bluuebunny/crossref_metadata_2025_split huggingface dataset:
63. Impact of Infectious Disease Fellow-Driven Antimicrobial Stewardship Interventions on Inpatient Fluoroquinolone Use
Authors: Nunez Carlos M , Mattappallil Arun , McCrink Katie A , Rybak Debbie , Taha Basil , Chew Debra 
Published: December 2021

Abstract

Background
Fluoroquinolone (FQ) antibiotics are frequently used in hospitalized patients to treat a wide range of infections but are often misused and implicated in antibiotic-associated adverse events. The purpose of this study is to evaluate the impact of Infectious Disease fellow (IDF)-driven antimicrobial stewardship program (ASP) interventions on inpatient FQ use.

Methods
This is a retrospective study of all admitted patients who received a FQ for greater than 48 hours from 01/01/2019 -12/31/2020 in an urban academic center. “Phase 1” (pre-intervention phase) covered 01/1/2019- 03/31/2019. “Phase 2” (intervention phase) covered 03/03/2020- 12/23/2020. In “Phase 2”, our ASP reviewed FQ use 2-3 days per week and an IDF provided feedback interventions that averaged 30-60 minutes of IDF time spent per day. We categorized FQ use as either: “appropriate”, “appropriate but not preferred”, or “inappropriate”, as determined by local clinical guidelines and ASP team opinion. We compared FQ use in both phases, indications for FQ use, and new Clostridioides difficile infections (CDI).

Results
A total of 386 patients are included (76 in “Phase 1”and 310 in “Phase 2”). Patient characteristics are similar (Table 1). Overall, 63 % of FQ use was empiric, and 50% FQ use was deemed “appropriate”, 28% “appropriate but not preferred”, and 22% “inappropriate”. In “Phase 2”, 126 interventions were conducted, with 86% of these accepted. Appropriate FQ use increased significantly in “Phase 2” vs. “Phase 1” (53.5% vs 35.5%, p = 0.008), with decrease in mean days of FQ use (4.38 days vs 5.87 days, p =.021). Table 2 shows “appropriate” FQ use by clinical indication. New CDIs occurred more in “Phase 1” vs. “Phase 2” (6.6% vs 0.6%, p=.001).

Conclusion
An IDF-driven ASP intervention has a positive impact on appropriate inpatient use of FQs in our hospital. This highlights a promising ASP model which not only improves appropriate use of FQ, but also offers an opportunity for IDF mentorship and use of available resources to promote ASPs.

Disclosures
Katie A. McCrink, PharmD, ViiV Healthcare (Employee)
64. Absolute Monocyte Count (AMC) as Early and Safe Marker for Discharge in Low-risk Pediatric Febrile Neutropenia with Cancer
Authors: Alali Muayad , Bartlett Allison , Danziger-Isakov Lara , Danziger-Isakov Lara 
Published: December 2021

Abstract

Background
Fever with neutropenia (FN) is common and the timing of antibiotic cessation in patients without an identified fever source is uncertain. Absolute neutrophile count (ANC) recovery has been used clinically to represent bone marrow recovery (BMR) but other options should be considered. We hypothesized that absolute monocyte count (AMC), and absolute phagocyte count (APC) are more sensitive, and an earlier safe marker of antibiotic cessation (AC) compared with ANC

Methods
A retrospective review was performed for FN episodes (FNEs) at UCM Comer Children’s Hospital between 2009 and 2016 in pediatric oncology patients. Eligible FNEs who were a febrile for 24 hours, had no bacterial source identified at time of AC, and did not receive chemotherapy 10 days following AC. Ten-day post-AC outcomes, length of stay and cost were assessed and compared among different BMR parameters (ANC vs AMC).

Results
A total of 928 FN episodes (FNEs) were identified. 391 eligible FNEs occurred in 235 patients. Three groups were compared based on ANC (cells/μL) at the time of AC : &lt; 200 in 102 (26%), 200-500 in 111 (28%), and &gt;500 /uL in 178 (46%) (Figure1) with an overall ten-day recurrent fever rate 7.4% (29/391) and readmission rate of 5.6% (22/391). No significant differences in recurrent fever rates were identified among 3 ANC groups (11.7%, 6.3% and 5.6% respectively, P=0.08) and readmission (10%,4.5%, 4%, respectively; P=0.07)(Table 1).In subset analysis of AMC for each ANC group, patients with AMC &gt;100 at AC have favorable outcomes, regardless ANC threshold (P&lt; 0.01) (Table 1). Median of length of stay of FN was 3 days shorter using AMC &gt;100/uL for BMR compared with any threshold of ANC (P&lt; 0.01) and decrease overall FN cost stay (P&lt; 0.01) (Table 2). Similar analysis show APC &gt;300/uL at time of AC has favourable outcomes and decrease LOS regardless ANC threshold (data not shown here).

Conclusion
Our results suggest that a AMC &gt; 100 /uL regardless of ANC/uL, is a safe threshold value for empiric AC and discharge. This approach may shorten length of stay, reduce burden of cost of febrile neutropenia cost and potential long term antibiotics side effects.

Disclosures
Lara Danziger-Isakov, MD, MPH, Ansun (Individual(s) Involved: Self): Scientific Research Study Investigator; Astellas (Individual(s) Involved: Self): Scientific Research Study Investigator; Merck (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Pfizer (Individual(s) Involved: Self): Scientific Research Study Investigator; Shire (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Viracor: Grant/Research Support
65. Impact of an Antibiotic Side-Chain-Based Cross-Reactivity Chart on Antibiotic Use in Patients With β-lactam Allergies and Pneumonia
Authors: Collins Curtis D , West Nina , Shankar Tara , Leo Harvey L , Bookal Renee 
Published: December 2021

Abstract

Background
β-lactam antibiotics with dissimilar R-group side chains are associated with low cross-reactivity. Despite this, patients with β-lactam allergies are too often treated with alternative antibiotic therapy. An institutional β-lactam side-chain-based cross-reactivity chart was developed and implemented to guide in antibiotic selection for β-lactam allergies patients.

Methods
This single center, retrospective, cohort study analyzed the impact of the implementation of the cross-reactivity chart for patients with documented β-lactam allergies with pneumonia. Study time periods were defined as January 2013 to October 2014 prior to implementation of the chart (historical cohort) and January 2017 to October 2018 (intervention cohort) following institutional implementation and adoption. The primary outcome was the incidence of β-lactam utilization between time periods. Propensity-weighted scoring and interrupted time-series analyses compared outcomes across time periods.

Results
A total of 341 and 623 patient encounters were included in the historical and intervention cohorts, respectively. There was a significant increase in the use of β-lactams for treatment of pneumonia (70.4% vs 89.3%; p &lt; 0.001) and the use of any alternative therapy decreased between cohorts (58.1% vs. 36%; p &lt; 0.001) (Figure 1). β-lactam use per patient significantly improved between cohorts in patients with mild, Type 1 IgE-mediated hypersensitivity reactions (HSRs) and in patients with unknown reactions. There was no difference in overall HSRs between cohorts (2.4% vs. 1.45; p = 0.628), or in patients who received β-lactam antibiotics (1.3% historical group vs 1.1% intervention group; p = 0.467). Median alternative antibiotic days of therapy (3 vs. 2; p = 0.027) and duration of therapy per patient (3 days vs. 2 days; p = 0.023) decreased between cohorts. There was a significant increase in mortality while healthcare facility-onset Clostridioides difficile infections decreased between cohorts.
β-Lactam vs. Alternative Therapy Use per Patients by Calendar Quarter

Conclusion
Implementation of a β-lactam side-chain-based cross-reactivity chart significantly increased the utilization of β-lactams in patients with pneumonia without increasing HSRs.

Disclosures
All Authors: No reported disclosures
66. Improving Antimicrobial Stewardship through Allergy Testing Referrals
Authors: Smith Clarissa , Poplin Victoria , Barry Brogan , Mason Mathew J , Gregory Eric , Clough Lisa A , Gierer Selina , Newman Adelyn R 
Published: December 2021

Abstract

Background
Penicillins and cephalosporins (PCN/CEPH) are considered first-line antibiotics for numerous infections for their efficacy, tolerability, and cost effectiveness. Unfortunately, their use may be precluded in approximately 10% of the general adult population who self-report ‘allergy’. As a result, suboptimal antimicrobials are substituted which may increase toxicities, length of hospitalizations, and antimicrobial resistance with subsequent expense and morbidity. Multiple organizations endorse beta-lactam allergy skin testing (BLAST) as an essential component of antimicrobial stewardship programs..In an attempt to better describe this patient population as well as to protocolize and improve rates of referral to allergy/immunology clinic, a quality initiative was undertaken at our institution.

Methods
Adult inpatients for whom an infectious disease consult was placed over a 6-month period were chart-reviewed for PCN/CEPH allergy. Inappropriately charted allergies were reconciled and patients were recommended referral to allergy/immunology for formal evaluation with BLAST when appropriate. Referrals were placed for agreeable patients who were then evaluated for appropriateness through history and then scheduled for BLAST. Patients who tolerated oral exposures without adverse effects had the allergy removed from their chart and were educated.

Results
322 patients met inclusion criteria for allergy referral. Of those, 103 agreed to further evaluation, and referrals were placed for 100%. Unfortunately, 7 patients died before referrals could be completed, and 88 referred patients did not complete BLAST for other reasons. In total 8 patients completed BLAST, and allergy was de-labeled in 75% (N= 6) of those cases.

Conclusion
Our data indicated similar prevalence of reported PCN/CEPH allergy between our institution and the general population. We achieved our aim of improving allergy referral rates among this population, however there was a high rate of attrition in the transitions of care. Qualitative review of selected patients highlights common thematic barriers including the COVID-19 pandemic, fiscal concerns, and acuity of condition. Future directions should include BLAST at the point of care or making referrals from the primary care setting.

Disclosures
Lisa A. Clough, MD, Merck (Scientific Research Study Investigator)Merck (Research Grant or Support)ViiV (Scientific Research Study Investigator)
67. Transitioning from Permissive to Restrictive Urine Reflex Criteria: Compiling the Data
Authors: Nix Chad D , Villamagna Angela H 
Published: December 2021

Abstract

Background
Reflex urine cultures (UCx) are a diagnostic stewardship practice that limit the progression of UCx to specimens that meet pre-defined urinalysis criteria, but there is no widely recommended threshold for culture. At our institution, urinalyses (UAs) are reflexed to UCx for positive nitrites, leukocyte esterase, presence of bacteria, or ≥5 white blood cells per high powered field (WBC/hpf). Our aim is to assess if a more restrictive criteria of &gt;10 WBC/hpf would result in missed UTI diagnoses.

Methods
We performed a retrospective chart review of a systematic sampling of urine specimens collected from July 2018 to June 2019 in the emergency department and adult inpatient units. Inclusion criteria were UA with a WBC/hpf of 5-10 – samples that would not reflex to culture under our proposed criteria – and a UCx. We recorded signs, symptoms and antibiotic use via chart review. Positive UCxs were defined as ≥10e5 CFU/mL of bacterial growth (BG) and these cases were assessed using standardized CDC UTI definitions.

Results
486 urine specimens with &lt; 10e5 CFU/mL BG and 96 with ≥10e5 CFU/mL BG met inclusion criteria. Chart review was performed on 99 cases. 81 (82%) specimens had negative UCxs and 18 (18%) were positive. 45% had documented localizing UTI symptoms. 26% of all urine studies were sent for an indication of fever, 15% for altered mental status (AMS), and 8% for malaise. Among the 18 patients with positive UCxs, 11 (61%) met UTI criteria. Among the 81 patients with negative UCxs, 33/81 (41%) had a local symptom compatible with UTI. 7/81 (9%) patients had positive tests from other body sites; all 7 of these UCxs were sent for a new or worsening fever.

Conclusion
Of the 99 UCxs reviewed, less than half had a urinary symptom consistent with UTI, and almost half of studies were sent for non-specific indications such as fever, which suggests reflex UCxs are overutilized at our institution. However, our data demonstrate that a more restrictive UCx criteria may not be the solution, as at least 11 clinically significant UTIs would have been missed under the new criteria. We recommend improved clinical decision support tools and more data to validate restrictive reflex UCx criteria before their implementation.

Disclosures
All Authors: No reported disclosures
69. Implementation of a Pharmacist-Driven Blood Culture Communication Process in a Non-Profit Community Hospital
Authors: Thumann Alexis , Williams Jennifer , Bernabe Megan , Hankewich Jillien 
Published: December 2021

Abstract

Background
Rapid diagnostic testing allows for faster identification of culture results and quicker time to targeted antimicrobial therapy. For this to be effective, however, the clinician needs to understand its capabilities and limitations. Pharmacists are well-positioned to assist providers in interpreting rapid diagnostic test results and in the selection of optimal antimicrobial therapy. This study aims to determine if implementing a process in which pharmacists communicate positive blood culture and rapid diagnostic test results improves time to optimal antimicrobial therapy in a community-based hospital.

Methods
In November 2020, Mercy Medical Center implemented a new process in which positive blood culture and rapid diagnostic test results are communicated to a pharmacist instead of a nurse on the patient care unit. The pharmacist is responsible for interpreting the results, assessing patient information, and providing the culture results along with drug therapy recommendations to the appropriate licensed independent practitioner. This study was a single-center, pre-post, quasi-experimental study (Pre: November 2019-March 2020; Post: November 2020-March 2021). The electronic medical record was used to identify admitted patients 18 years and older with positive blood cultures in which treatment was provided. Time from culture positivity to optimal antimicrobial therapy was collected and compared pre-post intervention. Secondary outcomes included hospital length of stay and mortality.

Results
A total of 480 patients were identified during the study period, of which 247 met inclusion criteria (n = 125 in 2019-2020; n = 122 in 2020-2021) with comparable baseline characteristics. There was no statistical difference in time to appropriate therapy between the groups (p = 0.796). Time to optimal therapy was 6.12 hours shorter in the post-intervention cohort (p = 0.0492). No difference was found for both secondary outcomes of hospital length of stay and inpatient mortality (p = 0.2958, p = 0.096, respectively).

Conclusion
A pharmacist-led blood culture communication process improved the care of hospitalized patients in a non-academic, community-based hospital by shortening time to optimal antimicrobial therapy.

Disclosures
All Authors: No reported disclosures
71. Diagnostic Stewardship of Clostridioides difficile Testing
Authors: Qamar Zahra , Spacek Lisa A , Coppock Dagan , Patel Kaya , L’Etoile Nathan , Huang Jingwen , Arya Akanksha , Flomenberg Phyllis 
Published: December 2021

Abstract

Background
C. difficile (CD) testing is frequently ordered inappropriately. Highly sensitive polymerase chain reaction (PCR) tests can detect CD colonization leading to misdiagnosis. Providers often overlook other causes of diarrhea, notably laxatives. To improve diagnostic stewardship, our hospital introduced an electronic medical record (EMR)-based order set (OS).

Methods
In a 926-bed, teaching hospital, we conducted a 3-step intervention to improve CD diagnostic stewardship. (1) A retrospective analysis of CD orders before and after OS implementation was done to assess its impact on inappropriate orders. The OS included two questions: (a) Did patient have ≥ 3 loose bowel movements in past 24 hours? and (b) No laxatives in past 24 hours? An appropriate order was defined if “yes” to both questions. It was still appropriate if “no” to either question but ≥ 2 unexplained following features: fever &gt; 100.4 F, abdominal pain, megacolon, ileus or leukocytosis &gt; 11,000 cells/mm3 in prior day. (2) After implementation of OS, house staff compliance with OS was surveyed via email. (3) Rationale for inappropriate orders was discussed with providers.

Results
Of 238 patients in retrospective analysis, 44% were ≥ 65 years and 37% had other potential causes of diarrhea. Common clinical features were leukocytosis (40%) and fever (31%). There was no significant difference in inappropriate testing: pre-OS 27/99 (27%) vs post-OS 44/139 (32%) (p=0.47). Of 43 house officers who participated in the survey, 75% indicated they over rode the OS. When asked to provide rationale of inappropriate CD testing, providers acknowledged inappropriate ordering but did not want to miss a CD diagnosis and frequently overlooked other causes of diarrhea.

Conclusion
Appropriate CD testing relies on providers’ appreciation of a clinical picture consistent with CD infection, confirmation of clinically significant diarrhea, and consideration of other causes of diarrhea. Providers order inappropriate tests, not due to lack of knowledge, but likely fear of missing diagnosis and overlooking other causes of diarrhea.

Disclosures
All Authors: No reported disclosures
74. Evaluation of the Differences in Appropriateness of BioFire® FilmArray® Gastrointestinal Panel Testing between Emergency Department and Inpatient Services
Authors: Weichman Brittani , Bushman Amanda , Rosa Rossana M 
Published: December 2021

Abstract

Background
Use of rapid molecular diagnostic panels in the evaluation of diarrhea provides increased sensitivity for organism identification and decreased time to results. However, their inappropriate use can lead to unnecessary expenditures and antimicrobial exposures. We aimed to characterize the appropriateness of testing using the BioFire® FilmArray® Gastrointestinal Panel (SFA) in different clinical settings and to describe the impact of SFA results on patient care.

Methods
Retrospective study of adult patients presenting to hospitals part of an integrated health system in Des Moines, Iowa, between July 30 and September 30, 2019, and who had a SFA ordered and collected in the Emergency Department (ED) or an inpatient service. The appropriateness of SFA testing was determined according to adherence to a local algorithm available through the hospital’s intranet (Figure 1). Reason for testing, appropriateness of SFA test, molecular targets identified, and antibiotic exposures were collected.

Results
We identified 257 patients, 111 (43.2%) who had SFA done in the ED and 146 (56.8%) as inpatients. Testing was deemed inappropriate in 46 (41.4%) of ED patients compared to 100 (68.5%) of inpatients (p&lt; 0.0001). Documented indications for SFA are presented in Table 1. Among ED patients testing was most frequently considered inappropriate due to absence of diarrhea on the day of test collection (41.3%), and among inpatients due to the use of SFA for assessment of hospital-onset diarrhea (47.0%) (Table 2). Overall, there were 94 (36.6%) positive SFA (Figure 2). Among ED patients, the percentage of positive SFA samples was 30.4% and 50.8% for inappropriate and appropriate testing respectively (p=0.03), while for inpatients it was 33.0% for inappropriate orders and 30.4% for appropriate orders (p=0.76). Antibiotics were prescribed to 28.2% and 28.1% of patients tested in the ED and inpatient service respectively.

Conclusion
High proportions of inappropriate SFA testing were identified both in the ED and inpatient services, with distinct issues in each site. Characterization of the reasons underlying inappropriate use of SFA can aid in the design of diagnostic stewardship interventions tailored to each clinical setting.

Disclosures
All Authors: No reported disclosures
75. Utility of Fungal Blood Cultures in Portland, Oregon
Authors: Govindan Sujeet , Strnad Luke 
Published: December 2021

Abstract

Background
Fungal blood cultures (fungal isolators) should be used, if at all, primarily for identification of mold infections. At our institution we noted patients having fungal blood cultures drawn in many other situations, including when the primary team was concerned for candida bloodstream infection. We sought to describe the utility of this practice and of fungal blood cultures in general.

Methods
We retrospectively reviewed the results of fungal blood cultures for 2 years, from 3/1/2019-3/1/2021. We evaluated the number of episodes, culture results, whether there was a had prior bloodstream infection, and risk factors for fungal infection including renal replacement (RRT), ECMO, and immunosuppression (IS). Immunosuppression was defined as chronic systemic steroid use, recent receipt of high dose steroids within 2 weeks, history of organ transplantation, history of stem cell transplantation, hematologic malignancies, or receipt of a biologic agent.

Results
187 fungal blood cultures were drawn in 143 patients - 80 cultures in 70 patients from 3/2019-3/2020 and 107 cultures in 73 patients from 3/2020-3/2021. Only 3 patients had positive fungal blood cultures:1 (Candida krusei) from 3/2019-3/2020 and 2 (Candida albicans and Cyrptococcus neoformans) from 3/2020-3/2021; in all 3 cases the organism also grew from standard blood culture isolators. From 3/2019-3/2020, 1/80 cultures were drawn from an individual on ECMO while 15/80 were drawn from individuals on RRT, and 32/80 were in a IS individuals. From 3/2020-3/2021, 45/107 cultures were drawn from an individual on ECMO, 24/107 were drawn in an individual on RRT, and 73/107 were drawn in a IS individuals. The majority of individuals in whom a fungal blood culture was drawn during 3/2020-3/2021 were individuals with COVID-19. Upon chart review most of the cultures were drawn due to concern for candidemia.

Results of fungal blood cultures drawn from 3/2019-3/2021 at OHSU

Conclusion
Fungal blood cultures have an extremely low yield at our institution, with a 1.6% positivity rate over a 2 year period, and all of those cultures were detected by standard blood culture isolators. Most of these cultures were drawn in situations where this test has no utility. Furthermore, the test has limited utility to detect dimorphic and mold bloodstream infections. Restriction of this test may limit inappropriate use.

Disclosures
All Authors: No reported disclosures