bluuebunny/crossref_metadata_2025_split huggingface dataset:
1217. Game of Trophs: Stenotrophomonas maltophilia Management 2.0: Before and After an Antimicrobial Stewardship Intervention
Authors: Son Andrea H , Hecker Michelle T 
Published: November 2023

Abstract

Background
IDSA guidance on the treatment of Stenotrophomonas maltophilia infections version 2.0 recommends caution in the use of levofloxacin, reserving its use as a second line option for mild infections and using it only as a component of combination therapy for moderate to severe infections. The use of ceftazidime is not recommended. In July 2022 we implemented a multifaceted intervention including suppression of levofloxacin and removal of ceftazidime susceptibility reporting in the electronic medical record, education to ID providers, and prospective audit and feedback (PAF). We herein describe S. maltophilia treatment and outcomes before and after this intervention.

Methods
This was a retrospective single center cohort study including all patients from whom S. maltophilia was isolated in culture between 7/1/2021 – 6/31/2022 (before) and 7/1/2022 – 3/31/2023 (after). The primary objective was to describe the rates of adherence to the recommended use of levofloxacin and ceftazidime for each period. The secondary objective was to describe clinical outcomes.

Results
One hundred eleven patients were included in the study. The respiratory tract was the most common culture source. Levofloxacin susceptibility data were visible to providers in 100% and 2% of cultures in the before and after periods, respectively. Ceftazidime susceptibility data were visible to providers in 20% and 7% in the before and after periods, respectively (table 1). ID was consulted more often in the after period (30% before vs 47% after). Adherence to recommended treatment overall was greater in the after period. Fewer patients received levofloxacin monotherapy and no patients received IV ceftazidime in the after period (table 2). S. maltophilia was isolated in subsequent cultures in 12% and 13% of patients and levofloxacin resistance developed in 3% and 2% of isolates during the before and after periods respectively (table 3).

Conclusion
A stewardship intervention including changes in susceptibility reporting, education, and PAF was associated with an increase in the percentage of patients receiving appropriate therapy. Clinical outcomes did not change.

Disclosures
All Authors: No reported disclosures
1220. Comparing Breakthrough Fungal Infections in Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS) Patients Receiving Prophylaxis with Different Azoles
Authors: Chen Catherine , Tverdek Frank P , Escobar Zahra , Liu Catherine , Simmons William F , Bui Hanh 
Published: November 2023

Abstract

Background
Posaconazole is recommended for primary prophylaxis in neutropenic patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) receiving induction chemotherapy. Despite prophylaxis, breakthrough invasive fungal infections (bIFIs) still arise. Initiating posaconazole is not always feasible, and may necessitate use of alternative azoles. The primary objective of this study was to evaluate the rate of bIFIs in patients receiving prophylaxis with posaconazole versus alternative azoles. The secondary objective reviewed reasons for alternative azole use.

Methods
A retrospective chart review was conducted at University of Washington Medical Center (UWMC) and Fred Hutchinson Cancer Center (FHCC). Patients who received induction chemotherapy for AML/MDS from March 2021 to November 2022 and received a prophylactic azole for at least 7 days during neutropenia were included. Outcomes were evaluated with Chi-Square. The incidence of bIFI was evaluated up to 12 weeks from induction chemotherapy, or until consolidation chemotherapy or hematopoietic stem cell transplant, whichever came first.

Results
The initial query yielded 175 patients with AML/MDS. Of these, 88 patients were included: 74 received posaconazole and 14 received an alternate azole (Table 1). BIFIs occurred in 9 patients (posaconazole (n=7, 9.5%), alternative azole (n=2, voriconazole, 14.2%); p=0.631) (Figure 1). The most common reason for initiating an alternative azole was insurance restrictions/high cost (Figure 2).

Conclusion
Numerically, we found reduced incidence of bIFIs among patients receiving posaconazole compared to alternative azoles. Insurance restrictions/cost was the most common reason for alternative azole utilization. This barrier may increase risk of bIFIs, and additional efforts should be considered to use posaconazole over alternative azoles.

Disclosures
Catherine Liu, MD, Pfizer: Site Investigator|SNIPR BIOME: Advisor/Consultant
1221. Non-severe, non-immune mediated intolerances: simple targets for direct non-invasive delabeling opportunities of beta-lactam antibiotic allergy labels (BAAL)
Authors: Polisetty Radhika S , Dickens Michael , Tran Hoang , Khankan Nour , Weslander Erin , Bertram Christie M , Moore William J , Wang Sheila K 
Published: November 2023

Abstract

Background
Majority of patients with a BAALs can tolerate a β-lactam without concerns for a severe IgE-mediated reaction. Many BAALs are confirmed to be intolerances or adverse events versus a true allergy. False BAALs can result in the use of alternative non-BLs, posing risk for collateral health consequences. Current strategies to delabel a false BAAL can be restricted, time consuming and invasive, requiring skin and drug provocation testing. An alternative approach involves direct delabeling of reported BL allergies in patients with non-severe, non-immune mediated intolerances. This method of assessment relies on the review of the electronic medical record (EMR) versus invasive assessments. The aim of this study was to identify the prevalence of reported non-severe, non-immune mediated intolerances across a system of hospitals for prospective non-invasive delabeling opportunities.

Methods
Eligible patients seen within the Northwestern Medicine Healthcare System (NMHS) between 8/1/20 and 8/1/22 were included. Eligible patients: 18 years and older, admitted to a NMHS hospital with &gt; 1 overnight stay, and a BAAL in the allergy profile of the EMR. Examples of non-severe, non-immune mediated intolerances were GI upset, rash w/o pruritus, headache, and pharmacologically predictable reactions. Demographic and allergy data reported in the allergy profile of the EMR was retrospectively obtained through from the Epic Enterprise Data Warehouse.

Results
Over the study period, 25,768 unique patients were eligible for inclusion. During this time, the NMHS admitted 194,670 patients, suggesting a BAAL prevalence rate of 13.2% system-wide. Included patients were mostly White (81%), female (65%) with a median age of 64 (18-109). Of the 25,768 BAALs, 16,561 (64%) were reported as immune mediated reactions, 2,534 (9.8%) as non-severe, non-immune mediated intolerances, 3,405 (13.2%) as indeterminant, and 3,268 (12.7%) had no reaction type reported in the allergy profile of the EMR.

Conclusion
Our prevalence of BAAL across NMHS hospitals was 13.2%. At least 2,534 BAALs reported as a non-severe, non-immune mediated intolerance could be directly delabeled using a non-invasive approach, possibly offering a simpler and broader approach compared to current (invasive) strategies.

Disclosures
All Authors: No reported disclosures
1223. Utilizing Multiple Antimicrobial Stewardship Metrics to Trend Vancomycin Use in an Implementation Study
Authors: Wolfe Kaleb H , Smiley Casey , Hasse Eileen , Millman Nina , Chambers Michael , Hendrickson Sage , Parvaz Parmida , Lokant Matthew , Patel Nishant , Pellegrino Rachael , Okafor Kimberly C , Vojtek Christina , Staub Milner , Fiske Christina T , Norwood Jamison 
Published: November 2023

Abstract

Background
Inpatient IV vancomycin use is often inappropriately prolonged. Methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) nares swabs have shown high negative predictive values for many infections and can guide appropriate vancomycin de-escalation. Antibiotic stewardship programs (ASPs) often monitor vancomycin use in days of therapy (DoT) per 1000 patient days present (PDP). This measure can be affected, especially for smaller facilities, by changes in bed capacity and prolonged stays and thus may not accurately reflect vancomycin use. We evaluated whether alternative metrics of vancomycin use would show different impacts during a multi-step ASP intervention to reduce inappropriate vancomycin use at Veterans Affairs Tennessee Valley Healthcare System.
Figure 1
Run chart of vancomycin DoT/1000 PDP at the Tennessee Valley Healthcare System (TVHS) in two years prior to intervention.

Methods
In September 2021, the ASP, with multiple stakeholders, initiated use of MRSA nasal swabs to inform vancomycin de-escalation. From 7/2022 to 3/2023, we performed iterative Plan-Do-Study-Act intervention cycles including educating medicine and surgical divisions on MRSA swab result interpretation, educating nurses on timely swab collection, replacing MRSA culture swabs with PCR swabs, and adding MRSA swab orders to vancomycin order sets. In April 2022, in addition to DoT/1000 PDP, we began measuring mean, median, and mode DoT per vancomycin course initiated by start week.

Results
Despite multiple interventions beginning July 2022, vancomycin use in DoT/1000 PDP increased to a peak of 106 DoT/1000 PDP in September 2022. In that same period, median and mode DoT per vancomycin initiation remained steady at 2 days and 1 day, respectively.
Figure 2
Run chart of vancomycin DoT/1000 PDP at the TVHS from April 2022 to March 2023. Specific ASP interventions are annotated on the dates they occur.
Figure 3
Run chart of mean, median, and mode days of vancomycin therapy per vancomycin course initiated at the TVHS from April 2022 to March 2023. Specific ASP interventions are annotated on the dates they occur.

Conclusion
DoT/1000 PDP may not be the best metric to evaluate efforts to reduce inappropriate vancomycin use. By tracking mean, median, and mode of DoT per individual vancomycin course, we determined that most providers already practice rapid de-escalation, minimizing patient vancomycin exposure. This method also allows us to quickly detect changes in prescribing patterns and determine whether interventions were warranted. More evaluation of antibiotic use metric appropriateness based on desired outcome is needed in ASPs.

Disclosures
Milner Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds
1228. Evaluation of the Practice of Switching from Intravenous to Oral Antimicrobial Therapy at King Abdulaziz University Hospital
Authors: Alharbi Reem , Baghdady Nour 
Published: November 2023

Abstract

Background
Conversion from intravenous (IV) antibiotics to an oral (PO) in eligible patients is an important antimicrobial stewardship strategy. Recently, King Abdul-Aziz University Hospital (KAUH) in updated its IV to PO conversion policy. This policy describes eligibility criteria for patients to be switched to oral therapy from IV and it suggests PO alternative to IV medications. The aim of this prospective observational study is to observe IV to PO conversion practices on selected antimicrobials in selected ward after updating and implementing this policy.

Methods
Adult patients admitted to the medical, surgical, and hematology/oncology wards who received either metronidazole, ciprofloxacin or clindamycin IV were evaluated for antibiotic need and for eligibility for IV to PO conversion according to the policy. Evaluation period spanned from November 2021 – December 2022.

Results
194 patients were evaluated. Of them, 154 (80%) had a clear indication for the antibiotic of which 98 (63%) required IV administration for the following reasons: impaired oral route (59%), impaired gastrointestinal absorption (15.3%), acute treatment phase of the infection (15.3%), and other reasons such as surgical prophylaxis (3%) and severe sepsis/septic shock (2%). The remaining 56 (36.7%) met the policy’s eligibility criteria for IV to PO conversion.

Conclusion
We found that most patients received antibiotics appropriately in the appropriate route for an existing indication. However, there are plenty of opportunities for improvement in discontinuing unnecessary antibiotics and de-escalating from IV to PO. Ideally, this discussion should be had while rounding on the patient for collective decision making at the point of care.

Disclosures
Nour Baghdady, PharmD, BCPS, MPH, BCIDP, CSL Seqirus: Advisor/Consultant|CSL Seqirus: Stocks/Bonds
1230. Optimization of a Public-Facing Health System Antimicrobial Stewardship Website
Authors: Bertram Christie M , Wang Sheila K , Moore William J , Borkowski Jaime , Weslander Erin 
Published: November 2023

Abstract

Background
Following health system integration of an academic medical center and 10 community hospitals, efforts were made to unify the individual antimicrobial stewardship programs (ASP) and standardize resources within a system-wide Antimicrobial and Diagnostic Stewardship Program (NM ADSP). We assessed the impact of optimizing our public-facing website with updated resources, improving platform usability and convenience, and promoting the new ADSP website to stakeholders.

Methods
Previously conducted focus group sessions of the general public and internal questionnaires to clinicians were used to assess the value of antimicrobial stewardship (AS) and available resources/education. Our system ADSP team worked to assess and merge existing AS resources across each site. Concurrently, the ADSP team partnered with marketing specialists and digital content creators at our institution to produce and launch the new ADSP website. Tracking of total website pageviews per week for 3 months before and 3 months after the ADSP website optimization was evaluated.

Results
Feedback from focus groups and clinical users confirmed the value of a website as a convenient and accessible platform in disseminating important AS resources and education to a broad audience. From these assessments, we identified and prioritized high-use AS resources and education content across the system (e.g. allergy, antibiograms, antimicrobial dosing, COVID-19, and guidelines/protocols) and prioritized these on the home page. Other information identified as useful included site-specific practice guidance, about us, clinical & patient education, news/events, and residency/fellowship information, which were also posted on the home page. A significant difference in the median unique website views per week was observed after optimization and launch of the new ADSP website (pre: 347; post: 524, p &lt; 0.001).
NM ADSP Website Resources

Conclusion
Antimicrobial stewardship is a collective effort. Establishing an organized and resourceful AS public-facing website that is user-friendly and reliable for our stakeholders betters our chances of improving the use of anti-infectives and reducing the threat of antimicrobial resistance. Our experience may be useful to identify educational best practices for enhanced ASP impact at other institutions.

Disclosures
All Authors: No reported disclosures
1232. Incorporation of Theory to Develop and Implement a Multi-Faceted Antimicrobial Stewardship Intervention for Hospitalized Adults with Bacteriuria
Authors: Black Emily , MacLean Dianne M , Bell Madison , Bonnar Paul , Kent Andrea J , Abbass Kim A , Murphy Valerie , Neville Heather L , Ramsey Tasha , Helwig Melissa , Kits Olga , Campbell Samuel G , Coulson Keri , LeBlanc Constance , Johnston B Lynn , Sketris Ingrid 
Published: November 2023

Abstract

Background
Inappropriate treatment of bacteriuria is commonly reported. While evidence to support antimicrobial stewardship (AMS) interventions has been published, few studies justify intervention components or incorporate theory into designing interventions. The objective of the study was to develop a theory-informed multifaceted AMS intervention to improve management of bacteriuria in adults admitted to hospital.

Methods
We used the 4-step approach described by French and colleagues to develop a theory informed intervention. A systematic review of AMS interventions to improve antibiotic use for bacteriuria was completed. In addition, local barriers to improving antimicrobial use in hospitalized adults with bacteriuria were assessed through a qualitative study using focus groups with health care providers. Barriers identified through the qualitative study were mapped to the Theoretical Domains Framework and the COM-B model then linked to the Behaviour Change Wheel. Published literature, focus group results, and practical considerations were used by our team to identify and rank possible solutions. Consensus on which interventions to implement locally was achieved using the Nominal Group Technique.

Results
Ten interventions that could address local challenges with antimicrobial prescribing for bacteriuria were identified. The highest-ranking interventions were audit and feedback (to individuals or teams), active educational sessions, development of clinical order sets, and incorporating clinical decision support with culture results. A multifaceted intervention that included monthly audit and feedback on management of bacteriuria to multidisciplinary teams in combination with case-based virtual education sessions was developed and is currently being piloted at four tertiary and community hospitals.

Conclusion
Use of theory to identify local barriers and facilitators to improving antimicrobial use in combination with evidence and practical considerations should be incorporated into design and implementation of AMS interventions. Further work will evaluate impact of this theory-informed AMS intervention on antimicrobial prescribing for bacteriuria in hospitalized adults.

Disclosures
Emily Black, BSc(Pharm), PharmD, Drug Evaluation Alliance of Nova Scotia: Grant/Research Support|Research Nova Scotia: Grant/Research Support Paul Bonnar, MD, BioMerieux: Honoraria|Paladin Labs: Honoraria Samuel G. Campbell, FRCP (Edin), Astra Zeneca: Board Member
1234. Three Year, Statewide, Assessment of Impact of Time to Sepsis Bundle Completion on Mortality in Patients with Severe Sepsis and Septic Shock
Authors: Carreno Joseph , Nero Alexa , Weber Mckayla , Racz Michael 
Published: November 2023

Abstract

Background
In 2013 New York State regulations mandated that all hospitals implement methods for rapidly identifying and treating patients with severe sepsis and septic shock. This study evaluates the impact of those regulations on patients with sepsis between 2016 and 2019.

Methods
Retrospective, statewide, cohort study of all patients in New York State Sepsis Clinical Dataset with severe sepsis or septic shock between 2016 and 2019. Patients were included if they were admitted through the emergency department (ED), had their 3-hour sepsis bundle (blood culture taken prior to antibiotics, antibiotics given within 1 hour, lactate level taken) started within 6 hours of presentation to the ED, and had their sepsis bundle completed within 12 hours of bundle initiation. The main exposure of interest was time to bundle completion from triage in ED. The main outcome of interest was all-cause inpatient mortality. Multilevel logistic regression was used to account for intra-hospital clustering. P-values &lt; 0.05 were considered statistically significant.
Sepsis Clinical Data Disclaimer
The data used to produce this publication was provided by the New York State Department of Health (NYSDOH). However, the conclusions derived, and views expressed herein are those of the author(s) and do not reflect the conclusions or views of NYSDOH. NYSDOH, its employees, officers, and agents make no representation, warranty or guarantee as to the accuracy, completeness, currency, or suitability of the information provided here.

Results
The weighted sample included 64,119 patients. Baseline characteristics are presented in Table 1. Most individuals (73.6%) had their bundles completed within 3-hours. The median (IQR) time to bundle completion was 1.83 h (1.07 – 3.12), the median (IQR) time to antibiotics was 1.72 h (1.00 – 2.83). Bundle completion within 3-hours from triage was associated with decreased risk of mortality in univariable analysis (17.07% vs. 18.59%, ≤ 3 hrs vs. &gt; 3 hrs, respectively, p &lt; 0.0001). In the multivariable analysis, delayed bundle completion ( &gt;3 h from triage) was associated with increased adjusted odds ratio (aOR, 95% CI) for mortality (1.097 [1.041 – 1.155], P &lt; 0.0001). Delayed antibiotics administration ( &gt; 3 h from triage) was associated increased odds of mortality (aOR [95% CI]: 1.089 [1.031 - 1.151], P &lt; 0.0001). Subgroup analyses are presented in Figure 1 and 2.
Figure 2. Impact of Delayed Antibiotics on Mortality in Subgroups
Data are for adjusted odds ratios and indicate adjusted odds ratios for &gt; 3 delay on mortality within subgroup.

Conclusion
Rapid (≤ 3h) completion of sepsis bundle was associated with decreased risk of mortality. This association was also observed for rapid administration of antibiotics. These data suggest that statewide mandates may improve outcomes for patients hospitalized with sepsis.

Disclosures
All Authors: No reported disclosures
1238. Evaluating the Impact of an Automatic Antibiotic De-escalation Protocol at an Acute Care Hospital
Authors: Diep Albert , Leonard Jacob , Cho Jonathan , Chromi Stephen E , Kronsberg Kelli 
Published: November 2023

Abstract

Background
Previously, pharmacist-led stewardship programs have been shown to result in more timely de-escalation of antibiotics and lack of adverse outcomes in patients treated for pneumonia in the intensive care unit (ICU). This study evaluated the effects of an automatic pharmacist-led antimicrobial de-escalation policy outside of the ICU.

Methods
This was a retrospective pre- and post-implementation study at a 425-bed tertiary care hospital in Las Vegas, Nevada. Inclusion criteria consisted of patients admitted from October 2017 to October 2021 who had Escherichia sp., Proteus sp., Klebsiella sp., Pseudomonas sp., or Enterococcus sp. isolated from specified sites that were susceptible to certain antibiotics included in the de-escalation policy. Exclusion criteria included concomitant infections, polymicrobial infections with organisms outside of those mentioned in the inclusion criteria, deep-seated infections, or hemodynamic instability. The primary outcome was time to de-escalation, which was calculated by determining elapsed time between culture susceptibility results and start of the new antibiotic if de-escalated. If de-escalation did not occur, then time to de-escalation was calculated by comparing time of susceptibility results to antibiotic discontinuation. Secondary outcomes evaluated included rates of antibiotic de-escalation, occurrence of readmission at 30- and 90-days, incidence of all-cause inpatient mortality, length of stay, incidence of Clostridioides difficile infection, and time to clinical resolution. Time to clinical resolution was defined by when patient met pre-specified laboratory values following the first antibiotic dose.

Results
A total of 174 patients were included in the pre-group and 52 in the post-group. The results are shown in Table 1; there was a statistically significant decrease in time to de-escalation, rates of de-escalation, and 90-day readmission rates favoring the post-intervention group, with no differences seen in the other outcomes.

Conclusion
An automatic de-escalation protocol can significantly shorten time to de-escalation in addition to improving rates of de-escalation outside of the ICU without negatively impacting patients.

Disclosures
All Authors: No reported disclosures