bluuebunny/crossref_metadata_2025_split huggingface dataset:
144. Antifungal Use Trends in Hospitalized Adults in the United States, 2016-2020
Authors: Kaip Emily A , Shippey Ernie , MacDougall Conan 
Published: December 2021

Abstract

Background
Surveillance of antimicrobial use is a cornerstone of antimicrobial stewardship, though antifungal (AF) use is less frequently characterized. AFs are a major driver of inpatient costs and their use both reflects and drives changes in fungal susceptibility patterns. We report on trends in AF use in a large sample of United States hospitals over time including predictors of AF use.

Methods
We performed a retrospective analysis of adult inpatient visits between 2016 and 2020 at hospitals contributing data to the Vizient Clinical Database/Clinical Resource Manager (www.vizientinc.com). Inpatient use of systemically administered AFs was investigated as a function of study quarter, diagnosis code, and underlying immunosuppressive condition. Changes in AF use were modeled using logistic and negative binomial regression.

Results
We examined over 23 million admissions across 470 hospitals, 43% of which were classified as teaching hospitals and 54% of which performed solid organ transplants. During the study period, 4.03% (951,284/23,565,493) of admissions were billed for one or more of the study AFs. Among admissions receiving AFs, 86% received an azole, with the most frequently used agent being fluconazole, which accounted for for 46% of total AF days. Likelihood of AF receipt during admission increased by quarter (OR 1.012, p&lt; 0.001), controlling for length of stay, presence of fungal infection, hematologic malignancy (HM), or solid organ transplant (SOT). Odds of any receipt and days of therapy (DOT) of fluconazole, isavuconazole, posaconazole, and echinocandins increased over the study period while those of voriconazole, itraconazole, and flucytosine decreased; odds of receipt of amphotericin products increased while DOT decreased; flucytosine receipt odds increased while DOT did not change. Only 30% of admissions with AF use were associated with a documented fungal infection, with 93% of these episodes documented as candidiasis. Admissions associated with SOT or HM represented 2% and 3% of all patient-days, but 11% and 25% of total AF days, respectively.
Antifungal Utilization

Conclusion
AF use increased significantly over the study period, with changes across agents and classes. Most AF use occurred in the absence of administratively documented infection and was more common among SOT and HM patients.

Disclosures
All Authors: No reported disclosures
145. Comparing Antibiotic Use Across Inpatient Facilities with Different Antibiotic Stewardship Typologies using Machine Learning and Joint Modeling Approach
Authors: Zhang Yue , Shen Jincheng , Willson Tina M , Stenehjem Edward A , Barlam Tamar F , Drainoni Mari-Lynn , Childs Ellen , Butler Jorie M , Goetz Matthew B , Goetz Matthew B , Madaras-Kelly Karl , Caitlin M. Reasdon , Samore Matthew H 
Published: December 2021

Abstract

Background
Hospital antibiotic stewardship programs (ASP) aim to promote the appropriate use of antimicrobials (including antibiotics) and play a critical role in controlling antibiotic costs and antibiotic-resistant bacterial infection risk, and improving patient outcomes. However, unlike other health care quality improvement intervention programs, the ASP implementation strategies vary among healthcare facilities, and little is known about whether different types of ASP implementation will lead to the shifting of antibiotic drug use from one class to another.

Methods
We proposed an analytical framework using unsupervised machine learning and joint model approach to 1) develop a typology of ASP strategies in facilities from the Veterans Health Administration, America’s largest integrated health care system; and 2) simultaneously evaluate the impacts of different ASP types on the annual antibiotic use rates across multiple drug classes. The unsupervised machine learning method was used to leverage the structural components in the surveys conducted by the Veteran Affair (VA) Healthcare Analysis and Information group and the Consolidated Framework for Implementation Research experts from Boston University, and reveal the underlying ASP patterns in the VA facilities in 2016.

Results
We identified 4 groups in the VA facilities in terms of enthusiasm and implementation level of antibiotic control in our ASP typology. We found the facilities with high implementation level and high enthusiasm in ASP and those with high implementation level but low enthusiasm had statistically significant 30% (p-value=0.002) and 22% (p-value=0.031) lower antibiotic use rates in broad-spectrum agents used for community infections, respectively than those with low implementation level and low enthusiasm. However, the facilities with high implementation and high enthusiasm also marginally increased antibiotic use rates in beta-lactam antibiotics (p-value=0.096).

Conclusion
The developed analytical framework in the study provided an approach to the granular assessment of the impact of the healthcare intervention programs and might be informative for future health service policy development.

Disclosures
Matthew B. Goetz, MD, Nothing to disclose
146. Predictors of Long Duration Antibiotic Therapy for Urinary Tract Infections and Community-Acquired Pneumonia in Pediatric Ambulatory Care Settings
Authors: Shah Rohan M , Sun Shan , Scardina Tonya , Patel Sameer 
Published: December 2021

Abstract

Background
Significant variation exists in the duration of antibiotic therapy for children in ambulatory care settings. Understanding drivers of variation for common conditions such as community-acquired pneumonia (CAP) and urinary tract infection (UTI) is important to informing antimicrobial stewardship interventions.

Methods
A retrospective observational study was conducted of patients with CAP and UTI seen in outpatient clinics or discharged from the emergency room (ER) of a tertiary care children’s hospital network from 2016 – 2019. Diagnoses CAP and UTI were identified via ICD-10 coding. Only oral medications ordered for ≥ 3 and &lt; 28 days were included. Multivariable logistic regression was performed to identify predictors of long antibiotic duration (defined as ≥ 10 days). Potential non-clinical drivers of longer duration included race, ethnicity, sex, primary language, and insurance status.

Results
A total of 2,104 prescriptions for CAP from 442 prescribers and 1,070 prescriptions for UTI from 314 prescribers were included. Antibiotic durations were ≥ 10 days in 59.9% and 47.6% of prescriptions for CAP and UTI, respectively. Long duration of therapy was more common in children discharged from the ER when compared to clinics for both CAP (OR 1.795, 95% CI: 1.107 - 2.929), and UTI (OR 5.149, 95% CI: 1.933 - 16.373). The proportion of patients with long duration of therapy increased with younger age for both diagnoses and decreased overall in the final year of the study. Race, gender, ethnicity, and primary language were not associated with prolonged duration of therapy. However, patients with Medicaid insurance were more likely to receive long duration of therapy for CAP (OR 1.337, 95% CI: 1.062 - 1.682) and UTI (1.654, 95%, CI: 1.181 - 2.325).

Conclusion
In pediatric patients in ambulatory care settings, younger age, care in the ER, and being insured through Medicaid were independently associated with prolonged duration of therapy for both UTI and CAP.

Disclosures
All Authors: No reported disclosures
147. Antibiotic Prescribing: Shorter is Also Better in the Emergency Department
Authors: Vuong Lisa , Faison Darius , Thomson Julie , Kenney Rachel , Davis Susan L , Davis Susan L 
Published: December 2021

Abstract

Background
Published information suggests room for improvement in antibiotics prescribed on discharge from the emergency department (ED). The objective of this study was to evaluate antibiotic prescribing in the ED for uncomplicated infections of the lower respiratory tract (LRTI), urinary tract (UTI), and skin and skin structure (SSTI).

Methods
IRB-approved retrospective cross-sectional study of patients discharged from the ED from January to June 2019 at 6 locations. Inclusion: ≥ 18 years old and uncomplicated LRTI, UTI, or SSTI. Exclusion: hospital admission. Appropriate prescribing was defined having all three of the following correct per local and national guidelines: antibiotic selection, dose, and duration. Correct duration: 5 days for LRTI and SSTI; 3 days for trimethoprim-sulfamethoxazole (TMP-SMX), 5 days for nitrofurantoin (NFT), and 7 days for beta-lactams for UTIs. Endpoints within 7 days: antibiotic escalation, readmission to ED or hospital, any outpatient contact, and report of adverse drug event (ADE). Endpoints within 90 days: Clostridioides difficile infection (CDI). Descriptive and bivariable statistics were performed.

Results
Inappropriate prescribing: 77% (304) vs. appropriate 23% (89). Infection type: 47.8% SSTI, 30% UTI, and 22.1% LRTI. SSTI was associated with the greatest proportion of inappropriate prescribing at 89.4% (Figure 1). Comparisons for inappropriate vs. appropriate groups: 15.8% vs. 22.5% for beta-lactam allergy and 23.4% vs. 19.1% for cultures drawn in ED. Most common antibiotics for inappropriate vs. appropriate: first generation cephalosporin at 70.1% vs. 7.3% (p&lt; 0.05), TMP-SMX at 14.3% vs. 12.2% (p=0.75), and NFT at 7.8% vs. 65.9% (p&lt; 0.05). Prescriptions considered inappropriate were primarily driven by excess duration (Figure 2). Endpoints for inappropriate vs. appropriate groups: antibiotic escalation at 6.6% (2.8% were due to cultures drawn in the ED) vs. 1.1% (p=0.06), readmission at 8.6% vs. 9.0% (p=0.9), any outpatient contact at 18.4% vs. 19.1% (p=0.89), and report of ADE at 1.3% vs. 1.1%. No CDI in either group.
Figure 1. Appropriateness of Discharge Prescriptions by Infection Type, N = 393

Figure 2. Subset Analysis: Reasons for Inappropriate Prescribing, n = 304

Conclusion
The main reason for inappropriate prescribing in the ED was excess duration of therapy, making this an area of opportunity for future antibiotic stewardship improvement.

Disclosures
Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder) Susan L. Davis, PharmD, Nothing to disclose
149. Impact of Stewardship on Antibiotic Utilization Rates During the COVID-19 Pandemic: Successes and Challenges in a Regional Hospital
Authors: Macias Ana , Elgin Jennifer , Duerson Donna , Warren Cirle A 
Published: December 2021

Abstract

Background
Antibiotic stewardship (AS) is at the core of patient safety and prevention of antimicrobial resistance. Healthcare providers prescribe antibiotics for COVID-19 despite low rates of bacterial co-infection. Our regional hospital had antibiotic utilization (AU) rates higher than other health systems even prior to the emergence of SARS-Cov2. We analyzed the effect AS on AU during the pandemic.
Total Antibiotic Utilization Rates Before and During COVID-19 Pandemic

Methods
Total and specific AU rates were benchmarked using BD MedMined’s medication analytics system from 2nd quarter 2019 to 1st quarter 2021. The AS team released yearly antibiogram and individual prescriber’s AU rates and performed weekly, and as needed, review of antibiotic ordering and feedback. To assist in appropriate prescribing decisions, remote educational sessions or mini-lectures and local antibiotic guidelines were developed during the pandemic period. AU rates were monitored quarterly to determine the effects of the AS interventions to prescribing practices.

Results
Total and specific AU rates were higher (up to 34% and 80%, respectively) in our index hospital compared to other non-teaching hospitals nationally prior to the pandemic. Total antibiotic utilization increased by only 5.5% in the 2nd quarter 2020, peak of AU during the pandemic. Total, vancomycin, piperacillin-tazobactam and quinolone utilization rates decreased by 19%, 41%, 38%, and 52%, respectively, at 1st quarter 2021 compared to 4th quarter 2019. Steeper decreases were noted with implementation of educational activities. Ceftriaxone use remained high and was 50% greater than comparator hospitals at 1st quarter 2021.

Conclusion
Although problematic during the COVID-19 pandemic, AS can have significant impact on provider prescribing practices and decrease total and specific antibiotic utilization rates. The use of ceftriaxone, an antibiotic commonly used for empiric bacterial coverage for community acquired pneumonia, presents as a continuing challenge.

Disclosures
All Authors: No reported disclosures
150. Improved Susceptibility of Pseudomonas aeruginosa to Cefepime (CEF) at a Veterans Tertiary Care Hospital, over a 7-Year Period (2011-2017): The Impact of Antibiotic Rotation/Cycling and Reversal of Drug Resistance in P. aeruginosa
Authors: Kuhn Ryan , Martinez Oscar , Ross Chris , Touleyrou Lauren , Natesan Suganthini Krishnan 
Published: December 2021

Abstract

Background
Background: Pseudomonas aeruginosa continues to be an important cause of nosocomial infections associated with a high morbidity and mortality. Despite the availability of ceftazidime-avibactam (CAZ-AVI) and ceftolozone-tazobactam (CFT-TAZO), CEF continues to be an empiric agent of choice in several institutions. Aim: To evaluate the prevalence and trend in susceptibilities of P. aeruginosa to CEF over a 7-year period, identify possible correlation with the use of CAZ, AZT, PTZ, CIP, and CAR, (DOT/1000 patient days), as a quality improvement (QI) measure for optimizing CEF use, introduce antibiotic cycling as a tool to avoid emergence of drug-resistance in P. aeuriginosa.

Methods
A retrospective review of antimicrobial susceptibility data of all isolates of P. aeruginosa, (inpatient and outpatient) at the Detroit VAMC pre and post implementation of antibiotic cycling, over a 7-year period (2011-2017) was performed. Susceptibility testing was performed by reference broth micro-dilution methods in a central laboratory. Data analysis was performed using Pearson correlation coefficient score. Being a QI project, clinical data were not reviewed.

Results
A total of 977 isolates were identified during the study period. (drug usage are in DOT/1000 PD); CAZ and AZT use surged during 2013-14 from 5 to 8 dropping in 2015-17 to &lt; 3; PTZ usage increased to 100 during 2011-14 but dropped to 38 in 2015-17 (drug shortage); CAR use averaged at 10 until 2016 and dropped to 8 in 2017; CIP use dropped by 50% from 30 in 2012 to 15 in 2017; P. aeruginosa susceptible to CEF decreased from 88% in 2012 to 81% in 2014 mirroring the increased use of CEF, AZT, CAZ, and CIP; AG use was very low at &lt; 5. With restrictions on the use of AZT, CAZ, and CIP, from 2014-15, CEF susceptibility increased significantly to 95.5% in 2015. Drug shortage of PTZ in 2015 and increased use of CEF from 2015-17 led to a drop in susceptibility to (82%); P. aeruginosa susceptible to CAR and AG averaged at 88% and 97% respectively (2011-17). However, reintroduction PTZ, resulted in improved susceptibility of P. aeuruginosa to CEF by 40% within a year.

Conclusion
Judicious antimicrobial use and antibiotic rotation play a significant role in reversing drug resistance in P. aeuruginosa.

Disclosures
All Authors: No reported disclosures
151. Association Between Outpatient Antibiotic Prescribing, Antimicrobial Resistance, and Initial Presentation to Inpatient Setting for Urinary Tract Infections Among Older Adults in New York State
Authors: Grillo Marissa N , Barlow Joshua , Carreno Joseph 
Published: December 2021

Abstract

Background
Antibiotic prescribing (AP) and resistance (AR) may influence severity of illness in urinary tract infection (UTI). Limited data exist assessing the relationship between county-level AP and AR on initial presentation to hospital for UTI. This study evaluated the association between county-level AP and AR on UTI severity of illness among hospitalized patients in New York State.

Methods
Retrospective, cross-sectional analysis, combining data from New York State Statewide Planning and Research Cooperative System (SPARCS) and previously published data on countywide antimicrobial resistance and antimicrobial prescribing. Inclusion criteria: female patients admitted to a New York inpatient setting in 2017, UTI (CCS 159), Medicare insurance. Exclusion criteria: missing countywide prescribing or resistance. All-patient refined (APR) clinical severity ≥ 3 was the primary outcome. Counties were classified as prescribing above or below the median prescribing proportion, and above or below the median prevalence of E. coli resistance for TMP-SMX and NTF. Countywide prescribing practices, antimicrobial resistance, patient factors, and location factors were evaluated for association with APR clinical severity ≥ 3 using chi-squared and logistic regression.

Results
8,024 patients met study criteria. Baseline characteristics are presented in Table 1. 3,597 (44.8%) had an APR severity of ≥ 3. Factors associated with APR severity ≥ 3 include age group (P &lt; 0.001), ethnicity (P = 0.013), hospital county (P &lt; 0.001), first line prescribing ≥ 45.4% (P = 0.049), E. coli TMP-SMX resistance ≥ 29.0% (P &lt; 0.001) via chi-squared test. In the logistic regression analysis counties with higher first line prescribing was associated with decreased odds for severe infection (aOR: 0.83 [0.72 – 0.97]). Additional factors associated with severe infection are presented in Table 2.

Conclusion
Prescribing patterns may have a significant influence on initial presentation to the hospital for urinary tract infections. Outpatient antimicrobial stewardship should endeavor to promote guideline driven prescribing. Further research is needed to corroborate the findings from this cross-sectional study.

Disclosures
All Authors: No reported disclosures
152. Use of Antimicrobials among Suspected COVID-19 Patients at Selected 12 Hospitals in Bangladesh: Findings from the First Wave of COVID-19 Pandemic
Authors: Mah-E-Muneer Syeda , Hassan Md Zakiul , Al Jubayer Biswas Md Abdullah , Akhtar Zubair , Das Pritimoy , Rahman Fahmida , Islam Md Ariful , Chowdhury Fahmida 
Published: December 2021

Abstract

Background
Antimicrobials are empirically used in COVID-19 patients resulting in inappropriate stewardship and increased antimicrobial resistance. Our objective was to assess antimicrobial use among suspected COVID-19 in-patients while waiting for the COVID-19 test report.

Methods
From March to August 2020, we collected data from in-patients of 12 tertiary-level hospitals across Bangladesh. We identified suspected COVID-19 patients; collected information on antimicrobial received within 24 h before and on hospitalization; and tested nasopharyngeal swab for SARS-CoV-2 using rRT-PCR. We used descriptive statistics and a regression model for data analysis.

Results
Among 1188 suspected COVID-19 patients, the median age was 34 years (IQR:2–56), 69% were male, 40% had comorbidities, 53% required oxygen, and 1% required ICU or ventilation support after admission. Antibiotics were used in 92% of patients, 47% within 24 h before, and 89% on admission. Patients also received antiviral, mostly favipiravir (1%) and antiparasitic drugs particularly ivermectin (3%). Third-generation cephalosporin use was the highest (708;60%), followed by macrolide (481;40%), and the majority (853;78%) who took antibiotics were SARS-CoV-2 negative. On admission, 77% mild and 94% moderately ill patients received antibiotics. Before admission, 3% patients had two antibiotics, and on admission, 27% received two to four classes of antibiotics at the same time. According to WHO AWaRe classification, the Watch group antibiotics were mostly used before (43%) as well as on admission (80%). Reserve group antibiotic particularly linezolid was used in 1% patients includes mild cases on admission. Antibiotic use on admission was higher among severely ill patients (AOR = 11.7;95%CI:4.5–30.1) and those who received antibiotics within 24 h before hospital admission (AOR = 1.6;95%CI:1.0–2.5).

Antimicrobials used among suspected COVID-19 patients and SARS-CoV-2 positive and negative patients 24 h before and on hospital admission at 12 selected hospitals in Bangladesh, March–August 2020

Antimicrobials used on admission among suspected COVID-19 patients according to disease severity at 12 selected hospitals in Bangladesh, March–August 2020

Conclusion
Antimicrobial use was highly prevalent among suspected COVID-19 in-patients in Bangladesh. Initiating treatment with Watch group antibiotics like third-generation cephalosporin and azithromycin among mild to moderately ill patients were common. Promoting antimicrobial stewardship with monitoring is essential to prevent blanket antibiotic use, thereby mitigating antimicrobial resistance.

Disclosures
All Authors: No reported disclosures
154. Antibiotic Use During Three Separate Waves of the COVID-19 Pandemic at a Large Academic Medical Center in Detroit, MI
Authors: Sivakumar Deepika , Herbin Shelbye R , Yost Raymond , Scipione Marco R 
Published: December 2021

Abstract

Background
Inpatient antibiotic use early on in the COVID-19 pandemic may have increased due to the inability to distinguish between bacterial and COVID-19 pneumonia. The purpose of this study was to determine the impact of COVID-19 on antimicrobial usage during three separate waves of the COVID-19 pandemic.

Methods
We conducted a retrospective review of patients admitted to Detroit Medical Center between 3/10/19 to 4/24/21. Median days of therapy per 1000 adjusted patient days (DOT/1000 pt days) was evaluated for all administered antibiotics included in our pneumonia guidelines during 4 separate time periods: pre-COVID (3/3/19-4/27/19); 1st wave (3/8/20-5/2/20); 2nd wave (12/6/21-1/30/21); and 3rd wave (3/7/21-4/24/21). Antibiotics included in our pneumonia guidelines include: amoxicillin, azithromycin, aztreonam, ceftriaxone, cefepime, ciprofloxacin, doxycycline, linezolid, meropenem, moxifloxacin, piperacillin-tazobactam, tobramycin, and vancomycin. The percent change in antibiotic use between the separate time periods was also evaluated.

Results
An increase in antibiotics was seen during the 1st wave compared to the pre-COVID period (2639 [IQR 2339-3439] DOT/1000 pt days vs. 2432 [IQR 2291-2499] DOT/1000 pt days, p=0.08). This corresponded to an increase of 8.5% during the 1st wave. This increase did not persist during the 2nd and 3rd waves of the pandemic, and the use decreased by 8% and 16%, respectively, compared to the pre-COVID period. There was an increased use of ceftriaxone (+6.5%, p=0.23), doxycycline (+46%, p=0.13), linezolid (+61%, p=0.014), cefepime (+50%, p=0.001), and meropenem (+29%, p=0.25) during the 1st wave compared to the pre-COVID period. Linezolid (+39%, p=0.013), cefepime (+47%, p=0.08) and tobramycin (+47%, p=0.05) use remained high during the 3rd wave compared to the pre-COVID period, but the use was lower when compared to the 1st and 2nd waves.
Figure 1. Antibiotic Use 01/2019 to 04/2019

Conclusion
Antibiotics used to treat bacterial pneumonia during the 1st wave of the pandemic increased and there was a shift to broader spectrum agents during that period. The increased use was not sustained during the 2nd and 3rd waves of the pandemic, possibly due to the increased awareness of the differences between patients who present with COVID-19 pneumonia and bacterial pneumonia.

Disclosures
All Authors: No reported disclosures