bluuebunny/crossref_metadata_2025_split huggingface dataset:
114. Optimization of Inpatient Antibiotic Use via an Electronic Antimicrobial Stewardship Module and an Infectious Diseases Pharmacy Resident
Authors: Chen Victor , Allen Lauren , Bao Hongkai , Cowman Kelsie , Nori Priya , Nori Priya , Guo Yi 
Published: December 2021

Abstract

Background
Antibiotic resistance is a public health crisis and antimicrobial stewardship (AMS) pharmacists serve a crucial role in preventing inappropriate use. At Montefiore Medical Center (1,500-bed hospital), a new electronic medical record AMS module was implemented with assistance from an infectious diseases (ID) pharmacy resident in October 2020. The module utilizes a dynamic scoring system to assist in prioritizing interventions, including bug-drug mismatches, insufficient coverage, or de-escalation. The AMS module is operationalized by ID pharmacists during the week and an ID pharmacy resident every other weekend. The objective of this study was to assess the impact of an ID pharmacy resident performing AMS module interventions on broad spectrum antibiotic use.

Methods
An observational study of AMS module interventions on antibiotic use (AU) in days of therapy per 1,000 days present and standardized antimicrobial administration ratio (SAAR) was performed. AU data for piperacillin-tazobactam (P/T) and SAAR prior to (October 2019– December 2019) and after (October 2020 – December 2020) the integration of an ID pharmacy resident and the AMS module was compared. Additional data collected included total number and type of interventions.

Results
A total of 539 interventions were made by AMS pharmacists and 36.5% of these were completed by the ID pharmacy resident. Across 6 different units, there was a statistically significant decrease in the SAAR for broad spectrum antibacterial agents (Figure 1), and a decrease of at least 10% in P/T use during the two different time periods (Table 1). An estimated P/T cost reduction of 26% of (&48,708 to &36,235.80) was observed. AMS pharmacists made 63 interventions in respective units. The top three intervention types were dose/frequency/duration recommendations, pharmacokinetic vancomycin dosing/monitoring, and de-escalation. The acceptance rate of interventions was 99% (534 accepted interventions/539 total interventions).
Figure 1. SAAR Comparison of Broad-Spectrum Agents

Table 1. AU Rate of Piperacillin-tazobactam

Conclusion
Overall, there was a statistically significant impact on SAARs and a &gt;10% change in P/T AU rate with an estimated cost reduction &gt;25% on select units after implementation of the AMS module with an ID pharmacy resident.

Disclosures
Kelsie Cowman, MPH, Merck (Research Grant or Support) Priya Nori, MD, Merck (Grant/Research Support) Priya Nori, MD, Nothing to disclose Yi Guo, PharmD, BCIDP, Merck (Research Grant or Support)
117. How Does Antimicrobial Stewardship Provider Role Affect Prospective Audit and Feedback Acceptance by the Attending Physician?
Authors: Hammond Keely , Chen Justin , Doucette Karen , Smith Stephanie , Kabbani Dima , Lau Cecilia , Bains Serena , Stewart Jackson J , Fong Karen G 
Published: December 2021

Abstract

Background
Antimicrobial stewardship (AMS) teams are commonly multidisciplinary. The effect of AMS provider role on prospective audit and feedback (PAF) acceptance has previously been investigated with mixed results. PAF of restricted antimicrobials (carbapenems, linezolid, daptomycin, and tigecycline) in adult inpatients at our large Canadian academic centre has been performed since 2018. Actionable feedback is communicated via chart note plus one of a phone call, direct message, or in-person discussion with the most responsible physician of the attending team in order to optimize the prescription if deemed necessary. The objective of this study was to assess the effect of AMS provider role on PAF acceptance.

Methods
A 3 year retrospective review of all PAF events was undertaken. All audited prescriptions were included. Logistic regression was used to determine odds ratios for acceptance for individual AMS provider roles of pharmacist, physician, and supervised post-graduate physician trainee.

Results
Out of 1896 prescriptions audited, actionable feedback was provided to the most responsible physician in 731 (39%) cases. 677/731 (93%) of audited antibiotics were carbapenems. The overall acceptance rate was 82% (598/731). Acceptance rate and odds of acceptance based on AMS provider role were as follows: pharmacist alone 171/208 (82%), OR 1.04, 95% CI 0.70-1.59, physician alone 141/160 (88%), OR 1.85, 95% CI 1.12-3.20, pharmacist-physician duo 211/268 (79%), OR 0.73, 95% CI 0.50-1.07, and supervised post-graduate physician trainee 75/95 (79%), OR 0.81, 95% CI 0.48-1.41.

Conclusion
The overall acceptance rate was high. There was a higher odds of acceptance if an AMS physician was providing PAF alone, highlighting the importance of physician involvement.

Disclosures
Dima Kabbani, MD, AVIR Pharma (Grant/Research Support, Other Financial or Material Support, Speaker)Edesa Biotech (Scientific Research Study Investigator)Merck (Scientific Research Study Investigator)
118. Feasibility of a Proactive Amoxicillin Oral Challenge Program for Inpatients with Penicillin Allergy at the Miami VAMC
Authors: Piazza Michael J , Lichtenberger Paola , Bjork Lauren , Lazo-Vasquez Alex , Hoang Minh , Temino Viviana 
Published: December 2021

Abstract

Background
Ninety percent of patients who report penicillin (PCN) allergy are not truly allergic. Penicillin skin testing (PST) followed by oral challenge (OC) with amoxicillin (AMX) can evaluate unconfirmed PCN allergy. PST is taxing and requires trained staff, while OC is an acceptable alternative in patients with low-risk histories, who can safely undergo OC without PST. OC is performed in the outpatient Miami Veterans Affairs Medical Center (MVAMC) setting. Collaboration between Allergy, Antimicrobial Stewardship Program (ASP), and Hospital Medicine identified patients with low-risk histories and offered OC to inpatients.

Methods
A daily report of MVAMC inpatients with PCN allergy was reviewed for appropriateness of OC (Fig 1). Hospice patients and those medically unstable or unable to consent were excluded. Appropriate consenting patients were challenged with AMX 500mg PO and observed for 60 minutes. If no reaction resulted, the PCN allergy label was removed. Epinephrine and diphenhydramine were available in case of adverse reaction. Those who were not OC candidates were offered outpatient PST (Fig 1).
Figure 1. Penicillin allergy history evaluation algorithm

Results
We evaluated 39 inpatients with PCN allergy from 3/10 - 5/27/21. Median age was 68 years; 94.9% were male (Table 1). The most common recorded reaction was unknown (Table 2). Thirteen (33.3%) did not qualify for OC, 7 (17.9%) refused, 2 (5.1%) were receiving a penicillin-derivative, 1 (2.6%) patient’s primary team refused consult, 2 (5.1%) patients were discharged prior to OC. Fourteen (38%) patients underwent OC with 0 adverse reactions; 0 patients required epinephrine or diphenhydramine. After OC, 5 patients had changes to their antibiotic regimen as a result of a negative OC. Limitations included 5 patients on beta-blockers, and 5 patients unable to consent.
Table 1. Demographics of Evaluated Inpatients, N = 39 (%)

Note that 1 patient out of the 39, underwent DPC with cefpodoxime 200mg PO instead of amoxicillin for a reported allergy to ceftriaxone.
Table 2. Reported Reactions, N = 41 (%)

Total N exceeds evaluated patient number as one patient reported multiple reactions to receiving penicillin.

Conclusion
Removing unnecessary PCN allergy labels using inpatient OC with AMX is safe and effective for those with low-risk allergy histories. Zero patients undergoing OC developed a reaction, suggesting that OC may be safely performed per our algorithm. Our protocol does not require specialized training and is reproducible in settings without an Allergy specialist. In the 3 months prior to this program there were 0 inpatient consults to evaluate PCN. Future plans include forming a multidisciplinary consult service.

Disclosures
All Authors: No reported disclosures
125. Antimicrobial Stewardship Hospital Activities to Promote Antibiotic Awareness Week 2019, Chicago, IL
Authors: Hanson Amy P , Walblay Kelly , Shane Elizabeth , Xydis Shannon N , Pacilli Massimo , Kim Do Young , Black Stephanie R 
Published: December 2021

Abstract

Background
U.S. Antibiotic Awareness Week (USAAW) is an annual campaign to increase knowledge of antimicrobial resistance (AMR) threats and the importance of appropriate antibiotic use. USAAW will be observed November 18-24, 2021 in cadence with World Antimicrobial Awareness Week.

Methods
In October 2019, the Chicago Department of Public Health (CDPH) surveyed 25 Chicago acute care hospital (ACH) antimicrobial stewardship programs (ASPs) via REDCap, an electronic data capture system, to assess their planned activities for USAAW in November 2019. Survey results from 14 (56%) respondent ACHs were collated and disseminated to all 25 ACHs prior to USAAW.

Results
ACH ASP survey responses were categorized by ACH size: smaller hospitals (SH) &lt; 350 beds (n=7) and larger hospitals (LH) &gt; 350 beds (n=7) and displayed in the Table. Nine respondents were Infectious Disease (ID) Pharmacists, 3 were ID Physicians, 1 was an Administrator and 1 was an Infection Prevention Nurse. Among SHs, the ASP was funded for an ID Pharmacist salaried position (FTE) &lt; 0.5 at 4 ACHs, 0.5 in 2, and 1 FTE at 1 ACH. LHs reported ID Pharmacist funding ranging from &lt; 0.5 – 2.5 FTE, with the majority with 1 FTE at 3 LHs. All ACHs reported 0.5 FTE or less ID Physician support for their ASPs. Eleven (79%) of respondent ACHs did not report an annual budget for ASP activities. Ten (71%) ACHs disagreed or strongly disagreed that funding was adequate in the outpatient setting compared to inpatient both for adult and pediatric ASP services. Types of planned activities for USAAW included social media posts, provider education, digital displays, and/or go-live with a new antimicrobial policy. Top three barriers to ASP advancements were financial considerations (n=9), competing responsibilities for ASP leads (n=7), and tied for third was personnel shortages (n=6) and other clinical initiatives with higher priority (n=6).

Conclusion
Public Health Departments can facilitate assessment of ACH ASPs within their jurisdiction to identify ways to advance the ASP agenda and combat AMR. A variety of strategies were used by Chicago ACHs to promote ASP initiatives during USAAW. Challenges continue with inadequate funding, especially in outpatient settings.

Disclosures
All Authors: No reported disclosures
141. A Blind Spot for Antibiotic Stewardship Programs: Misadministration of Perioperative Antibiotics
Authors: Boton Noah , Patel Payal K , Kendall Ronald E , Hershey Cheryl , Jarzebowski Mary 
Published: December 2021

Abstract

Background
Hospitalized patients requiring intravenous antibiotics frequently undergo surgical intervention. These surgeries involve multiple transitions of care that may lead to antibiotic delay, additional unnecessary doses, omission, or substitution. While many studies examine the use of antibiotics for surgical site infection prophylaxis, there are no studies investigating antibiotic use in the perioperative period for inpatients already on an IV antibiotic regimen. This study examined the incidence and nature of antibiotic misadministration in the perioperative period among inpatients.

Methods
We conducted a retrospective cross-sectional study at a Veterans Affairs Medical Center involving all inpatients who underwent surgery in 2019. Patients 18 years or older who were on an IV antibacterial regimen prior to surgery were included. Patients undergoing cardiac surgery and patients only receiving surgical infection prophylaxis were excluded. Through manual chart review, we collected information on the prescribed IV antibiotic regimen and timing of antibiotic doses in the perioperative period. Errors were classified as administration of additional unnecessary IV antibiotics and missed, delayed, and additional doses of prescribed IV antibiotics.

Results
There were 168 inpatients on an IV antibiotic regimen who underwent surgery in 2019. Complete data was available for 158 patients. Errors in antibiotic administration in the perioperative period were identified in 64 (41%) patients. Missed, delayed, additional unnecessary antibiotics, and additional doses of prescribed IV antibiotics were identified in 21 patients (13%), 14 patients (9%), 13 patients (8%), and 7 patients (4%), respectively (Figure 1).

Conclusion
We found errors in antibiotic administration for inpatients undergoing surgery to be common, with the most frequent error being a missed dose of a prescribed IV antibiotic. This illustrates an area for quality improvement in inpatient antibiotic stewardship in our hospital and we suspect in other hospitals as well. Future work will incorporate more centers and examine how these errors affect outcomes for inpatients undergoing surgery, particularly in patients with sepsis or those requiring surgery for infection source control.

Disclosures
All Authors: No reported disclosures
148. Implementation of Restriction Criteria within an Electronic Medical Record and Its Impact on Carbapenem Prescribing
Authors: Naderi Mandana , Welker Kimberly , Chan Gary , Nix David 
Published: December 2021

Abstract

Background
Carbapenem restriction criteria (CRC) were developed by our health system to conserve the prescribing of these broad-spectrum agents. The purpose of this study was to compare pre and post EMR implementation of adherence to the system-approved CRC and if there was an association with decreased utilization of carbapenems.

Methods
A retrospective cohort review from January 2018 to June 2020 was performed via the Cerner EMR at 3 community hospitals in Arizona (AZ) and California (CA) to determine if CRC was appropriate at time of carbapenem initiation. Admitted patients &gt; 18 years prescribed meropenem or ertapenem and received at least one dose were included. Health System approved CRC are shown in Table 2.

Results
A total of 160 patients were analyzed, including 60 pre-EMR CRC intervention and 100 post intervention. Forty-five patients (28%) had a documented history of ESBL infection as shown in Table 1. Figure 1 shows carbapenem utilization over the study period. An interrupted time series analysis was performed for both AZ and CA. After correcting for pre-intervention trends, AZ days of therapy (DOT) decreased by 6.2 DOT per 1000 patient days within 1 month post intervention (23%, p&lt; 0.0001); the model predicted a further drop of 0.6 DOT per 1000 patient days per month over the 6 months post intervention. The CA DOT decreased by 1.2 DOT per 1000 patient days 1 month post intervention (17%, p= 0.28), with a predicted further drop of 0.28 DOT per 1000 patient days per month over the 6-month period post intervention. Post implementation retrospective review as described in Table 2 aligned with EMR restriction criteria selection for 68% of patients; interfacility differences occurred with 96% of CA reviews supported by criteria and 59% of AZ reviews supported by criteria (p= 0.0025).

Conclusion
This analysis supports that implementation of an EMR tool is an effective intervention to decrease unnecessary carbapenem use at the time of prescribing. The ESBL rate was similar pre and post intervention which may indicate that decreases in DOT were not due to a difference in MDRO rate. This study also highlights the different baseline antibiotic prescribing practices that may exist between facilities.

Disclosures
All Authors: No reported disclosures
153. Utilization of Post-Exposure Prophylaxis to Prevent Lyme Disease in a Large US Healthcare Database
Authors: Marx Grace E , Fuller Candace C , Haug Nicole , Martin Dave , Corey Catherine , Beck Alyssa , Schwartz Amy M , Hinckley Alison F 
Published: December 2021

Abstract

Background
In the United States, at least 50,000 emergency department visits for tick bite and an estimated 476,000 Lyme disease diagnoses occur annually, with incidence of both high among children. The majority of these healthcare visits occur in the northeastern and midwestern states having high Lyme disease incidence and during the summer and fall months, corresponding to peak opportunities for exposure to blacklegged ticks. Post-exposure prophylaxis (PEP) with a single dose of doxycycline can effectively prevent Lyme disease after a tick bite that is high risk for transmission of Lyme disease. We describe characteristics of patients with dispensings of single-dose doxycycline in a large US-based system that includes patients enrolled in private and public health insurance plans.

Methods
Single-dose doxycycline (≤200 mg) dispensings during January 2009 – February 2020 were identified for patients enrolled in seven Data Partners that contributed electronic healthcare data to the Food and Drug Administration Sentinel Distributed Database, including large national insurers, an integrated delivery care network, a state Medicaid, and the 100% Medicare fee-for-service plan. We examined patient and PEP dispensing characteristics by patient age, state of residence, and month of dispensing.

Results
We identified 408,897 patients with PEP (n=474,414 total dispensings) with a mean age of 60 years at first dispensing. Overall, there were 21 patients per 10,000 eligible members with PEP dispensings. Dispensings were less common in children (&lt; 1 and 4 patients per 10,000 eligible members aged &lt; 8 and 8-18 years, respectively). Most dispensings (72%) occurred in states with high incidence of Lyme disease. Seasonality of dispensings was bimodal, with most occurring during April – July and October – November (71 – 83%, by year).

Conclusion
Lyme disease PEP was relatively common and mirrored geographic and seasonal trends observed for ED visits for tick bites and Lyme disease diagnoses. However, we observed more PEP among older adults, and few dispensings among children. Despite healthcare visits for tick bites and Lyme disease occurring disproportionately among pediatric age groups, PEP appears to be underutilized in children.

Disclosures
All Authors: No reported disclosures
162. Duration of Antibiotics Through Care Transitions: A Quality Improvement Initiative
Authors: Soto Caitlin , Dzintars Kate , Dzintars Kate , Keller Sara C 
Published: December 2021

Abstract

Background
Antibiotic resistance is increasing worldwide, largely driven by excessive antibiotic use. Antibiotic stewardship (AS) interventions have traditionally focused on acute care, long-term care, and ambulatory settings. However, as patients transition from one care setting to another, AS interventions should address antibiotic orders (agent, dose, duration) between the hospital and the home. The purpose of this study is to determine the appropriateness of a total course of antibiotics, including inpatient and outpatient prescriptions, to aid in prioritizing AS interventions.

Methods
A single-center, retrospective study was performed to evaluate antibiotic duration for adult patients discharged from a large quaternary-care academic hospital. All antibiotic prescribing data, including pre-admission, during admission, and after hospital discharge, as well as information on indication, was collected from the electronic medical record. Descriptive statistics were used to summarize the data collected.

Results
196 patients were included in the study. There were 100 instances of disagreement on antibiotic indication between the discharge summary and reviewer. However, 70% of patients were discharged on an appropriate antibiotic. The majority of patients (75%) were prescribed excess antibiotic days beyond guideline recommended total duration, and 68% of patients did not have appropriate duration of antibiotics post-discharge. Of those with excess duration, 31% were prescribed penicillins, 23% were prescribed cephalosporins, and 20% were prescribed trimethoprim/sulfamethoxazole. Excess antibiotic duration was associated most commonly with an unknown diagnosis (23%), a skin and soft tissue infection diagnosis (16%), and antibiotic prophylaxis (12%).

Conclusion
The results of this study showed that patients were often prescribed excess antibiotics at discharge, and the total duration of antibiotics from pre-admission to post-discharge were prolonged beyond guideline-recommended duration. Understanding the total duration of antibiotic prescription, including post-discharge and pre-admission durations, is key in assessing risk from antibiotics and targeting AS interventions.

Disclosures
Kate Dzintars, PharmD, Nothing to disclose
174. Development of a Machine Learning Prediction Model to Select Empirical Antibiotics in Patients with Clinically Suspected Urinary Tract Infection using Urine Culture Data
Authors: Kim Chungsoo , Park Rae Woong , Rhie Sandy J 
Published: December 2021

Abstract

Background
Increasing antimicrobial resistance and the emergence of superbugs are problems globally. Inappropriate empiric antibiotic use would be a reason to cause antibiotic resistance. However, it has been a challenge to prescribe empiric antibiotics as it is difficult to identify the causative organism beforehand. In this study, we aimed to develop a prediction model to estimate the risk of antibiotics resistance using urine culture tests.

Methods
The study population included adult patients who had at least one of the results from a urine culture test and antibiotic susceptibility tests (from ampicillin, ceftriaxone, ciprofloxacin, gentamicin, levofloxacin, nitrofurantoin, tetracycline, trimethoprim/sulfamethoxazole) on admission to Ajou University Medical Center. Outcomes were defined as a resistant or intermediate susceptibility. Candidate predictors were diagnosis, prescription, visit, laboratory, procedures of the study population. We split data to 75:25 for training and test. Lasso logistic regression (LLR), extreme gradient boosting machine (XGB), Random Forest (RF) were used as model algorithms. The models were evaluated by an area under the curve of receiver operator characteristics curve (AUROC), precision-recall curve (AUPRC), and its calibration. All codes are available in https://github.com/ABMI/AbxBetterChoice

Results
Total 33 covariates were selected for final prediction models. The RF showed the highest AUROC in the ceftriaxone and tetracycline models (0.823, 0.626, respectively). The XGB presented the highest AUROC for ciprofloxacin and nitrofurantoin (0.731, 0.706, respectively). The AUROC of RF and the XGB were the same in an ampicillin model (0.633). For gentamicin, levofloxacin, and trimethoprim/sulfamethoxazole, the AUROC of LLR was the highest (0.838, 0.831, 0.615, respectively). Among the models, the AUROC was the highest in the gentamicin model regardless of algorithms. All calibrations of the models were acceptable.

Conclusion
We developed prediction models with competing performances of discrimination and calibration. It would contribute to the proper selection of empiric antibiotics susceptible to those causative pathogens in hospitalized patients with a clinically suspected urinary tract infection.

Disclosures
All Authors: No reported disclosures