transplant followed by bacteremias, pneumonias, and UTIs (medians 10, 38 and 54 months respectively) (Table 1). 47% of patients were empirically treated with a regimen compliant with guidelines and 66% were provided compliant tailored therapies. Non-compliance with empiric management guidelines resulted in a significantly higher proportion of patients requiring ICU transfer when compared to compliance (25% vs. 9%; P = .02) (Table 2). Non-compliance with tailoring protocols resulted in an increased overall length of stay (medians 11 days vs. 8 days; P = .04). Within 30 days of discharge, no differences in readmission, development of Clostridium difficile infection, rejection, graft loss or death were observed between patients receiving compliant or non-compliant regimens.
Figure 1. Study Flow Diagram

Table 1. Baseline Characteristics of Patient Cohort

Table 2. Outcomes of compliant vs. non-compliant treatment in patients receiving antimicrobial therapy for an infectious syndrome

Conclusion
Non-compliance with locally developed antimicrobial management guidelines resulted in a higher proportion of patients being transferred to the ICU and an increased length of stay in our cohort, highlighting the benefits of adherence. Future studies will assess long-term outcomes associated with compliance to infection management guidelines.

Disclosures
All Authors: No reported disclosures
112. Prescriber Perceptions on Utilization of the Antibiotic Self-Stewardship Time Out Program (SSTOP) at Veterans Affairs Medical Centers (VAMC): A Strategy for Improved Antibiotic Use
Authors: Goedken Cassie , Judd Joshua , Butler Jorie M , Brown Nui G , Rubin Michael , Goetz Matthew B , Goetz Matthew B 
Published: December 2021

Abstract

Background
Evidence is lacking on how to implement effective and sustainable antibiotic stewardship strategies. The Antibiotic Self-Stewardship Time Out Program (SSTOP) evaluated the implementation at VAMCs of an “Antibiotic Timeout” 3 days after the initiation of antibiotics to encourage providers to review continued use of broad-spectrum antibiotics.

Methods
Sites launched the SSTOP note templates in a rolling fashion from June 2019-March 2020. Clinical pharmacists largely drove the implementation. The vancomycin note template was implemented at 6 of 8 sites and the antipseudomonal note template across 4 of 8 sites. Two sites were unable to launch the note templates due to lack of resources, however they utilized SSTOP principles/guided tools. From Sept 2019-Nov 2020 we conducted post-launch qualitative interviews with Antibiotic Stewardship Program (ASP) champions involved in implementation across the 8 VAMCs. Interviews were transcribed and analyzed for thematic content.

Results
Feedback from ASP providers suggests prescribers had mixed reviews on the note template, but overall liked the process and deemed it to be straightforward. Many valued the algorithm, indicating it was helpful in both thinking about antibiotics prior to initiation, and identification of appropriate antibiotics. Barriers included staffing (e.g., rotating residents/turnover), surgery service, information technology (IT) support, COVID-19, and the need to remind providers to use the template. Facilitators consisted of strong stewardship, local champions (e.g., ID Fellow), medicine service, and SSTOP data feedback reports. Recommendations largely centered on improvements to the note template usability and to SSTOP feedback reports (e.g., inclusion of patient/provider-level data).

Conclusion
Overall, the SSTOP note templates were considered acceptable and straightforward. By guiding providers to prescribe more appropriate antibiotics, they act as influencers for practice change, and may strengthen provider/ASP relations. Plans for continued utilization of the note templates after the project concludes suggest SSTOP may serve as a way to achieve sustainable promotion of antibiotic use improvements.

Disclosures
Matthew B. Goetz, MD, Nothing to disclose
116. Impact of an Antimicrobial Stewardship Program in the First Year of Pandemic 2020 in a Large,Academic, Public Network Hospitals in Bogotá,Colombia
Authors: Solorzano Ramos Carlos A , Ruiz Palma Erika A , Muñeton Lopez Gerardo A , Rodriguez Camilo Gomez , Castro Solarte Elena V , Lemos Luengas Elkin V 
Published: December 2021

Abstract

Background
Antimicrobial resistance is a major public health threat internationally but, particularly in Colombia. High and increasing rates of carbapenemases are challenging. Implementing antimicrobial stewardship programs (AMSs) in a large, academic, public network hospitals in Bogotá, Colombia.will help curb inappropriate antibiotic use.
Adherence to AMS Program 2020. Subred Integrada de Servicios de Salud Sur Occidente E.S.E Bogotá, Colombia.

Impact of an Antimicrobial Use Optimization Program in the First Year of Pandemic 2020 in a Large, Academic, Public Network Hospitals in Bogota Colombia

Methods
AMS was established in April 2020 consisting of an administrative champion, Infectious Diseases staff, nurse, General Physician, microbiologist, and pharmacists. Antimicrobial stewardship program interventions included postprescriptive audit and establishment of institutional guidelines. The AMS tracked appropriate drug selection including loading dose, maintenance dose, frequency, route, duration of therapy, de-escalation, and compliance with AMS recommendations. Defined daily dose (DDD) of drugs and health economics evaluations of antimicrobials (April-December 2020). Recommendations are placed in the electronic medical record as a progress note.

Results
From April to December 2020, 1013 patients were evaluated by means of a prospective methodology. Unnecessary 689 days of hospitalization and 4420 days of antibiotic therapy were avoided. Among the top antibiotics discontinued were piperacillin tazobactam for the months of July, August, November and December, while for September and October was meropenem. The intensive care unit was the most frequently intervened service (52%), followed by hospitalization (43%) and the emergency department (5%).Over the course of the year, there was significant adherence to the program, with 100% in July, followed by 93.3% in April, 87% in December, 86.6% in May and June, 83% in November, 80% in September, 73.3% in August and 57% in October. The AMS program was able to save &47.409US in antibiotics and &55.529US in hospitalization, and 11% decrease in nephrotoxicity events (14 renal failures were avoided), which also saved additionally & 23.503 US for a total of an estimated cost saving for the network public hospitals of & 126.441 US by 2020.

Conclusion
Implementation of a multidisciplinary antibiotic stewardship program in this academic, large, academic, public network hospitals in Bogotá, Colombia demonstrated feasibility and economic benefits even in a Covid19 pandemic situation.

Disclosures
All Authors: No reported disclosures
120. Antimicrobial Prescribing Guidance and Communication Among Health Care Professionals in Five Guatemalan Hospitals
Authors: Ramay Brooke M , Secaira Clara I , Chavez Nuria , Toledo Mario Augusto Melgar , Lou-Meda Randall M , Sandoval Nancy V , Maldonado Herberth G 
Published: December 2021

Abstract

Background
Communication among health care professionals during antimicrobial prescribing is critical to ensure appropriate use. This is of concern in Guatemala where physicians seldom consider guidance from other professionals during antimicrobial prescribing activities.

Methods
We carried out a cross sectional questionnaire and open ended interviews with physicians from five hospitals in Guatemala to describe perceptions of communication between health care providers, and acceptance of antimicrobial guidance during prescribing.

Results
From January to April 2021 an electronic questionnaire was sent to enrolled physicians of which 74% completed participation (n=107/145). Fifty-five percent participated in open ended interviews (n=79/145). Respondents perceived high levels of communication between physicians and ID specialists (94% of respondents); 52%, and 54% perceived high levels of physician-pharmacist, and physician-nurse communication respectively. Significant differences in the perception of physician-pharmacist communication were detected when comparing responses between hospitals, and between respondent sex (chi2, p&lt; 0.05). Barriers to communication between professionals included lack of local guidelines or protocols, patient overload, COVID-19 pandemic, lack of mentorship, and little room to discuss antimicrobial therapy with higher-ranking physicians. Eighty percent and 45% of physicians were open to receiving antibiotic optimization recommendations from other physicians, and pharmacists respectively. Notable barriers to accepting recommendations from pharmacists included lack of regular communication, lack of clinical experience, and concern about evidence based recommendations.

Conclusion
Effective communication is perceived between physicians during antimicrobial prescribing activities. Marginal levels of communication and acceptance of prescribing recommendations have been detected between physicians and pharmacists.In this milieu, there is an opportunity to strengthen multidisciplinary teams to optimize antimicrobial use.

Disclosures
Mario Augusto Melgar Toledo, MD, Merck (Grant/Research Support)Pfizer (Grant/Research Support)