bluuebunny/crossref_metadata_2025_split huggingface dataset:
2244. What Happened? Antibiotic Resistance During the First Two Years of the SARS-CoV-2 (COVID-19) Pandemic
Authors: Crotty Matthew P , Henderson Joel , Hohulin Jacqueline , Wright Jennifer , Cui Mingyang , Alexander Julie , Hunter Leigh , Hupert Mark , Dominguez Edward A 
Published: November 2023

Abstract

Background
Increased antibiotic utilization and resistance have previously been demonstrated in the initial wave and surges of the COVID-19 pandemic but there are few evaluations of long-term impact. We sought to assess the utilization of antibiotics and incidence of resistant pathogens prior to and during the first two years of the COVID-19 pandemic.

Methods
Patients age ≥ 18 years admitted between March 2019 – February 2022 were eligible for inclusion. The study timeframe was divided into three phases: pre-pandemic (PRE, March 2019-February 2020), pandemic year 1 (PAN1, March 2020-February 2021), and pandemic year 2 (PAN2, March 2021-February 2022). Antimicrobial utilization (administration) data was summarized as days of therapy per 1,000 patient days (DOT/1000PD). Antibiotic resistance data was summarized as incidence per 100 hospital admissions. Interrupted time-series analysis with linear regression was performed to assess trends in antibiotic utilization and resistance between study time periods.

Results
Significant increases in ceftriaxone (+20.4 DOT/1000PD, P=0.002), azithromycin (+13.3, P=0.002), and anti-pseudomonal β-lactams (APBL; +17.4, P=0.001) utilization were observed between PRE and PAN1 (Figure 1). Subsequently, these increases were followed by significant decreases in utilization from PAN1 to PAN2.
Non-significant increases in the incidence of third-generation cephalosporin resistant bacteria (Figure 2A; +0.71, P=0.171) and carbapenem-resistant bacteria (Figure 2C; +0.34, P=0.068) were observed between PRE and PAN1 (Figure 2).
A non-significant decrease in MRSA slope (P=0.148) was observed from PRE to PAN1 resulting in a reduction in the average monthly incidence of MRSA infections going from 1.09 per 100 admissions in PRE and PAN1 to 0.75 in PAN2 (Figure 3A). A non-significant decrease in vancomycin-resistant enterococci (VRE) incidence per 100 hospital admissions was also observed for VRE over the three year study period (Figure 3B).

Conclusion
Increased use of key inpatient antibiotics and gram-negative resistance were observed in the first year of the COVID-19 pandemic. Utilization and resistance in PAN2 was similar to that of PRE levels and may represent encouraging signs for the long-term impact on antibiotic resistance.

Disclosures
Matthew P. Crotty, PharmD, BCIDP, Paratek Pharmaceuticals Inc.: Grant/Research Support
2246. A comparison between empiric carbapenem and non-carbapenem use for patients admitted with urinary tract infections and sepsis in the Dominican Republic
Authors: De Luna David , Roque Yori A , Lora Alfredo Jose Mena , Morel Danay Perez , Caraballo Jonas Sthir , Vargas Francelis 
Published: November 2023

Abstract

Background
Septic shock causes major morbidity and mortality. Early resuscitation and empiric antimicrobial therapy is the cornerstone of therapy. Mortality can increase up to 5 times in patients with septic shock treated with an empiric regimen that does not cover the primary pathogen. Carbapenems have broad spectrum and are commonly used in sepsis. The balance of empiric use and antimicrobial stewardship can be difficult in low and middle income countries (LMIC) where multi-drug resistance (MDR) is common.

Methods
This is a prospective observational study from September 1 to November 30, 2020. Patients admitted with urinary tract infection (UTI) and sepsis criteria by SOFA score were included. Patients were categorized by antibiotic into a carbapenem or non-carabpenem cohort. Data was collected prospectively and length of stay, mortality and outcome was compared between groups.Graphic 1.Distribution of antibiotic schemesGraphic 2Distribution of Gram negative bacteria isolation

Results
We evaluated a total of 44 patients. Most of the cases had length of stay (LOS) &gt; 7 days (72.2%). The antibiotic most frequently used were meropenem (36.4%) and cefepime (31.8%), alone or in combination with other drug (Figure 1). Table 2 shows that there was no increased LOS or death between the two study groups; however, medical complications were more common in the non-carbapenem cohort.Table 2.Outcome of studied population

Conclusion
Overall, there were no major significant differences between the groups. We did not find an significant increased risk of death or prolonged LOS between the carbapenem and non-carbapenem cohorts, however, the appearance of complication did have an impact depending on the type of antibiotic regimen. This may offer opportunities for empiric treatment guidelines and a target for antimicrobial stewardship.

Disclosures
All Authors: No reported disclosures
2247. Improvements in Antibiotic Stewardship for Patients Who Use Injection Drugs: Subgroup Analysis of Patients with Bacteremia
Authors: Duffield Olivia , Patel Kaya , Schultz Sara K , Spivack Stephanie 
Published: November 2023

Abstract

Background
Infectious complications are common in patients who inject drugs (PWID). In this population, infections include acute bacterial skin and skin structure, bacteremia, endocarditis, and osteomyelitis. Despite low rates of gram-negative (GN) infections, coverage for these organisms is often initiated on presentation. Herein, we describe the microbiological and clinical characteristics of PWID admitted to our large academic medical center in Philadelphia with a focus on GN bacteremia.

Methods
We queried Epic for admissions with patients that had documented opioid use disorder with injection behavior and positive blood cultures from September of 2021 to March of 2022. We conducted a retrospective chart review of these encounters and collected data regarding their hospital course and treatment.

Results
During the six-month study period, we reviewed 159 encounters of PWID with bacteremia on admission. Of these encounters, 156 (98%) patients had gram-positive (GP) organisms in their blood culture, 12 (7.5%) patients had GN organisms. Of the GP organisms, MRSA (65, 41%), MSSA (27,17%) and Group A streptococcus (53, 33%) were the dominant organisms. Of the patient encounters with GN bacteremia, 4 (33%) encounters were found non-attributable to injection behavior (2 in the setting of gastrointestinal infection, and 2 attributed to pneumonia without presence of septic pulmonary emboli). Three (20%) were found to be secondary to necrotizing soft tissue infections. Five (41%) patients with GN bacteremia left the hospital prior to identification of source. In addition to the 159 encounters for bacteremia, there were an additional 78 (33%) encounters with positive blood cultures later determined to be a contaminant. 61 of 78 encounters (78.2%) had timely discontinuation of antibiotics upon speciation of contaminant blood culture.
Figure 1
Characteristics of Positive Blood Cultures

Conclusion
Although PWID frequently present with infectious symptoms with bacteremia, GN bacteremia occurs in a minority of infections, challenging the notion that patients require empiric GN coverage. Furthermore, a notable percentage of GN bacteremia is secondary to a source non-attributable to injection behavior. We are continuing to explore why this population may have a high rate of contaminant blood cultures.

Disclosures
Sara K. Schultz, MD FACP FIDSA, AbbVie: Advisor/Consultant
2251. Evaluating the Financial Implications of Antimicrobial Therapy in Clinical Settings: A Prospective Observational Study
Authors: Gnanamani James , Dorairajan Suresh Kumar , Magesh Poojadharshini , Rajakumar Ratheesh 
Published: November 2023

Abstract

Background
Unnecessary antimicrobial use is a significant public health concern that can lead to antimicrobial resistance in hospitalised patients. The WHO defines the rational use of drugs as prescribing the right drug at an adequate dose for an appropriate duration based on the clinical needs of the patient and at the lowest cost possible. Inappropriate use of antimicrobials can lead to drug resistance, medication therapy problems and an increase in drug costs. The aim of this study is to assess the irrational use of antibiotics and to analyse the cost effectiveness of antibiotic prescriptions for patients

Methods
This prospective observational study was conducted in a tertiary care hospital in India for a period of three months. Data on patient demographics and antimicrobial usage were collected including any escalation, de-escalation, discontinuation or other changes to therapy recommended by the hospital's infectious disease specialist (ID) opinion in response to specific patient cases. Follow-up was performed to determine whether the ID opinion recommendations were followed. Financial implications, such as increase in drug costs were documented when the ID opinion was not followed. The necessity of antimicrobial usage and its cost effectiveness were analysed using basic statistical method.

Results
A total of 538 prescriptions for antimicrobial therapy were included in this study. Of these 349 prescriptions (64.8%) were in accordance with ID opinion, while 189 prescriptions (35.2%) were not in accordance with ID opinion. The data was analysed and correlated based on the cost of antimicrobial medication (Table 1)

Conclusion
The study found that the average expenditure for a person/day increases by ₹2469 ($30.20) for prescriptions that did not follow ID opinion. This highlights the unnecessary increase in drug expenditure and the risk of antimicrobial resistance. Moreover, these patients had a longer hospital stay on average, leading to additional healthcare costs. Implementing strategies such as antimicrobial stewardship programs and promoting rational use of antibiotics can help reduce unnecessary spending and improve patient outcomes. Further studies are needed to assess the cost-effectiveness of antimicrobial therapy in different clinical settings.

Disclosures
All Authors: No reported disclosures
2253. Hospitalist Antibiotic Prescribing Patterns by Hour and Weekday
Authors: Gray Joshua H , Wahid Lana , Moehring Rebekah W , Yarrington Michael E 
Published: November 2023

Abstract

Background
Hospital medicine physicians providing coverage during evening and night shifts are often responsible for higher patient volumes during these busy shifts. Data on decisions to start or broaden antibiotic therapy by covering physicians are limited.

Methods
We evaluated antibiotic administration data from Duke University Health System between July 1, 2021 and March 31, 2023 to identify antibiotic “starts” and “escalations” attributed to hospitalists. Starts were defined as the first administration per patient encounter without antibiotics on the preceding calendar day. Escalations were defined as an increase in cumulative spectrum score (using a previously validated antibiotic spectrum index) in the 48 hours following administration compared to the score in the 48 hours prior. Shifts from intravenous to only oral antibiotics were not counted as an escalation. We visualized these data as a heat map based on weekday-hour combinations and then compared the median number of starts and escalations between daytime shifts (weekdays 7AM to 5PM, weekends 7AM to 2PM), evening, “cross cover,” coverage shifts (weekdays 5PM to 10PM, weekends 2PM to 10PM), and overnight shifts (remaining times), using the Mann-Whitney U nonparametric test with daytime shifts as the comparator group.

Results
The analysis included 7,045 antibiotic starts and 4,879 escalations across 78,845 unique patient admissions. Heat maps (Figure 1A and B) revealed specific practice patterns. Median starts for night shift were significantly lower than day shift starts, but cross cover starts were significantly higher (p = 0.011 and p &lt; 0.001, respectively, Figure 2A). Night shift escalations were significantly lower than day shift while cross coverage showed no difference (p&lt; 0.001 and p = 0.51, respectively, Figure 2B).
Antibiotic starts and escalations by hour and day of week
Heat maps of counts of antibiotic (A) starts and (B) escalations by hour and day of week
Hourly starts and escalations of antibiotics by hospitalist shift
Box-and-whisker plots of counts of antibiotic (A) starts and (B) escalations per hour by hospitalist shift.

Conclusion
Antibiotic escalations differed across work shifts; visualization of these patterns aids in antimicrobial prescribing pattern recognition and may assist in finding opportunities for supportive antimicrobial stewardship strategies.

Disclosures
Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties
2258. "Identification of Respiratory Viral Pathogens Using Real-Time PCR Was Not Associated with Reduced Antibiotic Use During the COVID-19 Pandemic, but Displayed Viral-Viral Interactions"
Authors: Khan Asif , Marti Ojeda Daynha P , Murphy Richard A , Elzweig Joel , Lacasse Victoria W , Rovelsky Suzette 
Published: November 2023

Abstract

Background
We aimed to investigate the relationship between SARS-CoV-2 and other circulating respiratory pathogens. A secondary objective was to assess the correlation between respiratory pathogen detection and antibiotic use at a single medical center during the COVID-19 pandemic.Table 1.Negative and positive interactions among viruses at population scale (n=883)
Significant unadjusted correlations from bivariate cross-correlation analysis applying Spearman’s rank method to monthly viral infection prevalence are shown in gray, with negative and positive correlations indicated by − and +, respectively, and noncorrelated virus pairs in white.

Methods
For viral-viral interaction analysis, data were collected from infection control surveillance reports on all positive respiratory viral pathogen tests (e.g., antigen, PCR) conducted between October 2018 and February 2022. Real-time PCR respiratory panel (RT-PRP) results (negative or positive) were extracted from the VA Corporate Data Warehouse for inpatients and outpatients. A random subset of patients (15-20%) was selected for chart review. Baseline characteristics, signs and symptoms, laboratory results, imaging interpretation, and admission and discharge diagnoses were collected. Spearman's rank correlation was employed to identify viral-viral interactions. Chart review data were analyzed using Wilcoxon-rank sum tests and Fisher's exact test.Table 2.Correlations between results of RT-PRP result and antibiotics prescribed.

Results
A total of 883 positive surveillance tests were analyzed for viral-viral interactions. A significant negative relationship was identified between SARS-CoV-2 and the prevalence of 43% of other respiratory pathogen types. Among 1,002 RT-PRP results, 168 patients with an RT-PRP result were chart reviewed. Although numerically a smaller proportion of patients with positive RT-PRP – compared to negative RT-PRP – received antibiotics this difference did not reach statistical significance.

Conclusion
This project highlights the diverse influence of SARS-CoV-2 on the prevalence of other respiratory pathogens. No significant impact was detected on antibiotic use of a positive RT-PRP result. A positive RT-PRP result represents only one factor leading to the utilization of antibiotics, with other factors including clinician experience, symptom duration and severity, immunocompetency, and imaging. Based on these findings, we aim to enhance the integration of viral pathogen identification into antibiotic stewardship efforts.

Disclosures
All Authors: No reported disclosures
2263. Amoxicillin Use for Common Acute Respiratory Infections During a National Shortage: Results from the SHARPS-OP Benchmarking Collaborative
Authors: Lee Brian R , Poole Nicole M , Herigon Joshua C , Kronman Matthew , Olivero Rosemary M , Patel Sameer , Smith Michael J , Wattles Bethany A , Wirtz Ann , El Feghaly Rana E 
Published: November 2023

Abstract

Background
Amoxicillin is a first-line agent for most pediatric acute respiratory infections (ARIs). In Fall 2022, a nationwide amoxicillin shortage occurred. This study sought to provide precise estimates in outpatient amoxicillin usage during the shortage, using a nationally representative sample of institutions providing pediatric care.

Methods
Twenty-two institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship Outpatient (SHARPS-OP) Collaborative provided aggregate quarterly data from Jan 2019 - Dec 2022. Data included total counts of encounters with an ARI ICD-10 code and proportions of ARIs treated with any oral antibiotic, amoxicillin, and azithromycin. Data were stratified by location type (Emergency Department [ED], Urgent Care [UC], and primary care clinics [PCC]). We compared ARI prescribing (ARI encounters resulting in any antibiotic prescription) and the amoxicillin and azithromycin indices (ARI encounters resulting in amoxicillin or azithromycin prescription out of ARI encounters resulting in any antibiotic prescription) between pre-shortage (Jan 2019 - Sep 2022) and shortage (Oct 2022 - Dec 2022) time periods by location type.

Results
A total 4.89 million ARI encounters (4.24 million during pre-shortage and 0.65 million during the shortage) were reported across 22 institutions. Overall antibiotic prescribing for ARI encounters changed slightly from pre-shortage to shortage period for ED (28.7% to 22.6%; delta: -6.1 [-6.4, -5.8]), UC (41.1% to 39.6%; delta: -1.6 [-1.8, -1.3]) and PCC (38.1% to 38.1%; delta: 0.03 [0.001, -0.003]). Substantial declines in the amoxicillin index were observed for ED (76.1% to 60.9%; delta: -15.1 [-15.8, -14.5]), UC (71.9% to 60.1%; delta: -11.7 [-12.1, -11.3]) and PCC (63.9% to 53.3%; delta: -10.6 [-14.2, -9.6] with considerable variation within and between SHARPS-OP institutions (Figure 1). Azithromycin use among ARI encounters decreased slightly during the amoxicillin shortage (-0.3% [-0.38%, -0.20%]).Figure 1:Amoxicillin indices for pre-shortage and amoxicillin shortage time periods for included SHARPS-OP institutions, stratified by location type.Location types: Emergency Department [ED]; Urgent Care [UC]; Primary Care Clinic [Primary]

Conclusion
Amoxicillin utilization disproportionately decreased compared to overall antibiotic prescribing for ARIs during the shortage. Providers may have prescribed alternative antibiotics rather than no therapy for ARIs.

Disclosures
Michael J. Smith, M.D., M.S.C.E, Merck: Grant/Research Support|Pfizer: Grant/Research Support Bethany A. Wattles, PharmD, MHA, Merck: Grant/Research Support
2269. Inpatient Antibiotic Prescribing for Symptomatic COVID-19 Patients in a Large US Sample, 2020-2022
Authors: Pulia Michael , Griffin Meggie , Hekman Daniel J , Schwei Rebecca , Pop-Vicas Aurora E , Schulz Lucas , Shieh Meng-Shiou , Pekow Penelope , Lindenauer Peter 
Published: November 2023

Abstract

Background
Significant concerns have been raised regarding antibiotic exposure in patients with COVID-19 and the impact of the pandemic on antimicrobial stewardship in the acute care setting. Therefore, we assessed trends in inpatient antibiotic prescribing practices for symptomatic COVID-19 patients and patients with non-COVID-19 respiratory tract infections (RTIs).

Methods
We identified non-elective, inpatient and observation admissions from March 2020 – December 2022 for COVID-19 and non-COVID-19 RTIs at 765 hospitals in the Premier Healthcare Database using an ICD-10 code algorithm. We described antibiotic usage as the % of encounters with at least one antibiotic dose and by highest level of care (general care, intermediate care (IMC), intensive care unit (ICU)) and antibiotic appropriateness (inappropriate, appropriate) which was characterized as the cooccurrence of ICD-10 code(s) indicating a bacterial infection, as defined by the CDC. We used chi-squared tests to compare antibiotic usage by level of care and by year for 2020 v. 2021 and 2021 v. 2022.

Results
Our sample included 1,198,687 symptomatic COVID-19 cases and 1,713,714 non-COVID-19 RTIs. Antibiotic prescribing for COVID-19 declined from 75.6% in 2020 to 65.2% in 2021 (p &lt; 0.001) and remained at 65.0% in 2022 (p = 0.093) (Fig. 1a). Non-COVID-19 RTIs had a significant decrease in antibiotic prescribing from 90.9% in 2020 to 88.1% in 2021 (p &lt; 0.001) and 85.4% in 2022 (p &lt; 0.001) (Fig. 1a). Inappropriate antibiotic prescribing for COVID-19 declined from 31.2% in 2020 to 27.4% in 2021 (p &lt; 0.001) and 18.1% in 2022 (p &lt; 0.001) (Fig. 1b). Antibiotic usage was significantly different for ICU, IMC, and general care for both COVID-19 (p &lt; 0.001) (Fig. 1c) and non-COVID-19 RTIs (p &lt; 0.001) (Fig. 1d).
Figure 1. Monthly antibiotic prescribing trends for COVID-19 and non-COVID-19 RTI hospital encounters

Conclusion
Despite downward trends in antibiotic prescribing, a majority of COVID-19 patients are prescribed an antibiotic at some point during their admission. Our analysis suggests most of these patients have a co-occurring appropriate indication for antibiotics, yet nearly 1 in 5 COVID-19 patients still receive non-indicated antibiotics. Future work should identify drivers of inappropriate antibiotic prescribing in COVID-19 patients.

Disclosures
All Authors: No reported disclosures
2275. No "One-Size-Fits All": Chronic "Carryover" Diagnoses Dilute Antibiotic Prescribing Metrics in Primary Care
Authors: Smith Mary , Hawkens Marten , Laikijrung Chananid , Mui Emily , Leung Thomas , Zimmet Alex , Ha David R , Holubar Marisa 
Published: November 2023

Abstract

Background
International Classification of Diseases, Tenth Revision (ICD-10) encounter coding is used to identify sub-optimal outpatient antibiotic use, but the utility of a popular billing data based metric, antibiotic prescribing rate (APR), for diagnoses which antibiotics are situationally indicated remain unexplored. We assessed the impact of different ICD-10 groupings on outpatient sinusitis APR to characterize its use.

Methods
We included all adult telemedicine and office encounters from January 2021 to March 2022 with an acute or chronic sinusitis ICD-10 from two academic urgent care and eight academic primary care clinics. We calculated an APR (encounters with antibiotics/all encounters) by sinusitis ICD10 code, ICD10 group (acute vs. chronic) and clinic type (Table 1). We then reviewed 100 urgent and 182 randomly selected primary care sinusitis encounters conducted in 2021 to assess symptom documentation and guideline adherence (Table 2). This quality improvement project was deemed non-human subjects research.

Results
We included 987 sinusitis encounters of 821 unique patients with an overall APR of 56.5% (Table 3). The APR for acute sinusitis encounters was higher than chronic (72.7% vs 22.0%), with a larger difference in primary care (65.5% vs 10.4%) compared to urgent care (76.9% vs 54.2%). Upon chart review, 42.3% (77/182) of primary care sinusitis encounters had no active symptoms (60/77) or did not address sinusitis (17/77); the majority used chronic sinusitis ICD-10s (66/77) (Table 4). Antibiotic prescriptions were guideline adherent for 32.8% of primary care (23/70) compared to 58.0% (40/69) of urgent care encounters (Figure 1).

Conclusion
Combining acute and chronic sinusitis ICD10 codes yielded lower APR than acute sinusitis ICD10s alone, predominately in primary care, suggesting a dilution effect. Compared to urgent care, lack of documentation of active symptoms for chronic sinusitis encounters was common in primary care, hindering the assessment of antibiotic appropriateness. Until there is improved ICD10 utilization with methods to control for ‘carryover’ ICD-10s in primary care, acute and chronic sinusitis ICD-10 categories should likely be analyzed separately to increase the usefulness of sinusitis APR as a metric.

Disclosures
All Authors: No reported disclosures