bluuebunny/crossref_metadata_2025_split huggingface dataset:
86. Access to Antimicrobial Susceptibility Testing for Novel Gram-Negative Antibiotics
Authors: Lee Yuman , Kim Juliette , Bradley Nicole 
Published: December 2021

Abstract

Background
Antimicrobial susceptibility testing (AST) is critical in identifying the optimal antimicrobial regimen for individual patients with serious gram-negative infections. Limitations to AST for newly developed antibiotics include the lack of commercially available AST methods, challenges of implementation due to regulations, and delays in obtaining results. The purpose of this study was to evaluate the access to AST for cefiderocol (FDC), imipenem-relebactam (IPR), meropenem-vaborbactam (MEV), and eravacycline (ERV) in hospitals across the U.S.

Methods
An electronic survey was distributed to the American College of Clinical Pharmacist Infectious Diseases Practice and Research Network in May 2021. Hospital baseline demographics and current practices were collected.

Results
Based on 50 responses, specimens were sent to in-house microbiology labs (37, 74%), core microbiology labs (8, 16%), and 3rd party reference microbiology labs (5, 10%). AST for FDC was performed by 13 (35%) in-house labs, 4 (50%) core labs, and 1 (20%) reference lab. AST for IPR was performed by 11 (30%) in-house labs, 2 (25%) core labs, and 1 (20%) reference lab. AST for MEV was performed by 25 (68%) in-house labs, 3 (37.5%) core labs, and 1 (20%) reference lab. AST for ERV was performed by 1 (20%) in-house lab, 1 (20%) core lab, and 0 reference labs. 15 (30%) respondents were not able to get AST for any of the novel agents at their respective microbiology labs. Turn-around-times (TATs) for FDC, IPR, MEV, and ERV were ≥72 hours for 33 (66%), 35 (70%), 21 (42%), and 35 (70%) hospitals, respectively. When compared with 3rd party reference labs, in-house labs with the ability to perform AST for these novel agents had significantly shorter TATs (p&lt; 0.05). The average number of requests for AST for these novel agents was 20 times a year with an average of 113 minutes spent per patient on the coordination of AST.

Conclusion
Access to AST for these novel agents varied across hospitals in the U.S. Nearly 1/3 of the respondents were not able to obtain AST for these agents at all. Long TATs exist and a great deal of time is spent per patient for coordinating AST for these novel agents. There is a crucial need for a multidisciplinary, collaborative approach to resolve the challenges in obtaining AST for newly developed antibiotics to provide patient care.

Disclosures
All Authors: No reported disclosures
87. Effectiveness of a Best Practice Advisory in Reducing Inappropriate Urine Cultures
Authors: Cooper Margaret , Shihadeh Katherine C , Hussain Cory , Jenkins Timothy C 
Published: December 2021

Abstract

Background
Inappropriate urine cultures can contribute to overutilization of antibiotic treatment for asymptomatic bacteriuria. The objective of this study was to evaluate the appropriateness of urine cultures and the impact of a clinical decision support (CDS) intervention.

Methods
The CDS intervention involved embedding three questions in the urine culture order: whether the patient has fever, leukocytosis or urinary symptoms. When the answer to all three questions is no, a best practice advisory (BPA) alerts the provider that the patient may not meet criteria for a urine culture and suggests cancellation of the order. Cultures obtained in patients experiencing fever, leukocytosis, or urinary symptoms, and those who were pregnant, undergoing invasive urologic procedure, or &lt; 3 years old were classified as appropriate. We performed a quasi-experimental study assessing appropriateness of urine cultures before and after implementation of the BPA. The pre-intervention period was 5/9/19 to 7/31/20 and the intervention period was 2/3/21 to 4/27/21. Random samples of 100 cases from pre- and post-intervention were reviewed to assess appropriateness.

Results
There were 12,679 and 8,270 urine cultures performed pre-intervention and post-intervention, respectively. In 100 cases reviewed pre-intervention, 74% of the cultures were appropriate. Of these, 54% were ordered due to fever or leukocytosis, 50% due to urinary symptoms, and 12% in pregnant women.
Post-intervention, the BPA fired on 458 orders and 106 (23%) were subsequently discontinued. Of the 100 cases reviewed post-intervention, 5 orders were discontinued after the BPA fired. Of the remaining 95 cultures, 78% were appropriate. Of these, 41% were ordered for fever or leukocytosis, 69% for urinary symptoms, and 11% in pregnant women. The change in the proportion of appropriate cultures pre- and post-intervention was not statistically significant (74% vs 78%, respectively, p=0.906).

Conclusion
In nearly one quarter of urine cultures performed, there was not an appropriate indication. Our intervention led to cancellation of 23% urine culture orders and resulted in an absolute increase in 4% of the cultures being ordered appropriately. However, the change in appropriateness was not statistically significant.

Disclosures
All Authors: No reported disclosures
89. Follow-Up Blood Cultures (FUBC) in the Management of Gram-Negative Bacilli (GNB) Bloodstream Infections (BSIs): Frequently Obtained and Rarely Helpful
Authors: Robinson Evan D , Cox Heather , Mathers Amy J 
Published: December 2021

Abstract

Background
While GNB BSIs remain a major cause of morbidity and mortality, no clear guidelines exist on the utilization of FUBCs to guide management. Despite the recognition of persistent bacteremia as a risk factor for increased mortality, early studies suggested FUBCs were low yield in this setting, and thus had low utility. More recently, some controversy has arisen with multivariate analyses suggesting FUBC acquisition may be associated with lower mortality. We sought to characterize the utilization and yield of FUBCs for GNB BSIs at our institution.

Methods
We performed a retrospective review of 514 episodes of consecutive blood cultures from unique adult inpatients with GNB BSI between July 2017-July 2019. Exclusion criteria included prior positive culture, polymicrobial Gram stain, or discharge, death, or comfort measures only within 24 hours of Gram stain. FUBCs were defined as blood cultures collected between 24 hours to 7 days after the index blood culture. Baseline clinical and microbiologic characteristics were compared between groups, as well as clinical outcomes.

Results
Of 514 episodes, 338 (66%) had FUBCs performed, with a median of 2 FUBCs/episode. The majority of FUBCs (322/338; 95%) were negative, with 9 (3%) yielding the same organism and 9 (3%) yielding a different organism. Most initial FUBCs were obtained prior to index antimicrobial susceptibility results (227/338; 67%). Patients with FUBCs performed had a higher median Pitt bacteremia score (2 vs 1; p = 0.015) and were more likely to have hospital onset (36% vs 22%; p = 0.002), severe neutropenia (16% vs 4%; p &lt; 0.001) and a catheter-associated source (13% vs 4%; p = 0.001). 30-day mortality did not differ between patients with or without FUBCs (10% vs 11%; p = 0.84).

Conclusion
FUBCs were frequently obtained, but were of low yield even in comparison to recent similar studies. Though FUBCs were performed in more severe cases, a difference in mortality was not observed. Delaying the decision of whether to obtain FUBCs until after index antimicrobial susceptibility results are available would reduce unnecessary testing in most cases. Further study could better define where FUBCs after antimicrobial susceptibility testing would be most helpful.

Disclosures
All Authors: No reported disclosures
90. Deimplementation: Use of Electronic Clinical Decision Support to Reduce Unnecessary Erythrocyte Sedimentation Rate (ESR) Ordering
Authors: Fatemi Yasaman , Burns Julianne , Polsky Tracey , Nord Ellen , Coffin Susan 
Published: December 2021

Abstract

Background
In recent years, several de-implementation initiatives have focused on diagnostic testing. One such initiative, the Choosing Wisely campaign, recommends against routine use of erythrocyte sedimentation rate (ESR) for assessment of acute undiagnosed inflammation or infection. With the development of newer biomarkers of inflammation, particularly C-reactive protein (CRP), there is a decreasing role for ESR in screening for acute-onset conditions; however, ESR continues to be commonly ordered.

Methods
We examined ESR and CRP ordering practices at the Children’s Hospital of Philadelphia (CHOP) from July 2019 to July 2020 and found that 80% of ESR orders were placed concurrently with an order for CRP. We aimed to reduce ESR ordering by 20% at CHOP by using electronic clinical decision support in the form of embedded order guidance for ESR orders placed in the Emergency Department (ED) and inpatient setting. We examined the effect of the clinical decision support by assessing ESR ordering rate, defined by ESR orders per monthly patient days for the inpatient setting and ESR orders per monthly ED visits for the ED setting. We then examined differences in ordering rates using a quasi-experimental model with a concurrent control (basic metabolic panel).
ESR Electronic Clinical Decision Support Intervention

Inpatient and ED versions of the embedded electronic clinical decision support for ESR orders.

Results
Prior to implementation of the electronic decision support intervention, the median monthly rate of ESR orders was 13.6 per 1000 patient days and 70.3 per 1000 ED visits. During the initial month after implementation, we found that ESR ordering was 12.5 in inpatient and 46.4 in ED, reflecting decreased rates of ordering. The median monthly rate of basic metabolic panel orders (concurrent control) was 194.5 per 1000 patient days and 110.0 per 1000 ED visits. This was unchanged after intervention.

Conclusion
We conclude that electronic clinical decision support is a potentially effective deimplementation method for improving diagnostic test utilization, even with non-disease specific testing such as inflammatory markers. However, continued post-implementation data monitoring and analysis is needed to determine if this is a true difference and sustainable trend.

Disclosures
All Authors: No reported disclosures
95. Reduced Antibiotic Duration Defaults in Outpatient Automated Dispensing Cabinets Change Antibiotic Prescribing Habits in a Tertiary VA Healthcare System
Authors: Newman Nicholas J , Stiefel Usha , Wenzell Robert C , Papell Daniel , Cooney Jeffrey , Sims Sharanie , Shumaker Amy H , Akpoji Ukwen 
Published: December 2021

Abstract

Background
Ten percent of adult, outpatient visits result in an antibiotic prescription (Rx). At the start of our intervention, our VA healthcare system consisted of 13 community-based outpatient clinics (CBOCs), 9 of which did not have an onsite pharmacy but utilized automated dispensing cabinets (ADCs) for prepackaged outpatient Rxs. ADC antibiotic orders are generated from electronic medical record (EMR) order sets. The stewardship team shortened the durations of 5 antibiotics in the ADC order sets to make them consistent with current literature and guidelines. We assessed the impact of these changes on antibiotic prescribing habits.

Methods
We compared outpatient antibiotic Rx data between 10/1/2018-9/30/2019 (pre-intervention) and 10/1/19-9/30/20 (post-intervention) from 8 CBOCs with ADCs (1 closed during the pandemic). Amoxicillin-clavulanate 875/125mg (AMC), cephalexin 500mg (CPH), levofloxacin 500mg and 750mg (LEV 500 and LEV 750), and sulfamethoxazole-trimethoprim 800/160mg (SXT) prescription durations were all reduced by 3 days. Process metrics included days supplied/1000 prescriptions (DS/1000 Rx), median DS, and ADC utilization rates. We used Mann-Whitney U and correlation statistical analyses to assess differences and associations.

Results
The DS/1000 Rx of antibiotics with a default duration change decreased in the post-intervention phase for CBOCs with ADCs (AMC, -25.4%; CPH, -21.1%; LEV 500, -18.9%; LEV 750, -28.0%; SXT, -27.4%). The median DS for these antibiotics all reduced by 3 days in concordance with new ADC prescriptions defaults (AMC, 10 vs 7 days, P&lt; 0.001; CPH, 10 vs 7 days, P&lt; 0.001; LEV 500, 8 vs 5 days, P&lt; 0.001; LEV 750, 8 vs 5 days, P&lt; 0.001; SXT 10 vs 7 days, P&lt; 0.001). Due to COVID-19, 7/8 ADC CBOCs closed for in-person visits from 3/20/20-5/4/20. ADC utilization was inversely proportional to DS/1000 Rx for most antibiotics (R: -0.51 to -0.77) except SXT.

Conclusion
EMR-driven reductions in ADC default Rx durations led to a corresponding decrease in overall outpatient antibiotic prescribing. Higher DS/1000 Rx were often associated with lower ADC utilization. Informatics-driven antibiotic interventions may be potential outpatient stewardship tools to increase guideline-concordant prescribing across multisite healthcare systems.

Disclosures
Sharanie Sims, PharmD, AbbVie (formerly Allergan) (Speaker’s Bureau)
109. Develop and Implement a Novel Pediatric Antimicrobial Stewardship Program in a Non-Freestanding Children’s Hospital Located in an Adult-Centered Community Hospital in San Joaquin Valley, California
Authors: Lien Tsung-Chi , Covarrubias Laurie , Ip Alice , Husted Harlan , Suzuki Emi , Rongkavilit Chokechai 
Published: December 2021

Abstract

Background
A pediatric-specific antimicrobial stewardship program (Ped ASP) has been shown to optimize antimicrobial use, improve patient outcomes, and reduce healthcare expenditures in this population. Opportunities and challenges exist when developing a Ped ASP for a children’s hospital within an adult-centered medical center primarily due to mixed infrastructure. The objective of this study is to provide process and outcome data of a new Ped ASP in a non-freestanding children’s hospital within an adult-centered tertiary hospital.

Methods
A pediatric infectious disease physician and four pediatric pharmacists designed a Ped ASP utilizing direct and indirect patient care activities to optimize pediatric antimicrobial use in 21 bed-pediatric services within a 685-bed, adult-centered medical center. Implemented in 2020, Ped ASP activities include thrice weekly chart reviews followed by handshake rounds and quarterly reviews of documented interventions. The Ped ASP team also developed policies, education, and other resources to further guide appropriate antimicrobial use, in collaboration with the adult team.

Results
Ped ASP was initiated on general pediatric (PED) and pediatric intensive care (PICU) units. In 2020, a total of 286 charts were reviewed with 199 antibiotic interventions provided, including optimization of antimicrobial selection (23%), IV-to-PO conversion (15%), and antimicrobial dosage adjustment (13%). Annual average antibiotic length and days of therapy per 1000 patient-days were 241 and 290 respectively in PED, and 388 and 432 in PICU. The overall trend from 2020 to 2021 decreased in PED but increased in PICU (Fig. 1). The ratio of narrow to broad spectrum antibiotic use increased for both PED and PICU (Fig. 2). Simultaneously, a pediatric-specific antibiogram, extended-infusion protocol of beta-lactams, and neonatal sepsis treatment algorithm were developed and implemented.

Antibiotic Days of Therapy per 1000 Patient Days

Ratio of Narrow: Broad Spectrum Antibiotic Usage

Conclusion
A Ped ASP was successfully developed in a non-freestanding children’s hospital. Continual metrics served as an important tool to identify areas for improvement. Future goals include expansion of Ped ASP to other service lines, enhanced ASP education and development of additional pediatric antimicrobial treatment pathways.

Disclosures
All Authors: No reported disclosures
113. Improving Transitions-of-Care for Patients Discharged on High-Risk Antimicrobial Therapy
Authors: Zabrosky Ryan , Rubin Ellen C , Liu Erica , Brade Karrine , Serafin Hope , Sutton Spencer E 
Published: December 2021

Abstract

Background
Providing effective transitions-of-care (TOC) services improves outcomes for patients discharged on high-risk medications. Literature has shown that successful TOC for certain antimicrobials reduces hospital readmissions, medication errors, and improves post-discharge follow-up and laboratory monitoring. Prior to this quality improvement (QI) initiative, there was no formal TOC process for patients discharged on high-risk antimicrobial therapy (HAT) at our institution. Without standardization, only 55.1% of patients discharged on HAT had successful TOC. The aim of this initiative was to develop and implement a TOC protocol in at least 90% of patients discharged on HAT.

Methods
This QI initiative utilized the Institute of Healthcare Improvement model for improvement. A workgroup of key stakeholders developed a protocol to identify and standardize TOC services provided to patients discharged on HAT. Successful protocol completion was achieved if the following process metrics were evaluated, obtained, and documented prior to discharge: baseline laboratory values, pharmacokinetic monitoring, appropriate intravenous access, drug-drug interactions, medication availability, discharge medication counseling, and formal pharmacist documentation in a discharge note. Outcome metrics included referral to outpatient infectious disease (ID) follow-up, 90-day readmissions, and successful TOC. Balancing metrics included pharmacist time and protocol initiation for patients not discharged on HAT.

Results
Between October 2020 and May 2021, 218 patients met protocol inclusion criteria. Of these, 203/218 (93.1%) were appropriately identified with the new TOC process. The protocol was successfully followed in 78.9% of patients identified. Readmission rates were 42.8%, which was unchanged from baseline. Inpatient ID involvement increased from 80.9% to 95.7% and referral to outpatient ID follow-up from 59% to 94.8%.

Conclusion
This newly developed TOC protocol successfully identifies patients discharged on HAT, improves provision of TOC services to these high-risk patients, and significantly improves the rate of infectious disease involvement while inpatient and after discharge.

Disclosures
All Authors: No reported disclosures
115. Variable Use of Diagnostic Codes for Acute Respiratory Infections Across Emergency Departments and Urgent Care Clinics in an Integrated Healthcare System: Implications for Accuracy of Antibiotic Stewardship Metrics
Authors: Livorsi Daniel J , Nair Rajeshwari , Goto Michihiko , Perencevich Eli N 
Published: December 2021

Abstract

Background
Antibiotic stewardship initiatives can leverage metrics that make peer-peer comparisons. A commonly used metric measures how frequently a clinician prescribes antibiotics for acute respiratory infections (ARIs), as defined by diagnostic codes. However, it is unclear if clinicians differ in their use of ARI diagnostic codes. In this study, we evaluated differences in how frequently clinicians code for ARIs and factors that are associated with the use of ARI diagnostic codes in Emergency Department (ED) and Urgent Care (UC) visits across an integrated healthcare system.

Methods
We analyzed a retrospective cohort of all ED and UC patient-visits across 129 Veterans Affairs medical centers during 2016-2018. ARI visits were identified using ICD-10 codes for acute bronchitis, influenza, pharyngitis, sinusitis, and upper respiratory tract infections for clinicians with 100 or more visits. A generalized linear mixed model with a link logit function that accounted for clustering at the clinician and facility-level was used to calculate median odds ratios (OR) and to identify factors associated with increased likelihood of entering an ARI code.

Results
There were 6,016,499 patient-visits, and 519,389 (8.6%) were coded as an ARI (Table 1). The mean rate of ARI diagnoses across all visits was 8.9% (SD 2.5%) at the facility-level and 7.4% (SD 4.5%) at the clinician-level (Table 2). The median OR was 2.19 (95% CI 2.18, 2.22), suggesting there was between-clinician variation in coding for ARI diagnoses. Visits were significantly more likely to be coded as ARIs if seen by an advanced practice provider (OR=2.36, 95% CI 2.19, 2.54), if a fever was recorded (OR=4.20, 95% CI 4.18, 4.29), and if the visit occurred between December-March (OR=1.97, 95% CI 1.96, 1.98). Approximately 2/5th of the variability (41.4%) in assigning an ARI diagnostic code was explained by differences across individual clinicians.

Conclusion
There was substantial variability in how frequently ED and UC clinicians coded a visit as an ARI, and a large proportion of the variability was explained by differences across clinicians. Unmeasured factors could include different approaches to using diagnostic codes. ARI metrics based on diagnostic codes may need to account for differences in clinicians’ coding behavior.

Disclosures
All Authors: No reported disclosures
119. Performance of Infectious Diseases Specialists, Hospitalists, and Generalists in Case-Based Scenarios Illustrating Antimicrobial Stewardship Principles at 16 VA Medical Centers
Authors: Graber Christopher J , Simon Alissa , Zhang Yue , Goetz Matthew B , Goetz Matthew B , Jones Makoto M , Butler Jorie M , Chou Ann F , Glassman Peter A 
Published: December 2021

Abstract

Background
As part of a project to implement and evaluate antimicrobial dashboards at selected VA facilities nationwide, we assessed provider attitudes and knowledge related to antibiotic prescribing among physicians working in inpatient settings at 16 VA facilities.

Methods
The online survey explored attitudes toward antimicrobial use and assessed respondents’ management of four clinical scenarios: cellulitis, community-acquired pneumonia (CAP), non-catheter-associated asymptomatic bacteriuria (NC-ASB), and catheter-associated asymptomatic bacteriuria (C-ASB). Responses were scored by assigning +1 for an answer most consistent with guidelines, 0 for a less-guideline-concordant but acceptable answer and -1 for an incorrect answer. Scores were normalized to 100% correct to 100% incorrect across all questions within a scenario, and mean scores were calculated across respondents by specialty; differences in mean score per scenario were tested using ANOVA.

Results
One-hundred-thirty-nine physicians completed the survey (n=19 ID physicians, 62 hospitalists, 58 generalists). Attitudes were similar across the three specialties. There was a significant difference in cellulitis scenario scores (correct responses: ID=67.4%, hospitalists=51.2%, generalists=41.8% correct, p=0.0087). Scores were not significantly different across specialties for CAP (correct responses: ID 76.2%, hospitalists 63%, generalists 56.5%, p=0.0914) and NC-ASB (correct responses; ID 63%, hospitalists 55%, generalists 36.2%, p=0.322), though ID trended higher. Lowest scores were observed for C-ASB (ID 39.5% correct, hospitalists 4% incorrect, generalists 8.5% incorrect, p=0.12).

Conclusion
Significant differences in performance on management of cellulitis and low overall scores on C-ASB management point to these conditions as being potentially high-yield targets for antimicrobial stewardship interventions.

Disclosures
Matthew B. Goetz, MD, Nothing to disclose Peter A. Glassman, MBBS, US Pharmacopeia (formerly), PAG; Kaiser Permanente (current employee, spouse) (Advisor or Review Panel member, The above refers to USP (ended in 2020).)