bluuebunny/crossref_metadata_2025_split huggingface dataset:
93. Developing Urinary Tract Infection Clinical Vignettes for the Nursing Home Setting: A Mixed-Methods Approach
Authors: Taylor Lindsay N , Irvine Jessica , Jolles Sally , Bej Taissa A , Crnich Christopher J , Jump Robin L , Jump Robin L 
Published: December 2021

Abstract

Background
Little is known about how providers choose antibiotics for nursing home residents when concerned about urinary tract infections. To better assess this in a simulated setting, we used a mixed-methods approach to develop robust clinical vignettes.

Methods
First, we developed 7 vignettes and distributed them to resident physicians as a survey, randomizing participants’ response type to rank-order or free-text entry. Second, we shared 5 vignettes with nursing home prescribers and conducted semi-structured interviews that asked providers to explain their thinking out loud (Think Aloud structure). Interviews were continued until content saturation was achieved. Two authors (LT & RJ) determined appropriateness of decisions about antibiotic initiation and antibiotic choice; two authors (LT & JI) coded feedback on the vignettes with adjudication by a third (RJ).

Results
Of 23 residents (11 rank-choice; 12 free-response) that participated in the pilot survey, only 6 (26%) completed 7 vignettes, with a mean completion of 69.4%. Completion of all vignettes was similar between groups, however, greater attrition at the first question was observed in respondents randomized to rank-choice (4/11) compared to free-response (6/12). Of the original 7 vignettes, 5 free-response cases were chosen for further development. We conducted semi-structured interviews with 7 nursing home prescribers, 4 of whom were physicians. The prescribers had a median age 39 (range 34 to 54) and a median of 10 years of post-graduation experience. Figure 1 summarizes appropriateness of respondents’ answers regarding antibiotic initiation and antibiotic choice. The most common inappropriate choice was a fluoroquinolone. Vignettes were edited iteratively based on participant feedback on each case’s realistic characteristics, missing necessary clinical data, formatting changes, and clarity (Figure 2).
Figure 1. Appropriateness of antibiotic initiation and antibiotic choice per clinical vignette.

Figure 2. Example of vignette editing process based on Think Aloud interview responses

Conclusion
This mixed-methods approach effectively captured prescribers’ feedback about length, response method, and case characteristics for our clinical vignettes. Responses assessed differences in prescribers’ decision to initiate antibiotic treatment and antibiotic choice. The refined vignettes will be used in a national survey.

Disclosures
Robin L. Jump, MD, PhD, Pfizer (Individual(s) Involved: Self): Consultant
94. Implementation of Antibiotic Prescribing Scorecards in the Ambulatory Care Setting
Authors: Revolinski Sara , Njeri Wainaina J , Enzmann Maxx , Olexia Deanna , Sobczak Christopher 
Published: December 2021

Abstract

Background
Up to 56% of antibiotics prescribed in the ambulatory setting in the United States are inappropriately prescribed, with 30% of those determined to be unnecessary. In order to increase transparency and education about antibiotic prescribing in our ambulatory clinics at our institution, we implemented quarterly scorecards demonstrating antibiotic prescribing trends for primary care prescribers.

Methods
This pre-post interventional study analyzed the impact of prescriber scorecards on antibiotic prescribing, with the intervention consisting of real-time education and presentation of baseline data via scorecards. Prescribers were educated on the scorecard project via live meetings in Nov-Dec 2020. In Dec 2020, prescribers were sent individual emails describing their baseline antibiotic prescription rate (defined as number of prescriptions per 100 patient encounters), de-identified comparison data for other prescribers within their individual clinic, and average rate of the top 10% of prescribers with the lowest prescription rates. Baseline data was from prescriptions dated Jan-Mar 2020. The email also explained the project and shared that quarterly scorecards would be distributed in 2021. Baseline data was compared to prescription data from Jan-Mar 2021. Knowing the COVID-19 pandemic resulted in significantly fewer encounters for respiratory infections, data was also analyzed with respiratory diagnoses removed from the dataset.

Results
In the pre-intervention period, 11,769 antibiotics were prescribed during 92,239 encounters for a prescription rate of 12.8 (95%CI: 12.5-13.0). Of 96,449 encounters in the post-intervention period, 7,326 antibiotics were prescribed for a rate of 7.6 (95%CI: 7.4-7.8; p&lt; 0.0001). When respiratory diagnoses were removed, prescription rates were 6.1 (95%CI: 5.9-6.2) in the pre-group, compared to 6.3 (95%CI: 6.1-6.5; p=0.0546). When analyzed by prescriber, significant decreases were seen in prescriptions by physicians (5.8 vs 5.4, p=0.0035) while increases were seen in prescriptions by advanced practice prescribers.

Conclusion
Antibiotic scorecards sent to prescribers may result in reduced antibiotic prescribing, but further research is needed to elucidate the impact of the scorecards in light of the COVID-19 pandemic.

Disclosures
All Authors: No reported disclosures
96. Impact of Hospital-Based Pharmacist Discharge Prescription Review on the Appropriateness of Antibiotic Therapy
Authors: Spigelmyer Amy , Howard Catessa , Rybakov Ilya , Burwell Sheena , Slain Douglas 
Published: December 2021

Abstract

Background
Inappropriate antibiotic prescribing upon hospital discharge poses an increased risk of excess costs, adverse drug reactions, readmission, and resistance. Despite high rates of antibiotic prescription errors upon discharge, there is no widely accepted antimicrobial stewardship initiative to prevent such errors. This study evaluated the impact of hospital-based clinical pharmacist discharge prescription review on the appropriateness of antibiotic prescriptions.

Methods
This was a retrospective assessment of patients with discharge antibiotic prescriptions for treatment of pneumonia, urinary tract infections, Clostridioides difficile infections, acute skin and skin structure infections (ABSSSI), or Gram-negative bacteremia between January 2019 and July 2020. The two cohorts that were studied were patients on Hospitalist services versus patients on Medicine services, in which only the Medicine services had rounding pharmacists who perform discharge prescription reviews. Outcomes included demographics, appropriateness of therapy, 30-day readmission rates, and error types in discharge prescriptions. Appropriateness of therapy was validated by evidence-based guidelines and three Infectious Diseases-trained pharmacists.

Results
Our study included 300 patients, 150 per cohort. Baseline characteristics were similar between groups, with the exception of increased age (p=0.025) and fewer cases of ABSSSI (p=0.001) in the Hospitalist cohort. A statistically significant higher rate of inappropriateness was seen in the Hospitalist group versus Medicine (pharmacist) group, [69/150 (46% versus 25/150 (17%, respectively (p&lt; 0.00001)]. The difference in appropriateness was mainly driven by pneumonia and UTI prescriptions. Thirty day readmission rates were 17% (26/150) for the Hospitalist cohort versus 11% (16/150) in the Medicine (pharmacist) cohort (p=0.134). The most common prescription error was the duration of therapy.

Conclusion
Appropriateness of antibiotic discharge prescriptions significantly improved in the setting of pharmacist discharge prescription review. This initiative highlights the important role of clinical pharmacists in the setting of outpatient antimicrobial stewardship.

Disclosures
All Authors: No reported disclosures
97. Pharmacist Driven Antimicrobial Stewardship Interventions on the Management of Urinary Tract Infections in the Emergency Department at a Tertiary Military Treatment Facility
Authors: Ayalew Memar D , raiciulescu Sorana , Brooks Daniel , Williams Robin , Crull Paulette , Ressner Roseanne 
Published: December 2021

Abstract

Background
With the Joint Commission standards targeting ambulatory settings serving as a catalyst, we designed a quality improvement (QI) project was designed to evaluate the existing management and prescribing patterns for urinary tract infections (UTI) in the Walter Reed National Military Medical Center (WRNMMC) Emergency Department (ED) in order to identify targets for ASP intervention.

Methods
This was a Pharmacist-driven, prospective, QI project conducted over a 3-month period. The clinical presentations and microbiological data of uncomplicated cystitis and pyelonephritis cases managed in the ED were reviewed. Within 24-72 hours of ED discharge, recommendations were relayed to both patients and ED staff. Diagnostic criteria and management concordant with established clinical guidelines were assessed. Inclusion criteria included age ≥ 18, admission status, urine culture and antibiotics for UTI or pyelonephritis.

Results
A daily urinalysis (UA) report identified 1781 ED encounters of which 117 cases met inclusion criteria. Nitrofurantoin was most prescribed empirically at 39.3% followed by a cephalosporin (23.1%) or a fluoroquinolone (19.7%), accounting for 32% of inappropriate empiric antibiotic selection. Cases were identified with inappropriate duration of therapy (22.2%), dosage (9.4%), and drug-bug mismatch (9.4%). Nearly 38% of cases required intervention to discontinue (32.5%) or initiate new antibiotics (3.4%). Diagnostic concordance was defined as having positive urinary symptoms, clinically significant UA and positive urine culture. This was only observed in 37.6% of all cases, of which only 43.2% were treated with a guideline concordant empiric regimen, dosage and duration of therapy. Although not included in the final analysis, it was noted 916 urine culture results were ordered where 70% were not associated with genitourinary complaints or sepsis.

Conclusion
Despite guidelines for UTI management, considerable practice discordance was found in the ED. Multiple Pharmacist targeted interventions were identified. Prioritized areas for ED provider education include first-line therapy, treatment duration, and diagnostic stewardship. This QI project has potential for optimizing prescribing practices in Military Health System ambulatory settings.

Disclosures
All Authors: No reported disclosures
98. Outcomes of Clinical Decision Support for Outpatient Management of Clostridioides difficile Infection
Authors: Wu Tiffany , Davis Susan L , Davis Susan L , Church Brian , Alangaden George J , Kenney Rachel 
Published: December 2021

Abstract

Background
Our antimicrobial stewardship program identified high rates of suboptimal metronidazole prescribing for Clostridioides difficile infection (CDI) within ambulatory clinics. An outpatient best practice advisory (BPA) was implemented to notify prescribers “Vancomycin or fidaxomicin are preferred over metronidazole for C.difficile infection” when metronidazole was prescribed to a patient with CDI.

Methods
We conducted an IRB approved quasi-experiment before and after implementation of the BPA on June 3, 2020. Inclusion: Adult patients diagnosed with and treated for a first episode of symptomatic CDI at an ambulatory clinic between 11/1/2019 and 11/30/2020. Exclusion: fulminant CDI. Primary endpoint: guideline-concordant CDI therapy, defined as oral vancomycin or fidaxomicin. Oral metronidazole was considered guideline-concordant if prescribed due to cost barrier. Secondary endpoints: reasons for alternative CDI therapy, patient outcomes, prescriber response to the BPA. Descriptive and bivariate analyses were completed.

Results
189 patients were included in the study, 92 before and 97 after the BPA. Median age: 59 years, 31% male, 75% Caucasian, 30% with CDI-related comorbidities, 35% with healthcare exposure, 65% with antibiotic exposure, 44% with gastric acid suppression therapy within 90 days of CDI diagnosis. The BPA was accepted 23 out of 26 times and optimized the therapy of 16 patients in six months. Guideline-concordant therapy increased after implementation of the BPA (72% vs. 91%, p=0.001) (Figure 1). Vancomycin prescribing increased and metronidazole prescribing decreased after the BPA (Figure 2). Reasons for alternative CDI therapy included medication cost, lack of insurance coverage, and non-CDI infection. There was no difference in clinical response or unplanned encounter within 14 days after treatment initiation. Fewer patients after the BPA had CDI recurrence within 14-56 days of the initial episode (27% vs. 7%, p&lt; 0.001).
Figure 1. Guideline-concordant CDI therapy

Figure 2. Specific CDI therapy

Conclusion
Clinical decision support increased prescribing of guideline-concordant CDI therapy in the outpatient setting. A targeted BPA is an effective stewardship intervention and may be especially useful in settings with limited antimicrobial stewardship resources.

Disclosures
Susan L. Davis, PharmD, Nothing to disclose Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)
100. Assessment of Emergency Department Prescribing Practices for Outpatient Treatment of Urinary Tract Infection, Community-Acquired Pneumonia, and Skin and Soft Tissue Infections
Authors: Thaller Matthew , Dempsey Casey J , Levine Alexander , Shepard Kelly 
Published: December 2021

Abstract

Background
Studies have found a need for improved antimicrobial stewardship in the outpatient setting. The literature is limited by the populations and disease states studied as many focus on viral infections. This study focuses on the adult emergency departments (EDs) in a large healthcare system and quantifies the proportion of antibiotic prescriptions deemed inappropriate for common outpatient infections.

Methods
A retrospective study was conducted in patients with selected common infections treated as an outpatient from the ED. Patients were reviewed for eligibility based on the inclusion and exclusion criteria in Table 1. Appropriateness was analyzed based on: need for antimicrobial therapy; agent choice, dose, duration, and directions in concordance with national guidelines and local resistance patterns; and no clinically relevant drug interactions, unnecessary dual coverage, or a better or safer alternative available. The entire prescription was marked inappropriate if any factor was deemed inappropriate.
Table 1. Inclusion and Exclusion Criteria

Based on the Epic report generated, a random sample of patients were selected for manual review. Only patients who met the following criteria were eligible for inclusion in the final analysis.

Results
Of the 318 patients reviewed, 274 were included. Treatment was deemed inappropriate 64% (174/274) of the time, significantly above the estimated 30% (p &lt; 0.001). The agent selection, duration, and dose were the most the frequent factors deeming a prescription inappropriate. The most inappropriately used agents were fluoroquinolones and azithromycin. A positive culture required modification of therapy 31% (22/70) of the time and more so when the drug was guideline recommended. For example, when empiric antibiotic selection was per urinary tract infection guidelines, 31% (14/53) required modification compared to 19% (3/16) when the agent was not. This was most apparent when cephalexin was used.

Conclusion
The use of antibiotics at the studied EDs was not in concordance with guidelines in the study period. However, the cultures were sensitive less often to agents deemed appropriate per guidelines for empiric therapy. It is possible that the ideal treatments of bacterial infections in this community are not representative of national resistance patterns. Using ED-specific antibiograms to create order panels for common infections, as well as prospective pharmacist review at ED discharge, could increase appropriate utilization of preferred agents.

Disclosures
All Authors: No reported disclosures
102. Evaluation of the Association between the Antibiotic Spectrum Index and Antibiotic Days of Therapy: A Retrospective Study across 124 Acute-care Hospitals
Authors: Kakiuchi Satoshi , Goto Michihiko , Casado-Castillo Fernando , Perencevich Eli N , Livorsi Daniel J 
Published: December 2021

Abstract

Background
Antibiotic stewardship programs often measure antibiotic days of therapy (DOT), but this metric does not reflect the antibiotic spectrum. In this study, we used the previously published Antibiotic Spectrum Index (ASI), which attaches a score (1-13) to the spectrum of each antibiotic, to evaluate the content of antibiotic use across all Veterans Health Administration (VHA) hospitals. We also assessed how benchmarking hospital performance changed when ASI was used instead of DOT.

Methods
We conducted a retrospective cohort study of patients admitted to 124 acute-care VHA hospitals during 2018. We obtained data on administered antibiotics, the days of antibiotic use (DOT), and days-present (DP) from the VHA Corporate Data Warehouse and then aggregated data to the hospital-level using the National Healthcare Safety Network’s methodology. We modified the original ASI by changing 3.8% of the bug-drug scores to ensure consistency across all scores and adding 27 new antibiotics agents. For each hospital, we calculated ASI/DOT, ASI/1,000 DP, and DOT/1,000 DP and ranked hospitals on their performance. We performed a Spearman’s rank-order correlation to compare hospitals on these metrics and their associated rankings.

Results
At the hospital-level, the median ASI/DOT, ASI/1,000 DP and DOT/1,000 DP were 5.4 (interquartile range: 5.2-5.8), 2,332.7 (1,941.8-2,796.2) and 443.5 (362.5-512.2), respectively. There was a strong correlation between the ASI/1,000 DP and DOT/1,000 DP metrics [Spearman’s correlation test: r=0.97 (p&lt; 0.01)] but only a weak and insignificant correlation between ASI/DOT and DOT/1,000 DP [r=0.17 (p=0.06), Figure 1]. Twenty (16.1%) hospitals showed a difference of 10% or more in their ranking for ASI/1,000 DP compared to their ranking for DOT/1,000 DP. The range of ranking difference was from -17.7% to 21.0% (Figure 2a and b).
Figure 1. Distribution of the Antibiotic Spectrum Index / Day of Therapy by Days of Therapy / 1000 Days Present for 124 Acute-Care VHA Hospitals during 2018. Black line: Median values of DOT/1,000 DP and ASI/DOT, respectively.

Figure 2. (a) Distribution of the rankings in DOT/1,000 DP and ASI/1,000 DP. Blue line: the position of same ranking between ASI/1,000 DP and DOT/1,000 DP. (b) Distribution of the differences in each hospital’s ranking for DOT/1,000 DP and ASI/1,000 DP

Conclusion
Our findings suggest that hospitals using fewer days of antibiotic therapy did not necessarily use narrower-spectrum antibiotics. ASI/1,000 DP, as a combined measure of antibiotic consumption quantity and average spectrum, provided a different view of hospital performance than DOT/1,000 DP alone. Future work is needed to define how this new metric relates to the quality of antibiotic use.

Disclosures
All Authors: No reported disclosures
103. Expansion of an Antimicrobial Stewardship Program Through Implementation of a Discharge Verification Queue
Authors: Rubin Ellen C , Blackman Alison L , Broadbent Eleanor K , Wang David , Plasari Ilda , Ketema Pawlose , Brade Karrine , Barlam Tamar F 
Published: December 2021

Abstract

Background
Antimicrobial stewardship programs (ASPs) have traditionally focused interventions on inpatient care to improve antibiotic prescribing. Support of effective interventions for ASPs targeting antibiotic prescriptions at hospital discharge is emerging. Our objective was to expand stewardship services into the outpatient setting through implementation of a process by the antimicrobial stewardship team (AST) to verify antimicrobials prescribed at discharge.

Methods
This quality improvement initiative incorporated a discharge order verification queue managed by AST pharmacists to review electronically prescribed antimicrobials Monday through Friday, from 8:00 am to 4:00 pm. The queue was piloted Sep 2020 and expanded hospital-wide Feb 2021. Patients &lt; 18 years old and those with observation or emergency department status were excluded. The AST pharmacist reviewed discharge prescriptions for appropriateness, intervened directly with prescribers, and either rejected or verified prescriptions prior to transmission to outpatient pharmacies. Complicated cases were reviewed with the AST physician to evaluate intervention appropriateness. Interventions were categorized as either dose adjustment, duration, escalation or de-escalation, discontinuation, or safety monitoring.

Results
A total of 602 prescriptions were reviewed between Sep 2020 and Apr 2021. An AST pharmacist intervened on 28% (171/602) of prescriptions. The most common intervention types were duration (41%, 70/171), discontinuation (18%, 31/171), and dose adjustment (17%, 30/171). The most common indications in which the duration was shortened was community acquired pneumonia (26%, 18/70), skin and soft tissue infection (21%, 15/70), and urinary tract infection (17%, 12/70). The most common antibiotics recommended for discontinuation were cephalexin (32%, 10/31) and trimethoprim-sulfamethoxazole (10%, 3/31). The overall intervention acceptance rate was 78%.

Conclusion
An AST pharmacist review of antimicrobial prescriptions at discharge improved appropriate prescribing. The discharge queue serves as an effective stewardship strategy for inpatient ASPs to expand into the outpatient setting.

Disclosures
All Authors: No reported disclosures