bluuebunny/crossref_metadata_2025_split huggingface dataset:
Perspectives on nonprescription antibiotic use among Hispanic patients in the Houston metroplex: A qualitative study
Authors: Laytner Lindsey , Chen Patricia , Nash Susan , Paasche-Orlow Michael , Olmeda Kiara , Salinas Juanita , Street Richard , Zoorob Roger , Trautner Barbara , Grigoryan Larissa 
Published: September 2023

Background: Nonprescription antibiotic use includes taking an antibiotic without medical guidance (eg, leftover antibiotics, antibiotics from friends or relatives, or antibiotics purchased without a prescription). Nonprescription use contributes to antimicrobial resistance, adverse drug reactions, interactions, and superinfections such as Clostridioides difficile colitis. Qualitative studies exploring perspectives regarding nonprescription use among Hispanic patients are lacking. We used the Kilbourne Framework for Advancing Health Disparities Research to identify factors influencing Hispanic patients’ nonprescription use and to organize our findings. Methods: Our study includes Hispanic primary-care clinic patients with different types of health coverage in the Houston metroplex who endorsed nonprescription use in a previous quantitative survey. Semistructured interviews explored the factors promoting nonprescription use in Hispanic adults. Interviews were conducted remotely, in English or Spanish, between May 2020 and October 2021. We used inductive coding and thematic analysis to identify the factors and motives for nonprescription use. Results: Of the 35 Hispanic participants surveyed, 69% were female and between the ages of 27 and 66. All participants had some form of healthcare coverage (eg, Medicare or private insurance, Medicaid, or the county financial assistance program). Participants reported obtaining antibiotics from their own leftover prescriptions and through trusted persons (eg, herbalists, pharmacists, friends/relatives, and others), buying them under the counter in US markets, and purchasing them without a prescription outside the United States. Thematic analysis revealed the factors contributing to nonprescription use (Fig. 1). Themes included beliefs that the ‘doctor visit was unnecessary,’ ‘limited direct access to healthcare’ in the United States (due to limited insurance coverage, high costs of the doctor’s visits and medications, and long clinic wait times), ‘more open indirect access to healthcare’ abroad and under the counter in the United States, and communication difficulties (eg, language barriers with clinicians, perceived staff rudeness, and gaps in health literacy). Figure 2 shows representative quotes across thematic domains. Participants expressed having confidence in medical recommendations from pharmacists and trusted community members in their social networks. Conclusions: Antibiotic stewardship interventions that include pharmacist-driven patient education regarding appropriate antibiotic use may decrease nonprescription antibiotic use in Hispanic communities. Additionally, improving access to care while addressing communication barriers and cultural competency in clinics may improve primary care delivery and reduce potentially unsafe antibiotic use.Disclosure: None
Length of antibiotic therapy among adults aged ≥65 years hospitalized with uncomplicated community-acquired pneumonia, 2013-2020
Authors: McCarthy Natalie , Wolford Hannah , Kazakova Sophia , Baggs James , Attell Brandon , Kabbani Sarah , Neuhauser Melinda , Yi Sarah , Hatfield Kelly , Reddy Sujan , Hicks Lauri 
Published: September 2023

Background: The 2014 US National Strategy for Combating Antibiotic-Resistant Bacteria aimed to reduce inappropriate inpatient antibiotic use by 20% for monitored conditions, such as community-acquired pneumonia (CAP), by 2020. Clinical guidelines recommend treating uncomplicated CAP with a minimum of 5 days of antibiotic therapy. Total length of therapy (LOT) >7 days or >3 days after clinical improvement is rarely necessary. In a previous study estimating LOT in uncomplicated CAP patients, 71% of patients ≥65 years exceeded recommended duration of antibiotics in 2012–2013 (Yi et al, 2018). We evaluated annual trends in LOT in adults ≥65 years hospitalized with uncomplicated CAP from 2013 to 2020. Methods: We conducted a retrospective cohort study among patients in the CMS database with a primary diagnosis of bacterial or unspecified pneumonia using International Classification of Diseases 9th and 10th Revision codes, length of stay (LOS) of 2–10 days, discharged home with self-care, and not rehospitalized in the 3 days following discharge. Discharge home was used as a surrogate for clinical improvement. Because inpatient LOT is not available in CMS data, we used linear regression to model inpatient LOT as a function of LOS using data on CAP patients ≥65 years from the PINC AI healthcare database. Postdischarge LOT was based on prescriptions filled following discharge. Total LOT was calculated by summing estimated inpatient LOT and actual postdischarge LOT (Fig. 1). Total LOT >7 days and postdischarge LOT >3 days were considered indicators of likely excessive LOT. We reported trends in the proportion of patients with likely excessive LOT during the study period. Results: From 2013 through 2020, there were 400,928 uncomplicated CAP hospitalizations among patients aged ≥65 years. Patients were more likely to be female (55%), and they had a median age of 76 years and a median LOS of 3 days. The median total LOT decreased from 9.5 days in 2013 to 7.7 days in 2020. The proportion of patients with total LOT >7 days decreased from 68% in 2013 to 50% in 2020 (% change, −27%); the proportion with postdischarge LOT >3 days decreased from 73% in 2013 to 62% in 2020 (% change, −16%) (Fig. 2). Conclusions: Likely excessive total LOT for adults ≥65 years hospitalized with uncomplicated CAP decreased by 27% in 2020, a considerable improvement from 2013. However, the high proportion of patients with likely excessive postdischarge LOT in 2020 (62%) demonstrates the need for antibiotic stewardship to optimize prescribing at hospital discharge.Disclosures: None
Teams in transition: Increasing role of advanced practice providers in inpatient antimicrobial use
Authors: Perez Reinaldo , Yarrington Michael , Deri Connor , Smith Michael , Hayes Jillian , Wrenn Rebekah , Moehring Rebekah 
Published: September 2023

Background: Antimicrobial stewardship strategies must be tailored to effectively engage prescribers with distinct training, experiences, and career paths. Advanced practice providers (APPs) have taken on increasing roles as primary team members in acute-care hospitals, but the impact of this practice shift on antimicrobial prescribing is unknown. We describe longitudinal trends in antimicrobial days of therapy (DOT) by attributed provider type in 3 hospitals. Methods: We performed a retrospective time-series analysis of antimicrobial use for the 7-year period of July 2015–June 2022 to investigate the changes by provider type at 3 hospitals: a major university hospital and 2 community hospitals. DOT, antibacterial, and antifungal agent groups were defined using National Healthcare Safety Network methods. We included anti-influenza and antiherpesvirus agents in the antiviral group. We defined protected agents as those targeted by hospital antimicrobial stewardship program policy (eg, requiring preauthorization). Provider type was defined by electronic health record user profiles in 3 categories: physician, trainees (residents, fellows and medical students), and APPs (nurse practitioners, physician assistants, and nurse anesthetists). We evaluated DOT per 1,000 days present over time by agent group to assess quarterly rate trends. Then, we calculated the percentage of total DOT by provider group. We used multinomial logistic regression to measure changes in percentage DOT across the clinician groups over time using physicians as the referent. Results: Across hospitals and provider groups, we observed an overall decrease in use rates for antibacterial and protected agents (17% each) and increased use rates for antiviral agents (38%) and antifungal agents (4%) (Table 1). Baseline distribution of DOT by provider group and change in distribution over time varied by hospital and agent group (Fig. and Table 2). The largest increases in percentage DOT attributed to APPs compared with physicians occurred in the university hospital with the following average increases per quarter: 1.5% for antibacterials, 3.9% for antivirals, 3.3% for antifungals, and 3.8% for protected agents (Table 3). Community hospitals had higher initial percentage DOT attributed to physicians, but both hospitals experienced increased percentage DOT attributed to APPs. Percentage DOT attributed to trainees varied significantly across agent groups and hospitals. Conclusions: Hospitals had differing baseline patterns of DOT attributed to provider groups, but all experienced increases in DOT attributed to APPs. APPs have increasing involvement in antimicrobial use decisions and should be engaged in future antimicrobial stewardship initiatives.Disclosures: None
Handshake stewardship on adult acute-care surgical services
Authors: Neuner Elizabeth , Hsueh Kevin , Durkin Michael , Sayood Sena 
Published: September 2023

Background: Handshake stewardship is a variation of prospective audit and feedback that entails the individual review of patient charts by a physician–pharmacist collaborative team followed by in-person feedback to primary teams to communicate recommendations regarding optimal antibiotic use. Handshake stewardship has been shown to have durable effects in reducing antimicrobial use in children’s hospitals, but data regarding this intervention in adult hospitals are scarce. In particular, no data are available regarding the impact of this type of stewardship intervention on adult surgical units. We examined the effect of a handshake stewardship intervention at a large academic medical center on adult trauma and acute- and critical-care surgery (ACCS) units. Methods: The antimicrobial stewardship program (ASP) at Barnes-Jewish Hospital launched a handshake stewardship intervention targeting surgical floor teams in January 2022. These teams included the ACCS teams and a number of other surgical services. The intervention consisted of once weekly reviews and in-person rounds with the surgical floor teams along with the establishment of a 7 day per week “hotline” in which the surgical teams could contact an ID physician or pharmacist with questions regarding antibiotic use. Patients with formal ID consultations were not reviewed. Recommendations were tracked including the type, the antibiotic targeted, and recommendation acceptance or rejection. Descriptive statistics were performed to analyze these results. At the end of 12 months, antibiotic use in the floors covered by the ACCS teams were pulled from the NHSN AU module to perform an interrupted time-series analysis 12 months before and after the intervention. Results: Overall, 3,127 charts were reviewed during the intervention period and 637 recommendations were made to all the surgical teams. Opportunities for antibiotic use optimization were identified in ~20% of antibiotic orders. The overall recommendation acceptance rate was 71%. In the ACCS units, 272 interventions were recommended, with an acceptance rate of 67%. The most frequent recommendations were for antibiotic discontinuation (37%), antibiotic de-escalation (17%), shortening duration (12%), and broadening coverage (12%). Antibiotic usage trends (Fig. 1) on the ACCS floors, which were showing a nonsignificant increasing trend (P = .70) before and after the intervention, now show a nonsignificant decreasing trend (P = .20). Conclusions: There are numerous opportunities for antibiotic optimization on adult surgical floors. Although handshake stewardship is a labor-intensive intervention, preliminary findings after 1 year show that, on ACCS units, there may be a trend toward a sustained impact.Disclosures: None
Variations in implementation of antimicrobial stewardship via telehealth at select Veterans Affairs medical centers
Authors: Wilson Geneva , Vivo Amanda , Livorsi Daniel , Sabzwari Rabeeya , Crnich Christopher , Jump Robin , Evans Charlesnika 
Published: September 2023

Background: Antimicrobial stewardship programs (ASPs) seek to reduce the prevalence of antimicrobial-resistant and healthcare-associated infections. There are limited infectious disease (ID) physicians and pharmacists to support these ASPs, particularly in rural areas. The Veterans Health Administration has a robust telehealth program in place. Our previous work has demonstrated the feasibility of using telehealth modalities to support ASPs at rural Veterans Affairs medical centers (VAMCs) by pairing them with an ID expert from a larger, geographically distant, VAMC. This program, dubbed the Videoconference Antimicrobial Stewardship Team (VAST), emphasizes discussion of patients undergoing treatment for an active infection and additional relevant clinical topics with a multidisciplinary team at the rural VA. VAST implementation is ongoing at VAMCs. To understand and compare the qualitative differences in implementation, we used process maps to describe the VAST at 3 VAMC dyads. Methods: Team members from each dyad participated in interviews at 3, 6, and 9 months after beginning their VAST sessions. Questions addressed several aspects of VAST implementation and included identifying cases and topics to discuss; advance preparation for meetings; the frequency and general structure of VAST meetings; and documentation including workload capture. The research team used the responses to develop process maps to permit visual display and comparison of VAST implementation. Results: The first dyad began in January 2022 and the third in March 2022. The sessions had 3 phases: preparation, team meeting, and documentation of experts’ recommendations. Tasks were shared between VAST champions at the rural VAMC and the ID experts (Fig. 1). The preparation phase showed the most variation among the 3 dyads. In general, champions at the rural VA identified cases and topics for discussion that were sent to the ID expert for review. The approaches used to find cases and the type of preparatory work by the ID expert differed. Team meetings differed in both frequency and participation by professionals from the rural site. Documentation of expert recommendations processes appeared similar among the dyads. Discussion: Each of the 3 dyads implemented VAST differently. These results suggest that the overall structure of the VAST is readily adaptable and that each site tailored VAST to suit the clinical needs, workflow, and culture of their partner facility. Future work will seek to determine which aspects in the preparation, team meeting, or documentation phases are associated with successful ASPs, including assessment of quantitative and qualitative outcomes.Disclosures: None
Heterogeneous OPAT regimens within and across infection diagnoses: Day-level medication use patterns among 2072 OPAT patients
Authors: Ponder Madison , Boerneke Renae , Schranz Asher , Swartwood Michael , Farel Claire , Kinlaw Alan 
Published: September 2023

Background: Patients receiving outpatient parenteral antimicrobial therapy (OPAT) are often medically complex and require carefully tailored treatments to address severe and often concomitant infections. Our objective was to illustrate the heterogeneity in antimicrobials used for patients in OPAT, within and across infection diagnosis groups. Methods: We abstracted electronic health record data regarding day-level treatment into a registry of 2,358 OPAT courses (n = 2,072 unique patients) treated in the University of North Carolina Medical Center OPAT program during 2015–2022 (total, 11,861 person weeks; average, 7 OPAT weeks per patient). We classified infection diagnoses into 10 hierarchical or mutually exclusive categories (eg, bacteremia only, diabetic foot infection (DFI) only, osteomyelitis only) (Fig., vertical axes). Accounting for 64 antimicrobial medications and 520 cocktails administered for at least 1 patient day in our OPAT registry, we also defined 18 hierarchical or mutually exclusive classifications of treatment (eg, “daptomycin alone” or “daptomycin and any other antibiotic(s)” (Fig. key). We conducted 2 stratified analyses to describe the heterogeneity across infection diagnoses with respect (1) to medications used at OPAT initiation (patient as unit of analysis) and (2) to medications used throughout OPAT (person time as unit of analysis, allowing for differential OPAT course to other treatment classifications during follow-up). We present stacked bar charts to visualize the intersection between infection diagnosis and treatment group. Results: Among patients in this OPAT registry, 34.6% had osteomyelitis and/or DFI, 4.8% had bacteremia, and 44.6% had multiple infections (Fig. 1). The most common medications in initial OPAT regimens were vancomycin (30.8% of OPAT patients), ceftriaxone (15.0%), and daptomycin (10.9%). We observed overall similarity between the distribution of treatment groups at initiation compared to cumulative person-time during the OPAT course (Figs. 1 and 2). However, we observed heterogeneity in medications by infection diagnosis (Figs. 1 and 2); for example, vancomycin was used in 39% of osteomyelitis cases but only 14% for endocarditis (Fig. 2). For several infection groups (eg, osteomyelitis, DFI, multiple infections, “other” single infections), no treatment classification exceeded 20% use (Figs. 1 and 2). Conclusions: Day-level data on medication use in this monitored registry of patients provided evidence of heterogeneity in the types of medications used throughout treatment in OPAT, which varies within and across infection diagnoses. These data highlight the need for multilayered ascertainment of medication exposure in this medically complex patient population to inform surveillance for adverse effects and guide comparative effectiveness research for postdischarge antibiotic treatment.Disclosures: None
Estimating racial differences in risk for CLABSI in a large urban healthcare system
Authors: Licitra Giancarlo , Fridkin Scott , Wiley Zanthia , Gottlieb Lindsey , Dube William , Kumar Vishnu Ravi , Patzer Rachel , Asrani Radhika Prakash 
Published: September 2023

Background: Socioeconomic barriers or divergent implementation of prevention measures may impact risk of healthcare-associated infections by racial groups. We utilized a previously studied cohort of patients to quantify disparities in central-line–associated bloodstream infection (CLABSI) risk by race accounting for inherent differences in risk related to device utilization. Methods: In a retrospective cohort of adult patients at 4 hospitals (range, 110–733 beds) from 2012 to 2017, we linked central-line data to patient encounter data: race, age, comorbidities, total parenteral nutrition (TPN), chemotherapy, CLABSI. Analysis was limited to patients with >2 central-line days and <3 concurrent central lines. Patient exposures were calculated for each central-line episode (defined by insertion and removal dates); analysis of central-line episode-specific risk of CLABSI among Black versus White patients adjusted for clinical factors, duration of central-line episode, and central-line risk category (ie, low: single port, dialysis or PICC; medium: single temporary or nontunneled; or high: any concurrent central-lines) in Cox proportional hazards regression of time to CLABSI. Results: In total, 526 CLABSIs occurred a median of 14 days after insertion among 57,642 central-line episodes in 32,925 patients. CLABSIs occurred in similar frequency across racial groups: 217 (1.7%) among Black patients, 256 (1.6%) among White patients, and 11 (1.6%) among Hispanic patients (also 42 among unknown or other race). Duration of central-line episode was similar between racial groups (median, 5 days). Black patients were less likely to have medium-risk central lines (34%) compared to white patients (RR, 0.82; 95% CI, 0.79–0.84), but they had a similar frequency of high-risk central lines (21%; RR, 1.0; 95% CI, 1.0–1.1). Compared with low-risk central lines, risk of CLABSI was increased among medium-risk central lines (RR, 1.3; 95% CI, 1.0–1.7) and high-risk central lines (RR, 2.2; 95% CI, 1.8–2.7). CLABSIs were more likely in TPN central lines (RR, 2.3; 95% CI, 1.9–2.7) than others, but they were not more likely among Black patients than White patients (RR, 0.9; 95% CI, 0.1–1.1). In survival analysis, there were 24,700 central-line episodes among Black patients compared to 26,648 episodes among White patients; adjusting for central-line risk and TPN, the risk of CLABSI was similar during the first 21 days of central-line use (adjusted hazard ratio, 1.08; 95% CI, 0.88–01.32) (Fig. 1). Conclusions: After accounting for central-line configuration, Black patients did not have a higher risk of CLABSI within 21 central-line days. Further evaluation is warranted to assess racial disparities in risks of other healthcare-associated infections and to determine whether a lack of CLABSI-specific racial disparities can be replicated in other regions and healthcare systems.Disclosures: None
Utilizing data to foster equity in infection prevention outreach among skilled nursing facilities in Michigan
Authors: White Christine , David Michael , Juarez Ruben 
Published: September 2023

Background: Since October 2020, the Infection Prevention Resource and Assessment Team (IPRAT) has provided infection prevention guidance and support to congregate-care settings throughout Michigan. Specifically, outreach to skilled nursing facilities (SNFs) in response to reported positive COVID-19 resident and staff cases. Case rates provide limited data and do not factor in additional variables, such as staffing shortages, geographical location, or access to supplies, which can increase the vulnerability of staff and residents to outbreaks. To facilitate equitable outreach, a risk assessment was developed using variables related to infection prevention and poor COVID-19 outcomes utilizing local, state, and federal data reporting websites. Methods: A retrospective data review of IPRAT’s electronic data repository was performed, and 2 distinct periods were identified between November 6, 2020, and December 5, 2022. Outreach method 1 involved only using case counts from November 6, 2020, to September 24, 2021. Outreach method 2 (new risk-assessment–based outreach) involved additional data points from April 12, 2021, to December 5, 2022. Data included 17 self-reported items from the NHSN, 3 characteristics regarding facilities’ COVID-19 units, and 7 community-level variables derived from county vaccine rates, social vulnerability index (SVI), and COVID-19 community transmission level. The scoring of each data point ranged from 0–10, and outreach was prioritized to facilities with the highest overall scores. Successful referrals (resulting in a site visit) were compared to the SVI and healthcare emergency regional maps to determine whether the new outreach method reached more facilities in vulnerable communities. Results: Of 358 outreach attempts, IPRAT had a higher success rate with method 2 (6.9%) compared to method 1 (5.3%) and improved outreach in rural Michigan regions 7 and 8 (15% vs 3%). Site visits in counties with a high SVI rating with method 2 were 14.5% versus 10.6% using method 1. COVID-19 prevention referral success rates were higher (4.4% vs 3.1%) using method 2. Conclusions: The risk-assessment–based outreach method showed improvement in overall referral success rates among facilities in rural and higher-SVI counties. These communities tend to experience higher health disparities and poorer health outcomes. Incorporating the more nuanced data variables correlated with at-risk congregate-care settings receiving timelier outreach. The limitations of the study include sample size, period of data collected (2 years), and the complexity of objectively measuring equity.Disclosures: None