bluuebunny/crossref_metadata_2025_split huggingface dataset:
1952. Second Time’s the Charm? Low Yield of 3 AFB Smears among Inpatients Evaluated for Pulmonary Tuberculosis
Authors: Dugdale Caitlin , Zachary Kimon C , McEvoy Dustin S , Courtney Amy , Craig Rebecca L , Germaine Lindsay , Green Chloe V , Hooper David C , Hyle Emily P , Paras Molly L , Shenoy Erica S 
Published: November 2023

Abstract

Background
Among inpatients with suspected tuberculosis (TB), CDC and IDSA guidelines recommend collecting three respiratory specimens 8-24 hours apart for acid-fast bacilli (AFB) smear and mycobacterial culture. However, data supporting this approach are limited, particularly in the era of Xpert MTB/RIF PCR assays (Xpert). Our objective was to estimate the sensitivity of 1, 2, or 3 AFB smears +/- Xpert to detect pulmonary TB in a low incidence setting.

Methods
We conducted a retrospective study of inpatients at a large U.S. academic medical center with mycobacterial culture performed on one or more respiratory specimens July 2016 – December 2022. AFB smear microscopy, Xpert, or both, were performed on each specimen. We evaluated percent positivity on serial AFB smears and on Xpert among patients with confirmed TB, as well as the yield of a third AFB smear among all patients tested.

Results
A total of 7,445 inpatients underwent 15,710 mycobacterial cultures on respiratory specimens, of whom 52 (0.7%) were diagnosed with culture-positive pulmonary TB (Figure 1). Among patients with TB, the first AFB smear was positive in 22/52 (42%) cases and a second AFB smear was positive in 5/24 (21%) cases; there were no cases in which a third AFB smear was positive after two initial negative smears (Table 1). Among 1,523 instances in which a third specimen was obtained among patients with and without TB, the third sample yielded a diagnosis of TB by culture in 1 case. Overall sensitivity to detect a positive AFB smear or Xpert result among patients with TB was equivalent between 2 and 3 AFB smear pathways at 52%. Overall sensitivity to detect TB prior to culture positivity was highest with addition of an Xpert to 2 or 3 AFB smears at 67% (Table 2).

Conclusion
In a low incidence setting, TB screening with 2 AFB smears offers the same diagnostic yield as with 3 AFB smears while potentially reducing laboratory burden and duration of patient isolation. Xpert demonstrated high sensitivity for detection of TB, and it increased sensitivity to detect TB when added to AFB smear-based screening alone. However, a quarter of patients with TB diagnosed by mycobacterial culture were not detected by AFB smear or PCR, highlighting the importance of using clinical judgement when discontinuing isolation.

Disclosures
Emily P. Hyle, MD MSc, UpToDate.com: Royalties Molly L. Paras, MD, Angiodynamics: Honoraria|Angiodynamics: Honoraria
1226. Differences in diagnosis and procedure codes used among 5 Veterans Affairs telehealth antibiotic stewardship services
Authors: Abdelrahim Sara A , Wilson Brigid , Vivo Amanda , Walkner Tammy , Ewers Tola M , Livorsi Daniel J , Crnich Christopher J , Sabzwari Rabeeya , Webster Andrew S , Epstein Lauren H , Milner Amelia , Jump Robin L , Evans Charlesnika T , Bej Taissa A 
Published: November 2023

Abstract

Background
Telehealth offers an opportunity for rural healthcare settings to connect with infectious disease (ID) experts to augment clinical care of people with suspected infections and to support antimicrobial stewardship efforts. We are currently disseminating a project that uses Veterans Affairs (VA) telehealth systems to connect multidisciplinary teams from rural VA medical centers with ID experts at geographically distant locations to form Videoconference Antimicrobial Stewardship Teams (VASTs). Here, we used diagnosis and procedure codes to describe preliminary outcomes from 5 VASTs, assessing the time used for each consult as well as the infectious and other clinical syndromes discussed.

Methods
We extracted Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Revision (ICD-10) codes associated with clinical encounters from January 2022 – April 2023 for 5 VASTs. CPT codes indicated the time spent by the ID expert. ICD-10 codes were summarized into the following broad categories: infections, pathogens, other clinical diagnoses, signs and symptoms, treatments, and administrative codes.

Results
A total of 315 cases were discussed across all 5 sites, with most cases taking &lt; 30 minutes to complete (210; 67%; Figure 1). The cases yielded 600 ICD-10 codes, of which 219 (36%) described an infection and 165 (27%) described other medical diagnoses (Figure 2). The number of ICD-10 codes per consult ranged from 1.0 (Sites A and C) to 3.5 (Site D). Overall, the most common infections discussed pertained to the respiratory tract (57/219, 26%) and skin and soft tissue (53/219, 24%); the most common pathogen code was for Enterococcus spp. (10/59, 17%) (Figure 3).Figure 1:Length of Time per ConsultFigure 2:Types of ICD-10 CodesFigure 3:ICD-10 Codes for Infections

Conclusion
Our results reveal notable differences in the diagnosis and procedure codes used across the 5 VASTs. In general, the VASTs address a similar array of infectious disease syndromes, suggesting that the observed differences may relate to how the ID experts approached coding. Further evaluations will assess the patients discussed and may consider further evaluation of coding practices used for telehealth.

Disclosures
Daniel J. Livorsi, MD, Merck: Grant/Research Support Robin L. Jump, MD, PhD, Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support
1227. Analysis of Prescriber Interaction with an Electronic Antibiotic Time-out Best Practice Alert
Authors: Ackley Tyler , Bilinskaya Anastasia , Kuti Joseph L , Linder Kristin E , Dempsey Casey J 
Published: November 2023

Abstract

Background
The impact of antibiotic time-outs (ATOs) on antibiotic use relies heavily on prescriber interaction, which may be reduced due to workflow disruption or alert fatigue. In August 2022, Hartford HealthCare implemented a 72-hour ATO best practice alert. Herein, we evaluated prescriber behavior when interacting with the ATO alert to assess the impact on prescriber stewardship workflow.

Methods
An ATO alert was designed to fire between 0700 and 1630. Upon firing, prescribers were prompted to assess for antibiotic modification – a composite including discontinuation, de-escalation, inclusion of stop-date, and transition to oral therapies. Additional responses were included to defer re-firing for patients deemed not to be a candidate for antibiotic modification. The primary endpoint was defined as the rate of ATO response aligning with antibiotic modification for the 10 most frequently utilized antibiotics and assessed from 10/1/22 – 12/31/22. A predefined subset of patients was evaluated for ATO appropriateness by prescriber specialty and role.

Results
A total of 15,383 ATO alerts were included for analysis, corresponding to 3,498 unique patients. The primary endpoint occurred in 21.4% of cases. The most commonly selected ATO response was a reminder in 10 minutes (48.2%). The median time viewing the ATO alert was 5 seconds (IQR 4 – 8s). In a subset of 400 patients, ATO selections were found to be appropriate in 56% of cases. When stratified by prescriber role, attending physicians were more likely to appropriately utilize the ATO compared to resident and advanced practice practitioners (62.7% vs 48.5% vs 46.2%, p = 0.007) and were more likely to select an ATO response aligning with antibiotic modification (39.5% vs 7.6% vs 12.3%, p &lt; 0.001).

Conclusion
ATO selection corresponding to antibiotic modification was low regardless of prescriber role. Further work optimizing the ATO design will be required to improve integration into stewardship workflow.

Disclosures
Joseph L. Kuti, PharmD, bioMeriuex Inc.: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Merck & Co, Inc: Grant/Research Support|Shionogi Inc: Advisor/Consultant|Shionogi Inc: Grant/Research Support|Shionogi Inc: Honoraria
1229. Outpatient Penicillin and Sulfonamide Antibiotic Allergy E-Consult Service in Prospective Solid Organ Transplant Recipients
Authors: Bair Amanda M , Joshi Shyam , Anstey Karen , Streifel Amber C , Ham YoungYoon 
Published: November 2023

Abstract

Background
Solid organ transplant recipients (SOTr) are at increased risk for infections post-transplantation. A penicillin allergy incidence of 12% and sulfonamide antibiotic allergy incidence of 9% has been reported in transplant recipients. Documented penicillin and sulfonamide allergies lead to the unnecessary use of broad-spectrum antibiotics or suboptimal therapy leading to further adverse consequences. The purpose of this study is to improve the rates of antibiotic allergy delabeling in SOTr prior to transplantation through the implementation of an allergy testing pilot program.

Methods
From December 15, 2022 to April 28, 2023, prospective SOTr with a penicillin and/or sulfonamide allergy that was tested and delabeled at OHSU were included in this study. This process involves a clinical pharmacist contacting the patient and collecting a detailed allergy history via an e-consult. The e-consult is then routed to one of our allergists to determine patient testing eligibility. If the patient qualifies for testing, they are scheduled for a nurse visit at the clinic. After testing is completed, patients are notified of their results and the allergy is removed from their electronic health record with accompanying documentation.

Results
A total of 86 patients were evaluated for allergy testing (61% penicillin allergies and 39% sulfonamide allergies). Fourteen patients were successfully delabeled through the pilot program with one of the patients having both a penicillin and sulfonamide allergy delabeled. The primary reason for patients being excluded from this study was due to insurance not covering allergy testing done at OHSU as shown in Table 1. Although not included in the pilot program, 7 patients were successfully delabeled by obtaining a detailed allergy history and did not require allergy testing. Twenty-two patients have a future allergy testing appointment scheduled.Table 1:Patient Inclusion and Exclusion

Conclusion
The preliminary results of our study show the implementation of an e-consult service for antibiotic allergy testing in prospective SOTr prior to transplantation is an effective method for allergy delabeling. Allergy testing in this patient population has the potential to significantly improve the selection of antibiotics available for treatment as well as prophylaxis.

Disclosures
Shyam Joshi, MD, Cogent: Honoraria|Leo Pharma: Honoraria|Nectar Allergy: Advisor/Consultant|Nectar Allergy: Stocks/Bonds|Sanofi/Regeneron: Advisor/Consultant|Sanofi/Regeneron: Honoraria|Takeda: Honoraria
1237. Inpatients with a beta-lactam antibiotic allergy label (BAAL) and unrevealed tolerance: A prevalence study aimed to prioritize non-invasive delabeling for antimicrobial stewardship programs
Authors: Dickens Michael , Wang Sheila K , Weslander Erin , Qin Mingyu , Tran Hoang , Khankan Nour , Sutton Sarah , Peters Anju T , Watts Melissa M , Postelnick Mike 
Published: November 2023

Abstract

Background
This study aimed to use data analytics to retrospectively identify the prevalence of inpatients across a system of hospitals with a BAAL who received and tolerated the culprit or related beta-lactam (BL) without proper documentation in the allergy profile of the electronic medical record (EMR). Findings from this study could prioritize direct non-invasive delabeling opportunities as a feasible process measure for resource limited antimicrobial and diagnostic stewardship programs (ADSP).

Methods
Eligible patients were generated by a data analyst using the Northwestern Medicine (NM) Enterprise Data Warehouse. Patients eligible for inclusion: 1) adults &gt; 18 years of age, 2) inpatients at a NM System Hospital (NMSH) with &gt; 1 overnight stay between 8/1/2020 and 8/1/2022, 3) a BAAL in the allergy profile of the EMR, and 4) received &gt; 1 dose of a BL during the study period. Patients who only received aztreonam were excluded. The primary objective of this study was to determine the prevalence of inpatients with a BAAL who received and tolerated the culprit BL antibiotic during the study period without proper documentation in the allergy profile of the EMR. The secondary objectives were 1) to determine the prevalence of inpatients with a BAAL who received and tolerated a related BL antibiotic during the study period without proper documentation in the allergy profile of the EMR and 2) to determine the prevalence of reported BL allergy reactions and severity risk.

Results
Results of our study identified up to 751 inpatient BAALs (9.7%), including 87 BAALs of high priority, as valuable targets for early direct non-invasive delabeling, requiring minimal effort and resources from ADSP.

Conclusion
Using data analytics to empirically assess digital allergy information could streamline the antimicrobial stewardship process, proactively identifying and prioritizing BAALs to cast a wider net and efficiently achieve process measure outcomes related to allergies compared to conventional methods of delabeling.

Disclosures
Anju T. Peters, MD MSCI, Astra Zeneca: Advisor/Consultant|Astra Zeneca: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support|Optinose: Advisor/Consultant|Sanofi Regeneron: Advisor/Consultant|Sanofi Regeneron: Grant/Research Support
1239. Early Lessons Learned: Implementation of a Statewide Mobile Application for Antimicrobial Stewardship in Colorado Using the PRISM Model
Authors: Dimo Joana , Weber Matthew J , MacBrayne Christine , Miller Matthew , Parker Sarah K , Bakel Leigh Anne 
Published: November 2023

Abstract

Background
Antimicrobial resistance, driven by improper antimicrobial use, is a global epidemic recognized as an urgent health threat by the Centers for Disease Control and Prevention (CDC). Previous collaborative work uncovered several self-identified barriers to antimicrobial stewardship in various Colorado hospitals (n=100), the most significant being lack of clinical guidelines, dosing knowledge in pediatric populations, and understanding stewardship methodologies.

Methods
The overarching goal was to mitigate the self-identified barriers from prior studies through implementation of a mobile application decision support system (Firstline). We used the Practical Implementation Sustainability Model (PRISM) and RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework for implementation. We describe barriers encountered by our team as lessons learned for others considering similar implementation.
PRISM Domains and RE-AIM Framework
We used the Practical Implementation Sustainability Model (PRISM) to identify contextual factors and the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework for implementation of a mobile application to improve antimicrobial stewardship in Colorado.

Results
Utilizing PRISM domains, we evaluated if Firstline aligned with our organization’s priorities and offered an acceptable balance of practice and efficiency. Several barriers were encountered including navigating differing strategic planning approaches, financial relationships, and contracural arrangements among potential institutional partners, and navigating data sharing and liability for outfacing content. The external environment factors we evaluated included compliance performance measures, policies, and regulations to incentivize continued use of the application. We used the PRISM domains identified to develop our RE-AIM outcomes. Effectiveness will be measured through distribution of in-application surveys and user feedback. Implementation will be assessed though tracking use of the application by users, general location, and content used. For rural and critical access hospitals, adoption of the application may aid Joint Commission antimicrobial stewardship compliance, and is anticipated to contribute to maintenance.

Conclusion
Use of PRISM helped elucidate and mitigate early implementation barriers including understanding institutional strategic planning, financial relationships, and legal significance of data sharing. Using RE-AIM, we will monitor our mobile application implementation success.

Disclosures
All Authors: No reported disclosures
1244. Antimicrobial Stewardship Knowledge, Attitudes, and Practices (KAP) Among Nurses
Authors: Hayes Jillian E , Perez Reinaldo , Winters Ali R , Moehring Rebekah W , Wrenn Rebekah 
Published: November 2023

Abstract

Background
Nurses are underutilized members of the antimicrobial stewardship (AS) team. Understanding knowledge, attitudes, and practices (KAP) is essential to designing effective AS initiatives. While KAP surveys have been performed among a variety of provider types, less is known about KAP among nurses. We describe KAP pertaining to AS among nurses at a large, academic hospital.

Methods
An electronic, 24-question KAP survey was designed by the AS team with relevant nursing and infection prevention champions. Nine knowledge-based questions about antimicrobials focused on 4 domains: beta-lactams first in sepsis, intravenous to oral transition, urinary tract infections, and penicillin allergies. Voluntary responses were collected via Qualtrics from January 9, 2023-March 31, 2023. Surveys were distributed by email link, with reminders to enhance survey response. Incentives included a chance to win a meal voucher.

Results
85 complete survey responses were received. The majority of respondents worked on dayshift (69%) in a staff nurse role (66%). Discrepancies were seen in perceptions of issues of stewardship nationally and locally. While nurses felt antimicrobial resistance and harm caused by antimicrobials are high nationally (92 and 69%, respectively), this was not as commonly felt to be true on a local level (35% and 26%). The majority (87%) agreed or strongly agreed that nurses’ responsibility includes promoting appropriate antimicrobial use. When assessing knowledge of AS domains, reported confidence in performance was discordant with actual performance and differed by domain (Figure 1). Respondents were largely unfamiliar with common AS reference resources (73-74%) and were more likely to consult an ID pharmacist (81%), ID physician (78%) or infection prevention team member (78%) with questions.

Conclusion
Nurses recognized AS as an important part of their professional responsibilities, but perceived AS opportunities to be a national rather than local need. Differing patterns in knowledge vs. confidence among topic domains provides key information to then design relevant, sustainable, nurse-driven antimicrobial stewardship initiatives.

Disclosures
Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties
1248. Implementing Infection Prevention and Control with Antimicrobial Stewardship in a Tertiary Care Hospital in India: An Interprofessional Education and Collaborative Practice Approach
Authors: Dr Raksha K , Anand Kukkamalla , Prakash Peralam Yegneswaran 
Published: November 2023

Abstract

Background
Infection Prevention & Control (IPC) along with Antimicrobial Resistance (AMR) has complex problems, it requires distinctive disciplinary efforts. There are few data concerning the facilitators and barriers in India. Interprofessional practice and education (IPE & IPP) initiatives amongst various stakeholders is one amongst them. Current approaches to IPC & AMR are fragmented and unidisciplinary, more like ''An Elephant and the Blind Men'. Hence the need of this structured study.

Methods
We conducted a prospective interventional study for one year with an interprofessional team. After institutional ethical committee clearance, an Antimicrobial Stewardship team was formed which devised training modules validated by Delphi technique /& ADDIE (Analyze, Design, Develop, Implement & Evaluate) approach by the Infection Control Committee and external resource persons. Simulated sessions, case based discussions, patient education videos & pamphlets, online interactive classrooms, ward & laboratory rounds were instituted for all doctors, staff nurses, laboratory technicians, pharmacists, and patients. Key quality indicators for antimicrobials prescription & consumption was defined and monitored. High end antimicrobial policy was implemented. Checklists & surveillance forms were put in use. Feedback surveys and audits were conducted to assess the effectiveness of these interventions.

Results
We observed a statistically significant increase in compliance to hand hygiene, health care associated infections (HAI) monitoring, reporting of needle stick injury, adherence to isolation protocols, and antibiotic policy (P value&lt; 0.001) across all units. Maximum compliance to antibiotic policy was observed in medical intensive care units, least in nephrology & neonatal intensive care. Pre-test & post-test questionnaires were used for assessment. An improvement of ∼78 % in the knowledge domain was seen after the sessions. Key quality indicators for HAIs showed statistically significant improvement (P value&lt; 0.001).

Conclusion
A multimodal interprofessional approach aids the training aspect of IPC & AMSP. Such structured programs in the curriculum addresses the silent pandemic of health care associated infections and antimicrobial resistance.

Disclosures
All Authors: No reported disclosures
1251. Strengthening Antimicrobial Stewardship Programs through Public Health Support
Authors: Kriengkauykiat Jane , Mitsunaga Tisha , Epson Erin 
Published: November 2023

Abstract

Background
Antimicrobial stewardship programs (ASP) improve patient outcomes and reduce resistance and Clostridioides difficile infections. The California Department of Public Health (CDPH) Healthcare-Associated Infections (HAI) Program developed an Honor Roll to recognize and promote ASP and offers consultation service to hospitals seeking to strengthen their ASP. We evaluated the service and compared ASP who sought consultation (consult) versus those who did not (non-consult).

Methods
We included ASP applying for Honor Roll between Sep 2020 to Mar 2022. Each hospital ASP completed a standardized application and provided documentation for Bronze, Silver, or Gold designations. Criteria increases as designation increases; details are on the Honor Roll website (www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/Honor_Roll.aspx). ASP may apply for upgrade within one year of designation. Consultation was initial review of ASP; mentorship was ongoing support beyond initial review. We reviewed consultation and mentorship meetings for themes in type(s) of support provided. For ASP that applied for upgrades, we compared consult to non-consult, including facility characteristics, and receipt of upgrade.

Results
There were 168 ASP (176 hospitals) Honor Roll enrollees (44% of California hospitals): 29 consults with 13 receiving mentorship, and 139 non-consult. Community hospital was the majority facility type which was similar between consult, 16/29 (55%), and non-consults, 80/139 (58%). The proportion of community hospitals ≤250 beds was higher for consult 13/29 (45%) vs non-consult 52/139 (37%). Thirty ASP applied for upgrades: 13/13 (100%) consults received upgrades vs 10/17 (59%) non-consults. Among non-consults, 4 received no upgrades and 3 received a lower designation (i.e., applied for Gold, received Silver). Among consults, 15/29 (52%) required support in strengthening their program, 10/29 (30%) application assistance, and 4/29 (14%) metrics or tracking. Approximately 7% of both consults and non-consults were in lower population- dense areas (&lt; 1000 population/square mile).

Conclusion
Public health can support facilities improve their ASP through technical assistance and consultation; ASP in smaller facilities might require additional support.

Disclosures
All Authors: No reported disclosures