bluuebunny/crossref_metadata_2025_split huggingface dataset:
2222. A study of the role of trimethoprim-sulfamethoxazole in opportunistic infection prevention in lupus patients taking low-level immunosuppressive treatment: An open-labeled, randomized controlled trial
Authors: Munthananuchat Paopat , Ngamjanyaporn Pintip , Pisitkun Prapaporn , Rotjanapan Porpon 
Published: November 2023

Abstract

Background
Individuals with lupus are at risk of opportunistic infections (OIs), especially pneumocystis pneumonia and nocardiosis. The current recommendation to prevent OIs is to take trimethoprim-sulfamethoxazole (TMP/SMX) regularly while on treatment for lupus. However, there has yet to be a standard recommendation on whether TMP/SMX prophylaxis is necessary and when prophylaxis can be discontinued.

Objectives
To assess the role of TMP/SMX in primary prophylaxis of OIs and to study the incidence of TMP/SMX sensitive OIs and the adverse events of TMP/SMX in the real-world setting among lupus patients taking low-level immunosuppressive therapy.

Methods
An open-label, randomized controlled trial was conducted among lupus patients taking low-level immunosuppressive at Ramathibodi Hospital between May 2021 and April 2023. The patient's demographic and relevant data were retrieved. The patients were randomized to receive or not receive TMP/SMX in a 1:1 ratio. The dose of TMP/SMX was adjusted based on renal function. The incidence of TMP/SMX-sensitive OIs was monitored until one year from enrollment, and the adverse events were assessed.

Results
The study was terminated prematurely due to an exceedingly high rate of adverse events secondary to TMP/SMX use. The analysis was made for the enrolled 138 lupus patients at six months, and OIs were monitored until one year. The mean ages were 45.4 in both groups. Most patients (98.4%) had SLEDAI-2K score &lt; 4. The doses of immunosuppressive therapy were adjusted in six patients due to active disease and therefore excluded from the study. No TMP/SMX sensitive OIs documented in 114 lupus patients who completed follow-ups over nine months since enrollment. Eight from 10 patients had grade 1, whereas 2/10 patients had grade 3 adverse drug reactions, and all declined to resume prophylaxis. There was no mortality in the study.

Conclusion
The incidence of TMP/SMX-sensitive OIs among lupus patients taking low-level immunosuppressive was not a significant concern after a one-year follow-up, and high rates of adverse events with TMP/SMX prophylaxis were documented. Therefore, TMP/SMX primary prophylaxis may not be justified in this population.

Disclosures
All Authors: No reported disclosures
2226. Trough- Versus AUC-Based Vancomycin Monitoring for Treatment of Acute Pulmonary Exacerbations of Adult Cystic Fibrosis Patients
Authors: Smith Darrell , Monogue Marguerite , Sanders James 
Published: November 2023

Abstract

Background
Therapeutic drug monitoring (TDM) for IV vancomycin (VAN) in adults with cystic fibrosis (CF) historically has utilized trough concentrations. Recent VAN TDM guidelines recommend area under the curve (AUC)-monitoring to reduce the risk of vancomycin-induced kidney injury. However, limited data is available in adult CF patients to support this practice. The aim of the study was to determine the safety and efficacy of VAN AUC-monitoring in adult CF patients.

Methods
This single-center, retrospective, observational cohort study included adult CF patients admitted from July 1, 2017 to July 1, 2022 with an acute pulmonary exacerbation that received VAN for at least 72 hours with available VAN plasma concentrations for TDM. Eligible patients with multiple hospital admissions during the study period were incorporated as separate encounters. The primary outcome was incidence of acute kidney injury (AKI). A subgroup efficacy analysis was performed in patients with methicillin-resistant S. aureus (MRSA) in the sputum 3 months prior to or 3 weeks after hospitalization.

Results
One hundred forty-three patients were included in the study [AUC cohort (n=39) and trough cohort (n=104)]. Concurrent nephrotoxins was more common in the AUC cohort than in the trough cohort (97% vs 81%; p = 0.01), but rate of AKI was similar (7.7% vs 10.6%, respectively; p = 0.76). No significant differences were seen in achievement of TDM goal, incidence of supratherapeutic exposure or vancomycin accumulation, duration of vancomycin, length of stay, or number of vancomycin concentrations. AUC monitoring was associated with earlier achievement of TDM goal [median 0 days (0-2) vs 2 days (0-4); p &lt; 0.01], lower total daily doses to achieve TDM goal [38.6 ±13 mg/kg/day vs 58.4 ±18.7mg/kg/day; p &lt; 0.01], and fewer regimen changes [median 1 change (0-2) vs 2 changes (1-3); p &lt; 0.01] compared to trough monitoring. In patients with MRSA, pulmonary function recovery, readmission, and mortality was similar.

Conclusion
In adult CF patients, the rates of AKI were similar between VAN TDM methods, but VAN AUC monitoring resulted in a therapeutic regimen sooner at lower total daily VAN doses and fewer number of regimen changes without significantly increasing the number of concentrations compared to trough monitoring.

Disclosures
James Sanders, PhD, PharmD, Merck & Co., Inc.: Grant/Research Support|Shionogi Inc.: Grant/Research Support
2227. Assessing Clinicians' and Trainees' Knowledge and Practice of the IDSA Asymptomatic Bacteriuria Guidelines in the Elderly
Authors: Smith Eleanor E A , Nachimuthu Nagakrishnal , Negrete Jose A , Flynn John , Al Mohajer Mayar 
Published: November 2023

Abstract

Background
Asymptomatic bacteriuria (ASB) is common in the elderly; however, its treatment in this population is not beneficial. Older individuals are also more susceptible to the adverse effects of antibiotics. In practice, many older patients with ASB and new delirium or a fall are empirically treated for presumed UTI, despite a 2019 update to the Infectious Disease Society of America (IDSA) ASB guidelines that recommends against this practice. We aimed to identify self-reported familiarity with the IDSA ASB guidelines, gaps in knowledge, and cognitive-behavioral constructs (CBCs) relevant to treating ASB in older patients.

Methods
This cross-sectional study included advanced practitioners, physicians, residents, and medical students at one academic medical center with affiliated community practices in Southeast Texas. Compared to previous studies, this sample included a greater variety of practitioners from both academic and community settings. The main outcomes were self-reported guidelines familiarity, knowledge score, and behavior score. Chi-squared, one-way ANOVA, and two multivariable linear regressions were performed to assess the relationship between outcomes and categorical variables.

Results
154 out of 1,305 participants (11.8%) responded. The mean knowledge score was 64.87 (SD 23.65), and the mean behavior score was 2.73 (SD 0.91, Table 1). Higher knowledge scores were significantly associated with better antibiotic stewardship practices (P&lt; 0.001) and a better understanding of risks associated with treating ASB (P=0.019, Table 2). Self-reported familiarity with the guidelines did not correlate with knowledge scores (P=0.807). Higher behavior scores were significantly associated with better familiarity (P=0.002), workplace social norms (P&lt; 0.001), knowledge scores (P&lt; 0.001), and risk perceptions (P&lt; 0.001).

Multivariable analysis assessing relationship between knowledge and behavior scores and cognitive constructs, guidelines familiarity, and other categorical variables

Conclusion
There is a gap in knowledge and practice related to antibiotic use for ASB in elderly patients. To optimize antibiotic stewardship, efforts should focus on improving knowledge, familiarity with guidelines, social norms, and risk perceptions.

Disclosures
All Authors: No reported disclosures
2228. Knowledge, Attitudes, and Practices Regarding Antibiotic Use during the COVID-19 Pandemic: A Comparison of United States (US) Survey Respondents Living in the US-Mexico Border Region with those Living in Non-border Regions
Authors: Subelj Maja , Camarena Jose Luis , Hawkes Brooke A , Ellingson Katherine 
Published: November 2023

Abstract

Background
Inappropriate use of antibiotics is a driver of antimicrobial resistance globally. The US-Mexico border region is medically underserved and socially vulnerable. This study aimed to assess knowledge, attitudes and practices (KAP) regarding antibiotic use during the COVID-19 pandemic among US residents, and to compare KAPs for those living in border versus non-border regions.

Methods
A cross-sectional online survey with monetary incentive was deployed to a sample of adults ≥18 years old through Amazon Mechanical Turk with enriched sampling in the US-Mexico border region (defined as residency within 100 km of the border). Surveys were completed from 8/8/2020 to 8/4/2021. KAP questions were aligned with published tools and COVID-19-specific questions were added. Of 602 respondents from the US, 590 (98%) had complete KAP data and were included in this analysis. Chi-square tests were performed to examine the association between KAPs related to antibiotic use and border residency status.

Results
Overall, for 6 of 8 knowledge items about antibiotic use, fewer than 50% of survey respondents answered correctly (Table 1). 50% of border residents versus 71% of non-border residents (p&lt; 0.01) correctly agreed that “antibiotics should never be saved for the next time you get sick.” Conversely 44% of border residents, versus 31% of non-border residents (p=0.03), correctly disagreed with the statement “when I have a cold, I should take antibiotics to avoid getting a more serious illness.” There was no difference in knowledge about causes of antibiotic resistance by region of residency. Overall, 40% of respondents believed that their personal antibiotic use did not affect antibiotic resistance (Table 2). Finally 37% all respondents said they tried to obtain antibiotics, and 31% tried to obtain chloroquine or hydroxychloroquine, because of concerns about COVID-19 with no difference by region of residency.
Table 1: Number and percentage of survey respondents answering correctly to knowledge questions regarding antibiotic use, stratified by residency within 100 kilometers of the US-Mexico border. Table 2: Number and percentage of survey respondants with attitudes consistent with antibiotic stewardship among United States (US) residents, stratified by residency within 100 kilometers of the US-Mexico border.

Conclusion
KAP findings from this survey suggest that knowledge about antibiotic use is low regardless of proximity to the US-Mexico border. Further, practices related to antibiotic and chloroquine or hydroxychloroquine seeking in the context of COVID-19 suggest a role for public-facing information campaigns regarding medication seeking during public health emergencies.

Disclosures
All Authors: No reported disclosures
2230. Consumption of Quinolones, Macrolides, and Beta-Lactam Antibiotics at a Tertiary Care Veterans Affairs Medical Center (VAMC) during COVID-19 Pre-pandemic and Pandemic periods: A 4-year Analysis and Implications for Antimicrobial Stewardship
Authors: Ali Sajjad , Kuhn Ryan , Khaja Sumaiya F , Natesan Suganthini Krishnan 
Published: November 2023

Abstract

Background
During the coronavirus disease 2019 (COVID-19) pandemic, antimicrobial use increased tremendously. Evidence suggests that the pandemic has resulted in an increased rate of AMR due to inadvertent antibiotic use. This likely reflects difficulties in distinguishing COVID-19 from community-acquired pneumonia when patients first arrive at a hospital. Strengthening antimicrobial stewardship (AMS) efforts by formulating policies for the use of antibiotics is crucial to prevent emergence of AMR.

Methods
A retrospective analysis to assess changes in antibiotic use during the pandemic and pre-pandemic patterns was done.

Results
: In the inpatient setting, there was an overall decrease in antibiotic use (all units that follow are in DOT/1000 BDOC) from an average of 380 to 300, vancomycin from 90 to 62, cefazolin from 30 to 17, Linezolid from 5 to 2, Zosyn from 57 to 30 from pre-pandemic period (Jan 2019) to pandemic period (Dec 2022). Antimicrobials that showed an increase during the pandemic included ceftriaxone from 70 to 82, Cefepime from 5 to 8, Levofloxacin from 2 to 5, and fluconazole from 4 to 10 compared to pre-pandemic use. In the outpatient settings (units are in fills/1000 unique patients), levofloxacin use doubled from 3 to 6, cefuroxime use increased from 0.5 to 2 and Azithromycin use dropped from 80 to &lt; 20, with concomitant increase in doxycycline use from 45 to 60. Outpatient antibiotic prescriptions were high for levofloxacin, doxycycline and cefuroxime and increases corresponded to peaks in cases of COVID-19.

Conclusion
Our analysis demonstrates that COVID-19 had shifted the antibiotic consumption curve towards treatment of pneumonia and invasive fungal infections (in seriously ill patients) which has key implications for AMS. Implementation of stringent AMS and mandatory Infectious disease consultation for all COVID 19 infections helped keep our antibiotic consumption well below the national average and curtail AMR.

Disclosures
All Authors: No reported disclosures
2232. Comparison of Empiric Vancomycin Prescribing in Response to Gram Positive Cocci Alerts on Blood Cultures Between Primary and Overnight Physicians on General Medicine Services: A Retrospective Study
Authors: Almulhim Abdulaziz , Cox Heather L , Mathers Amy , Park Stacy 
Published: November 2023

Abstract

Background
Blood culture contamination is associated with unnecessary antibiotic use, increased length of stay, and increased costs. Assessing the likelihood of true bacteremia versus contamination requires consideration of clinical context and microbiologic data. This may be more difficult for covering physicians overnight, who typically cover more patients and may not know patients’ clinical history as well. We compared rates of vancomycin (VAN) initiation in response to microbiology alerts for gram-positive cocci (GPC) in blood cultures during primary team shifts versus overnight.

Methods
We queried the University of Virginia Clinical Data Repository for blood culture results positive for GPC from 07/01/2021 to 12/30/2022 in inpatient general medicine patients. Cultures were stratified by time of the initial positive gram stain alert, which is called as a critical result to the team. All new positive blood cultures are run on a rapid molecular diagnostic (ePlex GenMark Diagnostics) with speciation results passively entered into the chart 2 hours after gram stain. Results were excluded if the patient was already on VAN or daptomycin at the time of gram stain or if the gram stain resulted during hours when the physician coverage (primary vs covering) was not consistent. The primary outcome was the rate of VAN initiation within 2 hours of gram stain with GPCs. Secondary outcomes were number of repeat blood cultures, length of stay (LOS), and incidence of acute kidney injury (AKI).

Results
320 instances of positive blood cultures were reviewed. 141 were excluded. Of 179 included instances, there was no significant difference in VAN initiation by overnight physicians compared to primary teams (21% vs 26%; p=0.418). There was no significant difference in repeat cultures or incidence of AKI.
Comparison of primary and overnight physicians
Blood culture speciation

Conclusion
There was no difference in VAN use, repeat blood cultures, or AKI when positive gram stain alerts were received by overnight physicians versus primary teams. Stewardship interventions targeting VAN prescribing in the setting of a rapid diagnostic workflow may not need to be specifically adapted to covering physicians or teams.

Disclosures
Amy Mathers, MD, D(ABMM), Merck: Advisor/Consultant
2235. Characterization of the Adult Sepsis Treatment Guideline Utilization Within the Emergency Department at an Academic Medical Center
Authors: Berg Deanna M , Maguire Christina , Binkley Amanda , Hinton Matthew , Foster Sean , Dutcher Lauren 
Published: November 2023

Abstract

Background
The early initiation of antibiotics in patients with sepsis has been identified as the most effective intervention in reducing mortality. Screening tools have been developed for the early identification of sepsis. This study characterized Emergency Department (ED) patients initiated on antibiotics for suspected sepsis of urinary or abdominal sources to identify opportunities to improve institutional sepsis guidelines.

Methods
A retrospective chart review was performed of patients initiated on empiric antibiotics in the ED for sepsis with a suspected source of urinary tract infection (UTI) or intraabdominal infection (IAI) from September 2021 to September 2022. Epic SlicerDicer, an electronic medical record (EMR) data extraction tool, identified ED patients with an order for broad-spectrum antibiotics. Patients less than 18 years or initiated on antibiotics prior to arrival were excluded. The EMR was utilized to assess the signs of organ dysfunction, antibiotic regimen, EMR-based sepsis pathway use, and patient-specific risk factors. Institutional guidelines defined antibiotic regimen appropriateness. Descriptive statistics were used to characterize the results.

Results
Among the 6869 patients screened, 190 patients were included. The provider initiated the sepsis pathway in 141 (74.2%) patients, and 21 (14.9%) were initiated on empiric antibiotics determined to be congruent with institutional guidelines. The most common deviation from institutional guidelines was the addition of anti-methicillin-resistant Staphylococcus aureus (MRSA) treatment. Anti-pseudomonal therapy was used in 165 (86.8%) patients and anti-MRSA coverage in 117 (61.6%) patients. Of patients with MRSA coverage, 36 (30.8%) had community-acquired infections. An organism was isolated in 113 (59.5%) patients, and Enterobacterales were most commonly isolated (65.5%). P. aeruginosa was isolated in 15 (7.9%) patients, and no patients had MRSA.

Conclusion
Most antibiotic regimens used in ED patients for the treatment of sepsis with suspected urinary or abdominal sources of infection were contrary to institutional guidelines. This may be a result of an overestimation of MRSA or P. aeruginosa in community-acquired infections, highlighting an opportunity for education and stewardship.

Disclosures
Christina Maguire, PharmD, Viiv: Advisor/Consultant Amanda Binkley, PharmD, BCIDP, AAHIVP, Viiv: Advisor/Consultant
2240. Breaking Dogmas: A Single Center Evaluation of Empiric Vancomycin Use Among Intensive Care Unit Patients with Suspected Pneumonia, Bacteremia or Sepsis
Authors: Xie Christina Y , Walsh Ashton , Campion Maureen , Foong Kap Sum , Doron Shira , Vazquez Gabriela Andujar 
Published: November 2023

Abstract

Background
Augmented concern for methicillin-resistant Staphylococcus aureus (SA) infections in intensive care units (ICU) has led to increased empiric vancomycin use (EVU) in patients with suspected pneumonia, bacteremia, and/or sepsis. At Tufts Medical Center, vancomycin is prescribed at clinician discretion without restrictions. We aimed to evaluate the impact of cultures on EVU and identify predictors associated with prolonged EVU among ICU patients with cultures negative (CN) for SA.

Methods
A retrospective study from April 2022 to January 2023 of ICU adult patients with EVU for suspected pneumonia, bacteremia, or sepsis was conducted. ICU service, length of stay (LOS), duration of EVU, blood & respiratory cultures, mechanical ventilation (MV), central line presence, and vasopressor use were collected. Prolonged EVU was defined as vancomycin use for more than 2 days despite CN for SA. The primary outcome was the rate of prolonged EVU discontinuation. Linear regression included demographics, ICU service, LOS, indication, Charlson Co-morbidity Index, lactate, MV, and 0.5 mg/dL serum creatinine change. Logistic regression included the same variables plus age, positive respiratory cultures and MV interaction.

Results
A total of 165 ICU patients had EVU. Of these, 132 (80%) had cultures collected before EVU vs. 33 (20%) that did not. Blood cultures were collected in 117 (88.6%); 66 (49.6%) had respiratory cultures; 51 (38.6%) had both collected. Median vancomycin duration was 2 days (1-3). Prolonged EVU was observed in 47 (46.1%) patients, while 55 (53.9%) had EVU discontinued within 2 days with CN for SA. On average Cardiac Surgery (CS) spent 2 days longer on vancomycin compared to Surgical (p=0.037) and Pulmonary (p=0.01) patients. MV among ICU patients was less likely to be associated with vancomycin discontinuation within 2 days with CN for SA (aOR [adjusted odd ratio] 0.12, 95% CI 0.03, 0.50; p=0.003).

Conclusion
EVU discontinuation was more likely within 2 days in ICU patients with CN for SA, but less likely for MV or CS patients. In a substantial proportion of patients, cultures were not collected. Our findings highlight the importance of diagnostic testing in ICU settings to help reduce EVU.

Disclosures
Maureen Campion, PharmD, Shinoigi: Speaker
2242. Leveraging the McGeer criteria to Determine the Frequency of Potentially Inappropriate Antibiotic Prescribing for Urinary and Respiratory Tract Infections Prior to and During the COVID-19 pandemic at a Skilled Nursing Facility
Authors: Colombo Paulina M , Ramadan Ferris A , Kaur Dilsharan , Ellingson Katherine 
Published: November 2023

Abstract

Background
Considerable reductions in antimicrobial stewardship efforts have been attributed to the COVID-19 pandemic, especially among low-resourced healthcare facilities, such as long-term care settings. Our study objectives were to (1) assess the appropriateness of antibiotic prescriptions for urinary (UTI) and respiratory tract infections (RTI) using standardized infection definitions, known as the McGeer criteria, and (2) to determine whether the prescribing practices differed prior to and during the COVID-19 pandemic.

Methods
We employed a HIPPA-compliant REDCap data collection tool to abstract Electronic Medical Record data from an Arizona-based, Skilled Nursing Facility between March 2019 and January 2022. Clinical and microbiologic infection characteristics were abstracted to determine whether indications for antibiotic prescriptions met the McGeer criteria for UTI and RTI. The frequency and proportion of antibiotic prescriptions for suspected infections that did not meet McGeer criteria were compared for the time period prior to and during the COVID-19 pandemic.

Results
388 total antibiotic events prescribed for UTI and RTI infections between March 2019 – January 2022 were analyzed (Figure 1). 61% (n=14) and 78% (n=154) of UTI prescriptions did not meet McGeer criteria prior to and during the COVID-19 pandemic, respectively. 70% (n=14) of RTI antibiotic prescriptions prior to the pandemic and 60% (n=89) of antibiotic events during the pandemic were not in accordance with McGeer criteria (Table 1) (Figure 2).
Flow diagram to demonstrate Electronic Medical Record abstraction analysis inclusion criteria

Note: a suspected infection was defined as a laboratory order (e.g., urine analysis, chest x-ray), or an antibiotic prescription
Frequency and percent of UTI and RTI antibiotic prescriptions that did not meet McGeer criteria, prior to and during the COVID-19 pandemic
Note: suspected infections from March 01, 2019 - January 25, 2020 are considered “pre-pandemic,” and January 26, 2020 – January 23, 2022 are considered “during pandemic” *The McGeer criteria differentiate infection definitions based on the presence or absence of an indwelling catheter
Antibiotic prescription accordance with McGeer criteria from March 2019 – January 2022

Conclusion
Despite consorted efforts to improve antimicrobial stewardship infrastructure, the majority of antibiotic prescribing for UTIs and RTIs prior to the pandemic did not meet McGeer criteria. This trend also persisted during the pandemic, indicating a need for increased stewardship practices that can operate concurrently with future public health threats.

Disclosures
All Authors: No reported disclosures