bluuebunny/crossref_metadata_2025_split huggingface dataset:
2194. Implementation of the CDC’s Core Elements of Antibiotic Stewardship: A Survey of Long-Term Care Facilities During the COVID-19 Pandemic
Authors: Cichon Catherine (Cathy) , Preusker Jenna , Soma Mounica , Schroeder Danny , Van Schooneveld Trevor C , Bergman Scott J , Ashraf Muhammad Salman 
Published: November 2023

Abstract

Background
Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) is funded by the Nebraska DHHS to assist healthcare facilities with improving their antimicrobial stewardship programs (ASP). ASAP conducted a survey during the COVID-19 pandemic to learn about implementation of the CDC core elements (CE) of antibiotic stewardship in long-term care facilities (LTCF).

Methods
An online self-assessment survey of CE was created and hosted on the ASAP website. A link to the survey was shared with LTCF through ASAP’s email distribution lists, webinars, and other meetings. Data were summarized using descriptive statistics.

Results
54 of 196 licensed LTCF in Nebraska responded to the survey between 05/2021 to 12/2022. Of these, 26 (48%) had all 7 CE with reporting and education being the least likely CE to be met (Tables 1 and 2). Half (50%) of LTCF did not have a signed leadership statement of support for ASP. ASP leadership responsibility was often shared across multiple positions (physicians, directors or assistant directors of nursing [DON/ADON], pharmacists, and infection preventionists), but DON/ADON were most commonly accountable (69%). Consultant pharmacists were the most commonly identified ASP experts (74%) available to LTCF. Only 57% of LTCF reported successfully implementing at least one infection-specific intervention to improve antibiotic use (AU); addressing UTIs was the most commonly identified intervention (31%). Almost a quarter (22%) of LTCF did not monitor rates of C. difficile infection, and about a third (30%) did not track antibiotic-resistant (AR) organisms. While 78% of LTCF provided educational resources to their nursing staff on AR and opportunities to improve AU, only 48% provided these resources to their clinical providers. Out of 26 LTCF reporting areas of antibiotic misuse at their facility, 88% agreed that ASP could help address the issue. For 24 LTCF that reported barriers to starting or improving ASP, prescriber resistance and lack of time were the most commonly identified barriers (28% and 13%).

Conclusion
Implementation of the CE remains low in LTCF and was likely further impacted by the COVID-19 pandemic. The findings highlight the challenges to implementing ASP in LTCF along with opportunities for improvement.

Disclosures
Trevor C. Van Schooneveld, MD, FSHEA, FACP, AN2 Therapeutics: Grant/Research Support|Biomeriuex: Advisor/Consultant|Biomeriuex: Grant/Research Support|Insmed: Grant/Research Support|Thermo-Fischer: Honoraria Scott J. Bergman, PharmD, bioMerieux, Inc.: Honoraria Muhammad Salman Ashraf, MBBS, Merck & Co. Inc: Board Member|Merck & Co. Inc: Grant/Research Support
2204. Excess Antibiotic Therapy for 5 Common Conditions in Primary Care: Low-Hanging Fruit for Outpatient Antibiotic Stewardship
Authors: Patel Payal K , Buckel Whitney , Fletcher Rachel , Gangwer Nick , Hansen Jeni , Stanfield Valoree K , Hersh Adam , Stenehjem Eddie , Seibert Allan M 
Published: November 2023

Abstract

Background
Improving duration can be a key intervention in outpatient antibiotic stewardship as most conditions require only 5 days of therapy or less. Cellulitis, acute otitis media (AOM), sinusitis, community-acquired pneumonia (CAP), and uncomplicated urinary tract infections (UTI) encounters account for the majority of outpatient antibiotic prescriptions and have been associated with durations longer than necessary. We characterized the duration of antibiotic prescriptions associated with these conditions in our primary care (PC) network.

Methods
We retrospectively evaluated prescribing practices for cellulitis, AOM, sinusitis, CAP, and UTI encounters among patients ≥ 3 years-old from January 1st, 2022 – December 31st, 2022 in the Intermountain Health (IH) PC network. IH is an integrated healthcare system operating 119 PC clinics (69 family medicine, 22 internal medicine, 23 pediatric). System-specific evidence-based ambulatory guidelines for the conditions of interest during the study recommended 5-7 days of therapy. Encounters, patient characteristics, and prescription information were electronically extracted from the electronic health record. We analyzed duration of therapy by categories (≤5 days, 6-9 days, 10-14 days, or 14+ days) for each condition in pediatric (≥ 3-18 years-old) and adult (≥ 19 years-old) patients.

Results
There were 14,918 and 38,790 encounters for the studied conditions among pediatric and adult patients, respectively. The mean age of pediatric patients was 9.0 years and among adults, 56.8. Pediatric and adult patients were predominantly White, non-Hispanic, female, and preferred speaking English (Table 1). Overall, only 10.4% (8,965) of all prescriptions were ≤ 5 days and consistent with the recommended duration. Duration of prescriptions associated with each condition are presented in Figure 1. UTI exhibited the highest percentage of ≤ 5 day prescriptions (22.1% pediatrics, 29.1% adults) while sinusitis had the lowest (0.9% pediatrics, 2.6% adults).Table 1.Total encounters for all studied conditions and patient characteristicsFigure 1.Duration of antibiotic prescriptions associated with cellulitis, acute otitis media (AOM), sinusitis, community-acquired pneumonia (CAP), and uncomplicated urinary tract infection (UTI) encounters for patients 3-18 years-old (pediatric) and ≥19 years-old (adult) in the Intermountain Health primary care network.

Conclusion
Duration of therapy for cellulitis, AOM, sinusitis, CAP, and UTIs is almost always longer than the recommended 5 days of therapy in our PC network. There is substantial opportunity to improve duration for these conditions.

Disclosures
Payal K. Patel, MD MPH, qiagen: Honoraria
2205. Utilization of guiding comments imbedded within culture results to improve antimicrobial prescribing for enterococcal urinary tract infections in the ambulatory setting
Authors: Pepper Julia , Rosenberger Aundrea , Tirupathi Raghavendra , Logsdon Jarett 
Published: November 2023

Abstract

Background
Evaluate outcomes associated with utilizing guiding comments imbedded within the electronic health record’s (EHR) culture result to decrease the inappropriate use of cephalosporins in enterococcal urinary tract infections.

Methods
Data collected retrospectively from a regional health system from 02/01/22 to 02/28/23. Inclusion criteria was urine culture positive for enterococcus and active cephalosporin order. Exclusion criteria was cephalosporin treatment prescribed for a non-enterococcal organism and age less than 18 years. Patients were evaluated 6 months pre- and post-implementation of a microbiology comment added to streptococcus gamma and enterococcal cultures: “Enterococcus sp. are resistant to cephalosporins.” The primary outcome was rate of inappropriate prescribing of cephalosporins in enterococcal urinary tract infections in the ambulatory care setting. The secondary outcome was rate of 30-day follow-up visits required pre- and post-implementation of guiding comment. Follow-up was defined as either ambulatory visit, telephone visit, emergency department admission, or inpatient admission. Chi-Squared statistical test was utilized to compare nominal data.

Results
93 patients were not included based on inclusion and exclusion criteria. 141 patients in the pre group and 146 patients in the post group were analyzed. After guiding comment implementation, the incidence of inappropriate treatment continuation decreased from 67.4% to 43.8% (RRR=35%, p=0.001). Follow up events included patient encounters related to urinary symptoms such as emergency department admissions, inpatient admission, ambulatory visits, and telephone encounters. Total patients requiring follow-up decreased from 44.7% (63/141) to 26.0% (38/146); 41.8% relative risk reduction (p = 0.001).

Conclusion
Providers assume enterococcus sensitivity to ampicillin equates to sensitivity to all beta-lactams. The implementation of guiding comments results significantly reduced the inappropriate use of cephalosporins to treat enterococcal urinary tract infections. Total follow-up visits were also significantly reduced which has the potential to improve patient experience. Enterococcal guiding comments should be implemented at heath care facilities when possible.

Disclosures
All Authors: No reported disclosures
2224. A Novel Pediatric Antimicrobial Stewardship Program Intervention Leads to Decreased Use of Piperacillin-tazobactam in the Neonatal Intensive Care Unit at an Academic Institution
Authors: Pichilingue-Reto Patricia , Trimble Kelsey , Johnston Marissa , Dominguez-Garcia Maria G , Hill Katherine C 
Published: November 2023

Abstract

Background
Antimicrobial stewardship programs (ASP) were created to improve antimicrobial use without compromising patient outcomes. Nationwide, Pediatric ASPs have shown a very rapid growth during the past decade. Inpatient stewardship can present some challenges, particularly with special patient populations like newborns and premature infants.

Methods
A new Pediatric Antimicrobial Stewardship committee was established in April 2022 at Ochsner LSU Health Shreveport- St. Mary’s Hospital. The first process measurement was a medication usage evaluation (MUE) report of piperacillin-tazobactam from January 31st, 2020, to September 7th, 2021, in the Neonatal Intensive Care Unit (NICU) for early and late onset sepsis. Neonatologists received education about the recommended antibiotics for these indications. The stewardship committee obtained a report one year later to evaluate the impact of the intervention. Slicer dicer, a data extraction tool from EPIC Electronic Health Record (EHR) system was used to determine how many NICU patients received piperacillin-tazobactam.

Results
From January 31st, 2020, to September 7th, 2021, the charts of 64 neonatal patients, who were prescribed piperacillin-tazobactam, were reviewed. Out of these 64 patients, 46 (72%) were 4-28 days old when the antibiotic was received, 33 (72%) received piperacillin-tazobactam and vancomycin and 13 received additional antibiotics. Indications for the 46 patients included: Possible sepsis (15%), confirmed sepsis (6.5%), possible necrotizing enterocolitis (NEC) (2.2%) and confirmed NEC (10.9%). The report demonstrated a possible overuse of piperacillin-tazobactam for early and late onset sepsis, without the diagnosis of NEC. We reported this antibiotic’s usage in NICU patients during the years 2020, 2021 and 2022 (Figure 1).Figure 1:Piperacillin-tazobactam usage in newborns and infants admitted to the Neonatal intensive care unit (NICU).
Piperacillin-tazobactam was administered to a total of 27 patients admitted to the NICU in 2020, 46 patients in 2021, and only 15 patients in 2022. The medication usage evaluation (MUE) was presented by the Pediatric Antimicrobial Stewardship committee in April 2022.

Conclusion
Neonates and premature infants can represent a challenging patient population for Pediatric ASPs’ interventions. Before the introduction of this committee, there was no tracking of the use of broad-spectrum antibiotics in patients admitted to the NICU. We reported a possible overuse of piperacillin tazobactam for early and late onset sepsis, as well as NEC. Our interventions caused a dramatic reduction in the administration of this broad-spectrum antibiotic in the NICU.

Disclosures
All Authors: No reported disclosures
2946. Comparative Pharmacokinetics and Pharmacodynamics of Cefadroxil and Cephalexin for Pediatric Musculoskeletal Infections
Authors: Haynes Andrew , Wei Zixuan , Anderson Peter , Scheetz Marc H , Parker Sarah K , N Douglas 
Published: November 2023

Abstract

Background
Methicillin-susceptible Staphylococcus aureus (MSSA) is one of the leading causes of pediatric musculoskeletal (MSK) infections, such as osteomyelitis and septic arthritis. MSSA MSK infections are treated initially with an IV antibiotic, followed by prolonged oral therapy. Cephalexin is the most used oral option due to long-standing clinical experience and its well-described pharmacokinetics (PK) in children. Cefadroxil could be an attractive alternative requiring less frequent dosing, but it has minimal pediatric clinical or PK data. In this study, we describe the comparative PK of cephalexin and cefadroxil in children with MSK infections and evaluate dosing regimens to achieve effective free time above the MIC (fT &gt;MIC) for MSSA.

Methods
Children aged 6 months to 18 years admitted with an MSK infection were enrolled in a prospective, open-label, crossover study and given single oral doses of cefadroxil (50-75 mg/kg up to 2,000 mg) and cephalexin (50 mg/kg up to 1,375 mg). During a single dosing interval, 4-5 plasma samples were obtained per patient for each drug. Antibiotic concentrations were quantified using liquid chromatography-mass spectrometry. PK models were developed, and then Monte Carlo simulations were performed using various dosing regimens to estimate the probability of target attainment (PTA) for a range of pharmacodynamic (PD) targets, across various pediatric ages and common MSSA MICs (1-4 mg/L).

Results
Concentration-time data for cephalexin (n=15) and cefadroxil (n=14) were best described using a one-compartment model with first order absorption. PK parameters were notable for cefadroxil’s longer half-life than cephalexin. Monte Carlo simulation showed that cephalexin 120 mg/kg/day divided q8hrs (max 1,000 mg per dose) and cefadroxil 100 mg/kg/day divided q12hrs (max 1,500 mg) achieved &gt;95% PTA for fT &gt;MIC &gt;40% for MICs up to 4 mg/L, though cephalexin QID and cefadroxil TID dosing were required to achieve higher PD goals.

Conclusion
Among pediatric patients with MSK infections, oral cefadroxil and cephalexin both achieve PD targets for efficacy against MSSA. Twice-daily cefadroxil should be further considered as an alternative to cephalexin for oral step-down therapy given its similar PTA and possibility for less frequent dosing.

Disclosures
Marc H. Scheetz, PharmD, MSc, Abbvie: Advisor/Consultant|ASHP: Honoraria|Chambless, Higdon, Richardson, Katz & Griggs, LLP: Expert Testimony|Cidara: Advisor/Consultant|Entasis: Advisor/Consultant|F2G: Advisor/Consultant|GSK: Advisor/Consultant|Guidepoint Global: Honoraria|Hall, Booth, Smith, P.C.: Expert Testimony|Merck: Advisor/Consultant|Reminger Co., L.P.A: Expert Testimony|Spero: Advisor/Consultant|Takeda: Advisor/Consultant|Taylor, English, Duma, LLP: Expert Testimony|Third Pole Therapeutics: Advisor/Consultant Sarah K. Parker, MD, Pfizer: Grant/Research Support
2229. Impact of Elexacaftor/tezacaftor/ivacaftor on Utilization of Antibiotics at a Single Pediatric Cystic Fibrosis Center
Authors: Elson Elizabeth C , Lee Brian R , Burns Alaina N , Herigon Joshua C , Wirtz Ann , Duehlmeyer Stephanie 
Published: November 2023

Abstract

Background
Intravenous (IV) and oral (PO) antibiotics (ABX) are standard treatments for pulmonary exacerbations (PEx) in people with cystic fibrosis (pwCF). Frequent ABX use may lead to adverse events and ABX resistance. Cystic fibrosis transmembrane conductance regulator modulator treatments have significantly reduced PEx in qualifying pwCF, but impact on ABX use is unknown. The approval of elexacaftor/tezacaftor/ivacaftor (ETI) in 2019 makes these treatments accessible to the majority of pwCF. The primary objective was to examine utilization of ABX pre-and post-ETI in pwCF managed at Children’s Mercy Kansas City’s (CMKC) CF center.

Methods
A retrospective analysis of PO and IV ABX for CF PEx was performed at CMKC. The pre-ETI treatment period was defined as 1/1/2017-12/31/2019 and post-ETI treatment period as 1/1/2020-12/31/2022. A paired analysis including pwCF managed by CMKC during both periods was used to compare ABX courses pre- and post-ETI.

Results
A total of 293 pwCF and 110 pwCF received PO and IV ABX during the study period, respectively. Of these, 224 pwCF managed by CMKC during both periods were included. IV ABX were received by 25 pwCF in both periods whereas 138 pwCF did not receive IV ABX in either period. There were 43 pwCF who received IV ABX only in the pre-ETI period compared to 18 pwCF who received IV ABX only in the post-ETI period (p=0.0021) resulting in a discordance of 27.2%. PO ABX were prescribed for 119 pwCF in both periods whereas 35 pwCF did not have PO ABX prescribed in either period. There were 52 pwCF who received PO ABXs in the pre-ETI period only compared to 18 pwCF who received PO ABX in the post-ETI period only (p=0.0001) resulting in a discordance of 31.3%. The number of patients receiving ABX directed against Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus significantly decreased between periods. The median duration of ABX did not significantly change for IV (9.2 days vs. 8.9 days, p=0.958) or PO (14 days vs. 14 days, p=0.384) ABX during both periods.

Conclusion
CMKC pwCF experienced a dramatic decline in prescribing both PO and IV ABX following approval of ETI. Future investigations are necessary to determine this trend nationwide and ascertain the overall impact from decreased ABX exposure in pwCF.

Disclosures
All Authors: No reported disclosures
2234. Ambulatory Prescribing Trends of Azithromycin and Systemic Glucocorticoids in Patients Diagnosed with COVID-19: A Large Healthcare Network Analysis in Massachusetts
Authors: Anwar Shamsuddin , Campion Maureen , Foong Kap Sum , Doron Shira , Vazquez Gabriela Andujar 
Published: November 2023

Abstract

Background
Data do not support the use of azithromycin (AZ) and systemic glucocorticoids (GCS) for nonhospitalized adult patients with COVID-19. However, these two medications remain commonly prescribed in the ambulatory setting. We aimed to evaluate prescribing trends of AZ and GCS in patients diagnosed with COVID 19 at ambulatory clinics from a large Boston area healthcare network.

Methods
We performed a retrospective cohort study of all ambulatory clinics (i.e., primary care and specialty) affiliated with Tufts Medicine healthcare network from April 2020 through May 2022. These clinics were categorized into academic medical center-based (AMCB) clinic or community-based (CB) practices. We queried the system informatics database to identify all outpatient COVID-19 encounters using ICD-10-CM diagnosis code (U07.1). Demographics, treatment, and prescriber data were extracted. We performed χ2 to compare categorical variables.

Results
A total of 44,369 outpatient COVID-19 encounters were identified; 40.7% occurred in AMCB clinics and 59.3% in CB clinics. Within these encounters, 1,798 (4.1%) and 3,561 (8.0%) had prescriptions for AZ and GCS, respectively. Prescriptions varied by month, with a higher rate of prescriptions during SARS COV 2 variant surges (i.e., Winter period 2020-2021, Delta, Omicron)(Figure 1). The rates of AZ (3.6% vs 4.4%, p&lt; .001) was significantly higher in CB clinics compared to AMCB while rates of GCS (9.5% vs. 7.0%, p&lt; .001) prescriptions were significantly higher in AMCB.
Prescription Trends For Azithromycin And Systemic Glucocorticoids From May 2020 to April 2022

Conclusion
Despite national guidelines recommending against the use of AZ and GCS for nonhospitalized adult patients with COVID-19, we observed their use, and noted higher rates of prescription during SARS COV-2 variant surges. While the overall prescription rates for AZ and GCS were similar to national trends, we found use to be significantly varied in CB and AMCB clinics. Our study highlights opportunities for targeted intervention to reduce inappropriate prescribing practices for patients diagnosed with COVID-19 in the ambulatory setting.

Disclosures
Maureen Campion, PharmD, BCIDP, Shinoigi: Speaker
2947. Improving Access to Allergy Specialty Care in Houston through a Collaborative Penicillin Allergy Stewardship Program
Authors: Taylor Margaret G , Anvari Sara 
Published: November 2023

Abstract

Background
Approximately 5% of children carry a penicillin (PCN) allergy label, but less than 10% of reported reactions are IgE-mediated. Guidelines recommend formal evaluation of children with unconfirmed PCN allergy labels, but this evaluation occurs infrequently. We piloted a novel pediatric PCN allergy clinic in the infectious disease and allergy & immunology clinics, utilizing telemedicine services to provide prompt initial PCN allergy evaluation for children in the community with unconfirmed PCN allergy labels.

Methods
A collaborative PCN allergy clinic utilizing telemedicine services for initial evaluations, followed by in-person skin testing and/or oral challenge was implemented in a tertiary-care children’s hospital. Benchmark data of this piloted clinic was obtained via retrospective chart review of children evaluated between December 2021 and December 2022.

Results
Following the implementation of a collaborative PCN allergy clinic utilizing telemedicine for initial evaluations, referral rates for pediatric PCN allergy evaluations increased from an average of 15 per month to 53 per month. Of 459 referrals, 355 (77.3%) were successfully scheduled in one of the telemedicine clinics, and 348/355 (98%) completed their initial telemedicine evaluation. 89 children who completed their recommended in-person formal evaluation were de-labeled, and 23 failed their challenge and remain labeled as penicillin allergic.

Conclusion
Piloting a collaborative PCN allergy clinic within two ambulatory divisions of a tertiary care center and utilizing telemedicine services has resulted in a successful avenue to promptly evaluate and de-label children with PCN allergies. Future work will be needed to determine prescribing outcomes of children de-labeled in this PCN allergy clinic.

Disclosures
All Authors: No reported disclosures