bluuebunny/crossref_metadata_2025_split huggingface dataset:
1174. Impact of an Electronic Antibiotic Time-out Best Practice Alert on Antibiotic Use and Prescribing Behavior in Hospitalized Patients
Authors: Ackley Tyler , Kuti Joseph L , Bilinskaya Anastasia , Linder Kristin E , Dempsey Casey J 
Published: November 2023

Abstract

Background
Antibiotic time-outs (ATOs) are an evolving stewardship strategy capable of widespread impact with relatively low perceived personnel effort. ATO-based interventions have been shown to improve the rates of antibiotic de-escalation and increase the likelihood of antibiotic optimization. In August 2022, Hartford HealthCare implemented a 72-hour ATO best practice alert (BPA) within the electronic medical record (EMR). Herein, we evaluated the impact of this intervention on antibiotic use and describe behaviors associated with alert prompting.

Methods
This is a multi-center, quasi-experimental, retrospective chart review of admitted patients receiving empiric antibiotics for &gt; 72 hours. An ATO alert was designed and embedded within the EMR and set to fire between the hours of 0700 and 1630. On BPA firing, prescribers were prompted to assess for antibiotic modification – a composite including discontinuation, de-escalation, inclusion of stop-date, and transition to oral therapies. Differences in the rate of antibiotic modification and overall antibiotic prescribing patterns for the 10 most frequently utilized antibiotics were compared between a pre-implementation control period (10/1/21 – 10/31/21) and a post-implementation period (10/1/22 – 10/31/22).

Results
A total of 800 patients were included for analysis. There was no significant difference in the rate of antibiotic modification when comparing the pre- and post-implementation cohort (54.5% vs 57.5%, p = 0.433); however, there was a numerically lower rate of antibiotic escalation in the post-cohort (9.5% vs 5.8%, p = 0.062). The duration of antibiotic therapy was longer in the post-implementation cohort (4.7 vs 5.0 days, p &lt; 0.001).

Conclusion
Despite ATO implementation, rates of antibiotic modification were similar between the pre- and post-cohort. Further work to understand the optimal approach to implementing an ATO will be required to improve the impact on antimicrobial therapy.

Disclosures
Joseph L. Kuti, PharmD, bioMeriuex Inc.: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Merck & Co, Inc: Grant/Research Support|Shionogi Inc: Advisor/Consultant|Shionogi Inc: Grant/Research Support|Shionogi Inc: Honoraria
1175. Extended Infusion Beta-lactams in Pediatric Patients with Febrile Neutropenia
Authors: Nagel Jerod , Davidge Karen , King Madeleine , Al-Ajmi Abdullah 
Published: November 2023

Abstract

Background
Febrile neutropenia (FN) is associated with a high risk for infections in patients receiving chemotherapy. Mortality estimates in pediatric patients with FN range from 0.4-3%. Extended infusion (EI) of beta-lactam antibiotics leads to improved pharmacodynamic parameters and is associated with enhanced antimicrobial activity. A recent study demonstrated significantly better overall treatment response in adult patients with documented infections and high-risk FN who received EI vs. standard infusion (SI) piperacillin-tazobactam. There are currently no studies evaluating clinical outcomes of EI beta-lactam use in pediatric patients with FN.

Methods
This study was a single-center retrospective cohort study with a time frame between September 2016-September 2022. The primary objective was to assess the time to fever resolution in patients with FN who received EI vs. SI of beta-lactam antibiotics. Secondary objectives included the difference in 30-day mortality and hospital length of stay (LOS) between the EI and SI groups. This study included patients admitted to pediatric hematology, oncology, or BMT services at Michigan Medicine who were (1) diagnosed with FN during hospital admission or admitted for FN following chemotherapy and (2) treated with EI or SI cefepime, piperacillin-tazobactam, or meropenem for at least 48 hours.

Results
A total of 87 patients were included in the study analysis (40 in the EI group and 47 in the SI group). Baseline characteristics were similar between the groups. There was no significant difference in the time to fever resolution for the cohort (48.5 vs 39.1 hours, p=0.373). There were numeric non-significant differences favoring EI for 30-day mortality (0% vs. 4%, p=0.496), and avoiding need to escalate antibiotic therapy due to treatment failure (7.5% vs. 17%, p=0.214).

Conclusion
The small sample size limited the ability to detect differences in time to fever resolution between EI and SI beta-lactams. Although not statistically significant, secondary endpoints showed numerically lower mortality and lower rates of therapy escalation in the EI group.

Disclosures
Madeleine King, PharmD, BCOP, Elsevier, Inc: Board Member
1183. Implementation of a Nursing and Certified Nursing Assistant Antimicrobial Stewardship Competency-Based Educational Module at a Community Health System
Authors: Chandler Elisabeth , Cubillos Ashley L , Ducas Stephanie , Reyes Iraida , Stedcke Janet , Saunders Mary B 
Published: November 2023

Abstract

Background
The 2019 edition of the CDC Core Elements of Hospital Antibiotic Stewardship Programs created a new category of nursing-based interventions to optimize antimicrobial therapy, however many institutions have not yet implemented these actions. Additionally, accrediting bodies such as the Joint Commission are implementing requirements for multidisciplinary competency-based training as a part of updated standards. Nurses and certified nursing assistants (CNAs) play a valuable role in antimicrobial stewardship (AMS). However, awareness and education pertaining to AMS for nurses and CNAs is not consistent across practice settings, nor do standard recommendations for AMS competency-based education exist. This project aimed to implement and evaluate AMS competency-based education for nursing and CNA staff at a large community health system.

Methods
Implementation of a nursing and CNA AMS online learning module was a multi-step initiative within a community health system. A stepwise approach included assessment of key knowledge gaps, development of educational content specific to the user, creation of an engaging module that included patient cases and knowledge assessment questions, and modification of content to fit within an online learning system. A description of the initiative after competency implementation was assessed.

Results
The online learning module was implemented in December 2022, and the analysis was performed in March 2023. A total of 1,671 nurses and 591 CNAs completed the education in the 3-month time frame. The median duration for competency completion was 26 minutes for nurses (expected duration 30 minutes) and 13 minutes for CNAs (expected duration 20 minutes). Though a passing score of 80% was required for competency completion, 48% of nurses and 74% of CNAs received a passing score of 100%.

Conclusion
Utilizing a standardized online learning system to disseminate an AMS module to nursing and CNA staff achieved a rapid dissemination of AMS competency-based education, enhancing system compliance with CDC recommendations and accrediting organization requirements. Future investigation is needed regarding the impact of educational initiatives on AMS practices for nursing and CNA staff.

Disclosures
All Authors: No reported disclosures
1191. The Implementation of Nasal MRSA PCR for Pneumonia and Association with Antibiotic Use and Clinical Outcomes
Authors: Fenlon Luke A , Fong Karen , Spivak Emily S , Imlay Hannah 
Published: November 2023

Abstract

Background
Nasal MRSA PCR testing has been successfully implemented at many centers and limits vancomycin exposure among hospitalized patients with pneumonia. There are few studies of a Best Practice Alert (BPA) to direct nasal MRSA PCR use and vancomycin de-escalation in the absence of other stewardship oversight. On 1/2/2020, nasal MRSA PCR and a BPA were implemented at our institution. Providers ordering vancomycin for patients with an indication of pneumonia or undifferentiated sepsis were directed to order a nasal MRSA PCR and recommended to stop vancomycin if negative (Figure 1). Our aim was to examine the impact of BPAs implementation on vancomycin duration among patients with suspected pneumonia.

Methods
A retrospective chart review was conducted among hospitalized patients without prior MRSA PCR performed during their admission who had a listed indication of pneumonia or sepsis at the time of vancomycin order. Patients were categorized into “pre” (9/17/2018 – 1/1/2020) and “post” (1/2/2020 – 3/20/2021) cohorts based on date of vancomycin order. Demographics, comorbidities, and antibiotic duration were electronically extracted. Uni- and multivariable logistic models were used to examine the proportion of patients in the pre and post cohorts whose vancomycin was stopped within 24 hours of initial order.

Results
A total of 2,195 patients were included, 1210 in the pre-intervention and 985 in the post-intervention cohort. After BPA implementation, 771/985 (78%) patients received a nasal MRSA PCR. Vancomycin was discontinued within 24 hours after initiation in 384/1210 (32%) patients pre-intervention and 559/985 (57%) patients post-intervention (adjusted OR 2.92 [95% CI 2.44 – 3.49], p &lt; 0.001) (Table 1). Although “high risk” patient factors (e.g. need for mechanical ventilation) were associated with longer durations, vancomycin duration was significantly shorter in the post-implementation cohort for all “high risk” sub-groups (Figure 2).

Conclusion
BPA directed nasal MRSA PCR testing and vancomycin de-escalation effectively shortened duration of therapy among patients with suspected pneumonia. Utilizing a BPA directed approach can improve decision efficiency and allow valuable stewardship team resources to be allocated elsewhere.

Disclosures
All Authors: No reported disclosures
1192. Validation of an Electronic Dashboard in Identifying Excess Duration of Antibiotics for Pneumonia
Authors: Ferranti Mary , Degnan Kathleen , Do David , Hamilton Keith W , Dutcher Lauren 
Published: November 2023

Abstract

Background
Many inpatients receive inappropriately prolonged courses of antibiotics for community acquired pneumonia (CAP) and hospital acquired pneumonia (HAP). Identifying these patients is important for use in interventions to reduce unnecessary antibiotic exposure. In this study, we evaluate how well an electronic dashboard identifies inpatients receiving excess treatment for pneumonia and characterize reasons for excess antibiotic duration.

Methods
Within an academic health system, a dashboard was created to generate an alert when inpatients received antibiotics longer than 120 hours (5 days) or azithromycin longer than 72 hours (3 days) for CAP and 168 hours for HAP (7 days). We reviewed a random sample of encounters with an alert between November 2018 and January 2023. Through chart review, we collected medical history, provider documentation of antibiotic indication, duration of treatment, and reasons for excess duration. Descriptive statistics were used to report 1) the proportion of patients with true positive alerts (alerts generated for patients who truly received an excess duration of antibiotics for pneumonia) and false positive alerts (alerts generated but the patients had not received an excess duration of antibiotics for pneumonia) and 2) reasons for true positive and false positive alerts.

Results
Out of 200 patients, 156 (78.0%) were found to have a true positive alert, while 44 (22.0%) had a false positive alert. Of the patients who received a longer duration than needed for pneumonia (i.e. true positives), 24.5% had no documented reason for prolonged duration and 21.5% had documented inadequate clinical improvement as defined in Table 2. Excess days of azithromycin for CAP was also a common reason for true excess duration (13.5%). Incorrect antibiotic indication selection was the most common reason for a false positive alert (31.8%).

Conclusion
The electronic dashboard is a useful tool that can correctly identify inpatients receiving excess duration of treatment for pneumonia in a majority of cases. Future stewardship endeavors should focus on interventions to reduce such excess duration especially for the most common reasons found.

Disclosures
Kathleen Degnan, MD, Gilead: Grant/Research Support
1194. Implementation of Methicillin-Resistant Staphylococcus Aureus Nasal Swabs as an Antimicrobial Stewardship Tool in a Community Hospital
Authors: Gibson Heather D , Arnoczy Gretchen S , Lee Jayne , Cid Allison 
Published: November 2023

Abstract

Background
Methicillin-resistant Staphylococcus Aureus (MRSA) nasal PCRs are an effective stewardship tool in patients diagnosed with pneumonia and implementation has been shown to reduce use of anti-MRSA antibiotics.

Methods
A pre-post interventional study was conducted at FirstHealth Moore Regional Hospital from January 1st to March 31st, 2022 (pre-intervention, PRE) and January 1st to March 31st, 2023 (post-intervention, PO). Intervention was education by an antimicrobial stewardship (AMS) pharmacist to providers on the use of MRSA nasal PCRs. Primary outcomes were percent change in patients who had PCR ordered PRE and PO and percent patients who had anti-MRSA therapy (vancomycin, VANC) discontinued based on a negative result. Secondary outcomes include time from negative PCR to VANC discontinuation, length of VANC therapy, and number of VANC levels. Inclusion criteria were patients aged &gt; 18 years old hospitalized for community-acquired pneumonia admitted to a medical floor receiving VANC. Exclusion criteria were patients &lt; 18 years of age, pregnant patients, patients admitted to the ICU, or recent history of MRSA.

Results
For primary outcomes, 125 patients were in the PRE group. 42 were on VANC for &gt; 24 hours and 8 had a MRSA nasal swab (6.4%). Of the 8 swabs, 1 patient (12.5%) had VANC discontinued based on a negative PCR. 2 patients were not started on VANC in response to the negative PCR (25%). 112 patients were in the PO group. 32 were on VANC for &gt; 24 hours and 27 had a MRSA nasal swab performed (24.1%). Of the 27 swabs, 14 (51.9%) had VANC discontinued based on a negative PCR. 6 patients were not started on VANC in response to the negative PCR (22.2%). For secondary outcomes in the PRE group, time from negative PCR to discontinuation of VANC was 9 hours 54 minutes (1 patient), average VANC therapy was 4.8 days, and an average of 1.7 VANC levels were drawn. In the PO group, average time from negative PCR to discontinuation of VANC was 18 hours 18 minutes (14 patients), average VANC therapy was 3.4 days, and an average of 1.1 VANC levels were drawn.

Conclusion
Educating providers on the benefits of MRSA nasal PCRs led to a significant increase in number of PCRs orders and an increase in VANC discontinued with negative results. Secondary outcomes show continued room for improvement and potential for cost avoidance.

Disclosures
Jayne Lee, BSN, MPH, CIC, FAPIC, Medline: Advisor/Consultant
1196. Determining Risk Criteria for Direct Oral Penicillin Challenge in Hospitalized Adults with a History of Penicillin Allergy
Authors: Hamid Lina , Bell Christian 
Published: November 2023

Abstract

Background
Beta (β)-lactam antibiotics such as penicillin (PCN) and its derivatives are safe and effective for many bacterial infections. PCN allergies are self-reported in approximately 10% of Americans. Concerns for allergy cross-reactivity often causes the use of broad-spectrum antibiotics and second-line agents. This may increase the cost of care, lengthen therapy, increase side effects, contribute to the development of resistance, and worsen patient outcomes. Recent studies have shown direct oral penicillin challenge (DOC) may be safe and effective in patients with low to moderate risk for reaction.

Methods
This single-site retrospective analysis reviewed hospitalized adult patients with penicillin allergy assessment (PAST) completed by an antimicrobial stewardship team (AST) between May 1, 2017 and September 30, 2022 at a large academic medical center. Our primary aim is to determine risk stratification criteria for a DOC using primary literature and internal data. Secondary aims include cost avoidance analysis, updating PAST guidance, and creating an order set for the administration and monitoring of DOC.

Results
A total of 256 patients were screened and 200 were included. Most common reasons for exclusion were non-PCN allergies, PAST completed at a different hospital, and PAST not completed before discharge. There were 60 patients (30%) deemed to be high-risk for allergic reaction of which 58 (96.7%) received non-PCN alternative and 2 (3.3%) received no antibiotics. AST recommended oral or IV challenge for 107 patients (53.5%) of which 34 (31.8%) received a challenge, 68 (63.6%) received non-penicillin alternative antibiotics, 3 (2.8%) were directly de-labeled, and 2 (1.9%) received no antibiotics. No anaphylactic reactions occurred in patients that received a challenge. De-labeling based on history was recommended in 33 patients (16.5%) of which 12 (36.4%) were directly de-labeled, 2 (6.1%) received a challenge, and 19 (56.1%) received non-penicillin alternative antibiotics.

Conclusion
Our study confirms risk stratification for DOC is feasible and safe. Standardization of PCN allergy de-labeling with clinician and patient education may improve patient outcomes.

Disclosures
All Authors: No reported disclosures
1199. Effectiveness of Non-carbapenem vs Carbapenems Empiric Therapy for Extended-Spectrum β-Lactamase (ESBL)-producing Enterobacterales (PE) Infections in Non-ICU patients: A Real-world Investigation in a Hospital with High-prevalence of ESBL-PE
Authors: Kang Amy Y , Elkomos Mary W , Pham Danny , Guerrero Michelle , Miller Loren G 
Published: November 2023

Abstract

Background
Surviving Sepsis guidelines recommend empiric broad-spectrum therapy that covers likely pathogens. However, among hospitalized, non-ICU patients with less severe clinical presentations, it is unclear whether effective empiric antibiotics lead to improved outcomes.

Methods
We reviewed records of adult non-ICU patients admitted to a large urban medical center with confirmed ESBL-PE infection between Jan 2019 and Aug 2020. We excluded patients from our analysis if: antibiotics were started &gt;48 h from the first positive culture; culture was polymicrobial; hospital length of stay was &lt; 24 h; or positive cultures likely represented colonization. We grouped patients into receipt of empiric carbapenems or not. Our primary outcome was time until clinical stability from the first dose of the empiric antibiotic (in hours). Secondary outcomes included early clinical response and 30-day all-cause hospital readmission.

Results
Among 448 patients with ESBL-PE isolates during our study period, 143 met study criteria. Of these 143, 60 (42%) received empiric carbapenem therapy. Median age was 59 y, and 67% were Hispanic. The most common source was urinary (71%). Carbapenem receipt was associated with previous antibiotics within 6 months of admission (55% vs 28%, p&lt; 0.01) and history of ESBL (57% vs 17%, p&lt; 0.01). Most common empiric therapy in the non-carbapenem group was ceftriaxone (59%). We found no difference in hours until clinical stability from the first dose of the empiric antibiotic between carbapenem and non-carbapenem groups (24 (IQR 8-40) vs 25 (6-75), p=0.77). We also found no difference in early clinical response between groups (88% vs 90%, p=0.78). We found a non-significant trend towards higher 30-day all-cause hospital readmission in the carbapenem group (17% vs 8%, p=0.13).

Conclusion
Among hospitalized non-ICU patients with ESBL-PE infection, we found no difference in time to clinical stability after the first dose of the empiric antibiotic between those receiving carbapenems and those who did not. Our data suggest that empiric carbapenem use may not be an important driver of clinical response in patients with less severe ESBL-PE infection. Our findings may have important antibiotic stewardship implications.

Disclosures
Amy Y. Kang, Pharm.D., BCIDP, Paratek: Grant/Research Support Loren G. Miller, MD MPH, ContraFect: Grant/Research Support|GSK: Grant/Research Support|Medline: Grant/Research Support|Merck: Grant/Research Support|Paratek: Grant/Research Support
1202. Impact of CTX-M Rapid Diagnostic Testing via Biofire® FilmArray® Blood Culture Identification 2 Panel on Early Optimization of Antibiotic Treatment for Enterobacterales Bacteremia
Authors: Kim Brian , Kurator Kevin , Huizar Oscar E Gallardo , Arab Niki , Jeng Arthur 
Published: November 2023

Abstract

Background
Biofire® FilmArray® Blood Culture Identification 2 Panel (BCID2), compared to the original version, expands microbial targets and tests for seven additional resistance genes, including detection of CTX-M Extended-Spectrum Beta-Lactamase (ESBL). At Olive View-UCLA Medical Center (Sylmar, CA), BCID2 supplanted the original version for antimicrobial stewardship rapid diagnostic testing (RDT) of blood cultures (Bcx). We reviewed the impact of BCID2 CTX-M RDT on early optimization of antibiotic (abx) treatment (tx) for Enterobacterales bacteremia.

Methods
Retrospective chart review of adults (≥ 18 years) admitted with BCID2 detection of Enterobacterales from April 1, 2022 to March 31, 2023. Exclusion criteria included detection of carbapenemase, concomitant infection warranting continuation of empiric abx despite BCID2 result, suspected contamination of Bcx, and BCID2 detection of Serratia, Enterobacter, or Enterobacterales without identification of species. ESBL-active abx (EAA) was defined as either amikacin or a carbapenem; non-EAA was any abx except amikacin or a carbapenem. Days of therapy (DOT) saved was calculated by the difference in days between abx change and Bcx finalization (CF).

Results
120 BCID2 results met study inclusion. CTX-M was detected (CTX-Mpos) in 44 (37%) and was not detected (CTX-Mneg) in 76 (63%). In CTX-Mpos, 29 (66%) were started on an empiric non-EAA, of which 28 (97%) resulted in a change to an EAA &lt; 24 hours (H) of BCID2 result; all 29 had a change to an EAA prior to CF. An average of 3 DOT [IQR 2-5] was saved. Five had a history (hx) of ESBL from any source. In CTX-Mneg, 13 (17%) were started on an empiric EAA, of which 8 (62%) had a change to a non-EAA &lt; 24 H of BCID2 result. One had a change to a non-EAA ≥ 24 H of BCID2 result but prior to CF. Four had a change to a non-EAA after CF. An average of 3 DOT [IQR 2-3] was saved. Seven had a hx of ESBL from any source. BCID2 CTX-M results were 100% congruent with the presence or absence of ESBL on Bcx, respectively.

Conclusion
BCID2 CTX-M RDT resulted in early optimization of abx tx in the majority of cases, leading to early escalation of non-EAA empiric tx against ESBL-pathogens and early de-escalation of EAA against non-ESBL pathogens. Rapid diagnostic testing for CTX-M is a valuable tool for antimicrobial stewardship.

Disclosures
All Authors: No reported disclosures