bluuebunny/crossref_metadata_2025_split huggingface dataset:
52. Direct Communication Improves Response Time to Acceptance of Antimicrobial Stewardship Interventions
Authors: Shafi Humaira , Donoghue Stephen G , Seah Jonathan , Yong Pu En Ow , Lee Wee Boon 
Published: December 2021

Abstract

Background
Hospital antimicrobial stewardship program (ASP) reviews broad-spectrum antibiotics and recommends interventions to optimise antimicrobial use. However, about 30% of interventions are not accepted. This project aims to improve the response rate and time for acceptance of ASP interventions by direct communication with providers (via call or text messaging) once an intervention was made.

Methods
Pre-direct communication (PC) phase lasted from 1st Jan - 31st Dec 2017. A typed intervention was placed into the patient’s medical records for the team to review. Thereafter, a direct communication (DC) phase ran from 1st Jan 2018 - 31st Jan 2019. Teams were immediately notified of any ASP interventions made via a call or text message, in addition to the document placed in the medical records. Specialty, acceptance rates, type of intervention and time to acceptance was recorded. Overall acceptance was counted if team followed the ASP recommendations within 48 hours.

Results
A total of 621 interventions were made over the 25-month period (PC n=334, DC n=287). We found that direct communications did not improve the overall acceptance rates (PC 66% vs. DC 65%, p=0.791), but significantly improved same day acceptance rates (PC 15% [49/334] vs. DC 33% [96/287], p&lt; 0.001). This trend for higher same-day acceptance was also noted regardless of specialty. It increased from 15% to 45% (p&lt; 0.001) for medicine & 15% to 25% (p=0.025) for surgery. Furthermore, overall acceptance for medical discipline was significantly higher in the DC phase (68% to 80%, p=0.024); no significant difference noted for the surgical disciplines. Same-day acceptance also improved when we compared the most common types of interventions (culture based de-escalation, discontinue antibiotic, narrow empirical coverage). In addition, DC helped narrow empiric antibiotic choices, with improvements in both same-day and overall acceptance of interventions (increased from 8% to 43%, p&lt; 0.001 and 57% to 78%, p=0.12, respectively).

Conclusion
Direct communication with clinicians boosted same-day acceptance for ASP interventions. In addition, it increased overall acceptance for medical disciplines, and to narrow empiric antibiotic use. Future efforts will focus on in-person strategy with surgical teams for fruitful results.

Disclosures
All Authors: No reported disclosures
53. Optimizing Transitions of Care Antimicrobial Prescribing at a Community Teaching Hospital
Authors: Naik Kushal , Frens Jeremy J , Smith Jordan R 
Published: December 2021

Abstract

Background
Antimicrobial stewardship integral to patient care. Institutions with stewardship decrease antibiotic use, cost, and antibiotic-associated infections. However, few efforts have been formally made to address discharge antimicrobial prescribing, even though many patients started on antibiotic therapy in the hospital are prescribed oral antibiotics to complete their regimens.

Methods
This was an IRB approved, quasi-experimental, pre-post study. Patients were included if they were &gt;18 years and were discharged from the hospital with an oral antibiotic prescription. Patients discharged against medical advice, prescribed indefinite prophylactic antimicrobial therapy for legitimate reasons, or discharged to a skilled nursing facility were excluded. The retrospective group evaluated a random sample of patients discharged in 2/2020. The prospective group included patients discharged between 1/2021 – 6/2021. In the prospective group, a clinical pharmacist assessed the indication for antibiotics and pended discharge antibiotic prescriptions for physician review. Antibiotic choice and duration of therapy were based on local and national guidelines.
Patient Screening for Inclusion and Exclusion

Breakdown of patients screened, included, and excluded for study

Results
86 (53.1%) of 162 retrospective patients from 2/2020 prior to implementation of the program demonstrated were discharged on inappropriate antimicrobial therapy with excessive duration being the principal driver for inappropriateness. In the prospective group of 64 patients, the rate of patients discharged on inappropriate antibiotics decreased to 28.1% (p=0.001). The duration of inappropriate therapy decreased from a mean of 4.6 days to 2.7 days (p=0.001). 45 (70.3%) of 64 prospective pharmacist’s interventions were accepted by providers.
Study Outcomes

Outcomes including overall appropriate prescribing, appropriate duration, spectrum, frequency, and dose, as well as days of inappropriate therapy

Conclusion
Literature demonstrates that prospective evaluation of discharge antibiotics by a clinical pharmacist is effective in improving appropriateness of discharge antibiotic prescriptions, optimizing duration of outpatient antibiotics as well as reducing unnecessarily broad-spectrum therapy. The prospective results from this study demonstrate that this innovative approach can improve outpatient oral antibiotic prescribing and provide a framework for other institutions to implement similar programs.

Disclosures
All Authors: No reported disclosures
54. The Effect of Targeting High-Risk Patients for Antimicrobial Stewardship Intervention on Hospital-Onset Clostridioides Difficile Infection Rates
Authors: Yang Albert , Donnelley Monica 
Published: December 2021

Abstract

Background
Clostridioides difficile infection contributes to significant burden on patients and the healthcare system, costing billions in excess costs every year for hospital care. Continued use of antibiotics after C. difficile infection diagnosis is a risk factor for recurrent infection. Also, individuals who have had a recurrence of C. difficile infection are at a higher risk of subsequent episodes.

Methods
This prospective, observational, pre-post study evaluated the effect of implementing a targeted antimicrobial stewardship initiative towards a high-risk target population on the rate of in-hospital C. difficile infection rates. High-risk targets were identified through an electronic health system report of admitted patients at a large academic medical center who were toxin assay positive or had a documented history of C. difficile infection. Subjects who met the criteria were assessed for interventions by the pharmacy-driven antimicrobial stewardship service. The primary outcome compared the hospital-onset C. difficile rates and standardized infection ratio (SIR) before and after implementation of the initiative. The SIR is reported to the National Healthcare Safety Network (NHSN) and is calculated as a ratio between the number of observed and predicted infections, which is adjusted for facility-specific factors that contribute C. difficile risk. Negative binomial regression was used to calculate the predicted C. difficile infections in the SIR. Poisson regression was used to generate a 95% prediction interval for the predicted C. difficile infection rate.

Results
The mean age of subjects was 63 years old and 85% had no history of prior C. difficile infection. The most common intervention was de-escalation of antibiotics (46%). The post-implementation SIR was 0.55 and hospital-onset C. difficile rate was 13, both of which were significantly lower than predicted.

Conclusion
Targeting patients who have a history of or are newly diagnosed with C. difficile infection may decrease hospital-onset C. difficile rates.

Disclosures
All Authors: No reported disclosures
55. Impact of Testing Methodology and Reporting on Time to Preferred Antibiotic Therapy in Extended Spectrum Beta-Lactamase producing Enterobacteriaceae (ESBL-E) Bloodstream Infections
Authors: Bui Hanh , Tverdek Frank , Carnes Stephanie , Chan Jeannie D , Bryan Andrew , Bourassa Lori , Jain Rupali , Matsuda-Fong Brendon 
Published: December 2021

Abstract

Background
Harborview Medical Center (HMC) identifies organisms and an ESBL genotype (CTX-M) via Verigene® Gram-Negative Blood Culture Nucleic Acid Test (BC-GN). University of Washington-Montlake (UWML) uses matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) for organism identification directly from positive blood cultures and ceftriaxone results by Kirby Bauer disk diffusion (KB) are reported 18 hours later. No ESBL comment is reported at UWML. We aimed to determine whether the methodology in identification and reporting of ESBL-E from blood cultures between two hospitals has an impact on time to preferred therapy with a carbapenem antibiotic.

Methods
Retrospective observational study conducted at UWML and HMC in Seattle, WA between 1/10/2015 and 9/15/2020. Adult patients were eligible if they had ≥1 positive blood culture with an Enterobacteriaceae isolate resistant to ceftriaxone and were on antibiotic treatment. The primary outcome was the difference in time to preferred definitive therapy with a carbapenem antibiotic in patients an ESBL-E bloodstream infection (BSI) identified by Verigene® vs. MALDI-TOF MS/KB.

Results
A total of 199 patients were screened; 67 were included for UWML and 68 at HMC. The average time to initiation of a carbapenem antibiotic was 42 ±26.5 hours at UWML and 28 ±19.7 hours at HMC. A t-test detected a difference in time to preferred therapy between a Verigene® vs. MALDI-TOF MS/KB tested ESBL-E BSI [95% confidence interval (CI), 5.3-22.9]. The hazard ratio to carbapenem initiation for HMC is 1.73643 [95% CI, 1.1405-2.644].

Conclusion
A statistically significant difference in time to preferred definitive therapy among patients with an ESBL-E BSI processed by Verigene® was found compared to MALDI-TOF MS. The results suggest standardization in protocols between the UWML and HMC hospitals is warranted.

Disclosures
Andrew Bryan, MD, PhD, Shionogi Inc. (Grant/Research Support)
57. Financial Impact of a Regional Antimicrobial Stewardship Cost Saving Initiative in a Large Integrated Healthcare System
Authors: Nguyen Van , Taylor Colton , Christensen Alyssa , Footer Brent 
Published: December 2021

Abstract

Background
A regional antibiotic stewardship program (ASP) within a large integrated healthcare system covering two, non-academic, tertiary care medical centers and an additional six community hospitals implemented multiple interventions to optimize antimicrobial therapy and reduce unnecessary hospital costs, such as transition to extended-infusion (EI) piperacillin/tazobactam (TZP), formulary restriction of antimicrobials, and antimicrobial stewardship clinical review. The purpose of this study was to evaluate the cost savings associated with these regional ASP initiatives.

Methods
This was a multicenter, retrospective, observational review of regional stewardship interventions across eight inpatient medical centers in Oregon. Data was collected from January 2019 to December of 2020. Cost savings associated with reduced TZP administrations was based on the duration of therapy for each encounter in adults who received TZP for &gt;24 hours in 2020. The regional antimicrobial restriction policy was implemented in February 2020. Cost savings attributed to antimicrobial formulary restrictions and reduction in overall days of therapy/1000 patient days (DOT) were based on EPIC costs.

Results
The reduction in number of administrations with implementation of EI TZP resulted in &226,420 saved in 2020. &182,837 was saved due to decreased usage of restricted antimicrobial agents. An additional &433,341 was saved for overall antimicrobial costs due to 19,775 days reduction in overall DOT/1000 patient days.

Conclusion
A community-based regional ASP has resulted in substantial financial impact and identified areas for future cost savings within the region.

Disclosures
All Authors: No reported disclosures
58. Impact of Order-set Modifications and Provider Education on Broad-Spectrum Antibiotic Use in Patients Admitted with Community Acquired Pneumonia
Authors: Colmerauer Jessica L , Linder Kristin , Dempsey Casey J , Kuti Joseph L , Nicolau David P , Bilinskaya Anastasia 
Published: December 2021

Abstract

Background
Following updates to IDSA guidelines in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education.

Methods
This was a multi-center, quasi-experimental, retrospective study of patients with CAP from 9/1/19 to 10/31/19 (pre-intervention) and 9/1/20 to 10/31/20 (post-intervention). Patients were identified using ICD-10 codes indicating lower respiratory tract infection and excluded if had a positive SARS-COV-2 PCR during admission. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS).

Results
A total of 331 and 352 patients were included in the pre- and post-intervention groups, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period (p&lt; 0.001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs. [190/312] 60.9%; p = 0.003). There were no differences in order set usage (10% vs. 11.3%, p = 0.642) between the pre- and post-intervention groups, respectively. Hospital LOS was lower in the post-intervention cohort (4.8 days [2.9-7.2 days] vs. 5.3 days [IQR 3.5-8.5 days], p = .002).

Conclusion
Despite low utilization of the order-set, education surrounding order-set changes appeared to improve antibiotic prescribing and hospital LOS in our population. Further opportunities to improve order-set use and thus further increase guideline-concordant therapy are still available.

Disclosures
Joseph L. Kuti, PharmD, Allergan (Speaker’s Bureau)BioMérieux (Consultant, Research Grant or Support, Speaker’s Bureau)Contrafect (Scientific Research Study Investigator)GSK (Consultant)Merck (Research Grant or Support)Paratek (Speaker’s Bureau)Roche Diagnostics (Research Grant or Support)Shionogi (Research Grant or Support)Summit (Scientific Research Study Investigator) David P. Nicolau, PharmD, Abbvie, Cepheid, Merck, Paratek, Pfizer, Wockhardt, Shionogi, Tetraphase (Other Financial or Material Support, I have been a consultant, speakers bureau member, or have received research funding from the above listed companies.)
60. Penicillin Allergy Delabeling Program in the Post-acute Care Setting
Authors: Galipean Joseph , Jacob Jerry 
Published: December 2021

Abstract

Background
A significant proportion of inpatients labeled with penicillin allergies do not have a true IgE-mediated hypersensitivity, which may unnecessarily limit options for treatment of infection and lead to suboptimal antibiotic selection. Post-acute care settings may provide a unique opportunity to capture patients at risk for adverse outcomes related to penicillin allergy labels. The objective of the study was to assess the feasibility and impact of a penicillin delabeling program in an inpatient rehab setting.

Methods
We conducted a prospective observational study. Inpatients with penicillin allergies were identified weekly by manual review of electronic medical records. A clinical pharmacist reviewed each patient’s chart and identified patients for inclusion. Patients were excluded if they had a history of IgE-mediated hypersensitivity to penicillin within last 5 years, a history of a non-IgE mediated hypersensitivity, were severely immunocompromised, or were prescribed a contraindicated medication.

Results
A total of 72 charts were reviewed over nine months, and 37 (51.4%) had their penicillin allergy updated to reflect prior beta-lactam tolerance. Of the 72 patient that were evaluated, 28 (38.9%) were eligible for potential penicillin allergy delabeling, and 44 (61.1%) were ineligible. 59 (81.9%) of the patients had a moderate-high risk allergy, 12 (16.6%) had a low risk allergy, and 1 (1.4%) had an intolerance. Of the 28 eligible patients, 11 (39.3%) had their allergy removed, 13 (46.4%) deferred testing, and 4 (14.2%) could not be tested due to staffing. Of the 28 patients that had their allergy delabeled, 7 (21.4%) had their allergy removed by MAR review, 2 (7.2%) had a skin test with a negative result, and 2 (7.2%) had a direct oral challenge with a negative result.

Conclusion
A penicillin allergy delabeling program using a collaborative physician-pharmacist team model efficiently removed reported allergies in post-acute care patients. The post-acute care setting is an opportune environment to conduct a penicillin allergy delabeling program for patients not currently needing acute medical treatment.

Disclosures
All Authors: No reported disclosures
61. A Multidisciplinary Quality Improvement Initiative to Promote Penicillin Allergy Delabeling
Authors: Monday Lea , Michniak Jaclyn , Zoratti Edward , Weinmann Allison J 
Published: December 2021

Abstract

Background
Penicillin (PCN) allergies are reported in up to 10% patients and are associated with adverse clinical and antimicrobial stewardship outcomes. Here we describe a multidisciplinary quality improvement (QI) initiative to facilitate PCN delabeling at a large urban hospital.

Methods
Starting in August 2020, the departments of Allergy and Infectious Diseases (ID) began a joint QI effort to employ a part time allergist nurse practitioner (ANP) for PCN allergy assessment and delabeling. The ANP used a daily system generated list to identify and assess adult patients with PCN allergy and contact teams to request a consult. An ID fellow also assisted with identifying patients and contacting care teams. The ANP then offered skin/oral PCN challenge or direct label removal based on history after discussion with an allergist physician. Baseline, clinical, and allergy characteristics were compared between patients delabeled and not delabeled using Chi-square and Mann-Whitney U test. Primary endpoints were antibiotic utilization outcomes from index admission post ANP assessment to 30-days post discharge. Secondary endpoints included readmission, length of stay (LOS), mortality, and sustained removal of the PCN allergy at 30-days.

Results
Between 30 August 2020 and 6 May 2021 (250 days), 139 PCN allergic patients were assessed (81 delabeled versus 58 not delabeled) (Figure 2). Some patients (37%) were delabeled via history alone, while 63% had further skin/oral testing. Baseline characteristics were similar between groups (Table 1). In the delabeled group, we observed increased narrow-spectrum PCN use (p&lt; 0.001), and decreased vancomycin (p&lt; 0.001), fluoroquinolone (p=0.013), carbapenem (p&lt; 0.011), and overall restricted antimicrobial use (Table 2). Rates of 30-day readmission, LOS, and mortality were comparable. Four (5%) of delabeled patients had had PCN allergy re-entered in the chart at 30-days.

Patients were similar between groups on all baseline clinical and allergy characteristics except for more patients with infection classified as “other” in the non-delabeled group.

In the delabeled patients, we observed increased narrow-spectrum PCN use and decreased vancomycin, fluoroquinolone, carbapenem, and overall restricted antimicrobial use. Use of first and second generation cephalosporines was comparable between groups. Rates of 30-day readmission, LOS, and mortality were comparable.

Conclusion
This QI effort between the departments of Allergy and ID to employ an ANP increased narrow spectrum antibiotic use and reduced use of restricted antimicrobials. Challenges included the part time position of the ANP unable to see every patient, reemergence of allergy in the chart, and clinical or other exclusions for delabeling (Fig 3).

Disclosures
All Authors: No reported disclosures
62. Secondary Prophylaxis in Clostridioides difficile Infections: a Closer Look at Outcomes
Authors: Rodriguez Rubi , Mulugeta Surafel , Faison Darius , Kenney Rachel , Davis Susan L , Davis Susan L 
Published: December 2021

Abstract

Background
Clostridioides difficile infection (CDI) is an urgent public threat and carries a 25% chance of recurrence (rCDI). Data on safety and efficacy of oral vancomycin prophylaxis (OVP) in reducing rCDI is limited. We implemented a best practice advisory (BPA) to alert the prescriber and antibiotic stewardship (ASP) team for patients with CDI in the previous 60 days being initiated on systemic antimicrobials. The alert states “Don’t use antibiotics in patients with recent CDI without convincing evidence of need. Antibiotics pose a high risk of recurrence”. ASP team would recommended OVP if antibiotics are continued. This study evaluated the impact of the BPA alert on OVP prescribing and patient outcomes.

Methods
IRB approved, retrospective, observational cohort study comparing patients who received OVP to no OVP. Inclusion: adults with history of laboratory confirmed CDI, ≥ 14 days post-CDI treatment completion, BPA from 3/7/19 – 3/31/20, receiving non-CDI systemic antimicrobials, and without history of bezlotoxumab infusion. Data were reported using descriptive statistics and bivariate analysis. Primary endpoint: rCDI within 2-8 weeks post-OVP completion. Secondary endpoints: vancomycin-resistant Enterococcus spp (VRE) in clinical culture post-OVP and 1-year mortality.

Results
70 patients included: 32 (46%) no-OVP and 38 (54%) OVP. Baseline characteristics, previous CDI treatment, and outcomes were similar (Table 1). Index CDI was severe in the OVP group (18, 47% vs. 9, 28%). Median Charlson comorbidity index: 7 (3 – 9) no-OVP and 7 (5 – 9) OVP. OVP regimens, 125 mg by mouth: once daily 4 (10%), twice daily 22 (58%), and every 6 hours 12 (32%). Median prophylaxis duration: 10 days (6 – 13). rCDI occurred in 3 (9%) no-OVP and 2 (5%) OVP (P = 0.654). Mortality: 10 (31%) no-OVP and 16 (42%) OVP (P = 0.458).
Table 1. Patient Characteristics and Endpoints

Conclusion
OVP was utilized in approximately half of patients who required non-CDI antibiotics. Efficacy interpretation is limited by inconsistent dosing regimens and significant comorbid illness in the cohort. Future work will focus on further optimizing the BPA and standardizing the OVP regimen.

Disclosures
Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder) Susan L. Davis, PharmD, Nothing to disclose