bluuebunny/crossref_metadata_2025_split huggingface dataset:
2210. Reducing Inappropriate Antibiotic Prescribing for Acute Uncomplicated Bronchitis
Authors: Williams Sabrina , Olivero Rosemary M , Engels Julie , Ogrin Sara 
Published: November 2023

Abstract

Background
Antimicrobial stewardship (AS) programs aim to slow the growing threat of antimicrobial resistance. The majority of antibiotic prescribing occurs in outpatient settings. This study examines the effect of an AS intervention bundle on the proportion of inappropriate antibiotic prescriptions given to adult patients with bronchitis in outpatient settings of a large healthcare system.

Methods
The Institutional Review Board approved this retrospective study of antibiotic prescription rates for adults (≥18 years old) diagnosed with bronchitis (identified using ICD-10 codes J20.9 or J20.8) during 2020 and 2021 in outpatient settings. An AS intervention bundle involving training and auditing of physicians’ antibiotic prescribing habits was enacted in January of 2021. A total of 8,176 encounters were reviewed for appropriateness of antibiotic prescriptions. Instances where no antibiotics were prescribed or antibiotics were prescribed for a comorbid condition were considered appropriate. Percentages of inappropriate antibiotic prescribing pre- and post-intervention were then compared via Chi-square analysis using SAS Enterprise Guide version 7.15 software.

Results
The proportion of inappropriate antibiotic prescribing for bronchitis decreased significantly from 44.9% pre-intervention to 32.5% post-intervention (p&lt; 0.0001). Comparison of inappropriate prescribing rates by month showed significant decreases between the pre- and post-intervention periods in March (48.1% to 31.8%, p=0.0002), October (44.4% to 30.3%, p&lt; 0.0001), and November (42.2% to 27.0%, p&lt; 0.0001).

Conclusion
AS activities can decrease inappropriate antibiotic prescribing for bronchitis in outpatient settings. Further analyses on site-specific, seasonal and demographic differences on the effect of our AS intervention bundle may further enlighten on how programs can decrease unnecessary antibiotic use for respiratory tract infections.

Disclosures
All Authors: No reported disclosures
2214. Retrospective Analysis of the Implementation of a Novel Discharge Reconciliation service in OPAT by Pharmacists (RAINDROP)
Authors: Caverzagie Brady , Ross Jennifer 
Published: November 2023

Abstract

Background
Outpatient parenteral antimicrobial therapy (OPAT) has become a standard mechanism for delivery of antimicrobial regimens over a prolonged period in a non-acute care setting. Adverse drug reactions, vascular access device complications, and unscheduled healthcare use have been attributable to OPAT. Existing literature suggests OPAT errors at the time of hospital discharge are high, around 30-40%. The purpose of this study is to evaluate the impact of a novel OPAT reconciliation service on pharmacist interventions on OPAT discharge plans.

Methods
Adult OPAT patients who discharged from an academic medical center between 6/2020 and 6/2023 on parenteral antimicrobial(s) with placement of a pharmacist OPAT note were included in this retrospective pre/post implementation cohort study. Patients with cystic fibrosis were excluded. Data on patient characteristics, antibiotic regimen, labs, and any changes to the discharge OPAT plan were collected from the electronic health record. Categorical values and outcomes were reported as counts and rates.

Results
The implementation of a new OPAT plan reconciliation process for infectious diseases pharmacists was implemented on January 18th, 2023, and is outlined in Figure 1. Target enrollment will be approximately 640 patients split evenly between two cohorts. An interim analysis was performed on 553 patients, 320 patients in the pre-implementation cohort and 233 in the post implementation cohort. There was a total of 53 pharmacist interventions observed during the pre-implementation period and 61 interventions in the post-implementation period, yielding an intervention rate of 0.17 (6.04 patients/intervention) and 0.26 (3.82 patients/intervention), respectively. Common interventions included changes to lab and therapeutic drug monitoring, dose, agent chosen with culture follow-up, and changes to the infusion method (continuous vs. intermittent infusion). A breakdown of the interventions observed in the two cohorts is shown in Table 1.Figure 1:Pre and Post Implementation OPAT Plan Reconciliation Process for Infectious Disease PharmacistsTable 1:Pre and Post Implementation Infectious Disease Pharmacist Intervention Type Breakdown

Conclusion
During our interim analysis, we observed an increased rate of pharmacist interventions after the start of a new reconciliation service for OPAT discharges.

Disclosures
All Authors: No reported disclosures
2218. Evaluation of Bacteremia in Febrile Neutropenia and Implications on Antimicrobial Stewardship
Authors: Kalava Sowmya , Arab Niki , Gonzalez Rolando Zamora , Kim Brian , Jeng Arthur 
Published: November 2023

Abstract

Background
Febrile neutropenia (FN) is a common complication in cancer patients. IDSA guidelines for FN in cancer patients recommend the initiation of an empiric antibiotic (abx) against Pseudomonas aeruginosa (PsA). At Olive View-UCLA Medical Center (Sylmar, CA), we reviewed FN cases to determine the prevalence of PsA bacteremia and assess the necessity of anti-PsA abx.

Methods
Retrospective chart review on all adult (≥ 18 years) positive blood cultures (Bcx) from January 1, 2017 to December 30, 2022. Positive Bcx were matched with ICD-10 code for neutropenia on inpatient encounter. Exclusion criteria consisted of absolute neutrophil count ≥ 500, FN not related to malignancy, and untreated suspected contamination. Charts were reviewed for Bcx results, source of bacteremia, antibiotic prescribing, and 30-day all-cause mortality.

Results
Of 1,303 neutropenia encounters and 3,755 positive Bcx, 92 were matched, and 48 met inclusion criteria. Enterobacterales was found in 28 (58.3%), whereas PsA was found in 5 (10.4%) [Figure 1]. Gram negative bacteremia was more common than gram positive [Figure 2]. The most common source of bacteremia was intra-abdominal (n=17, 35.4%), followed by line-associated infection (n=9, 18.8%) [Figure 3]. All 48 cases were started on empiric anti-PsA abx; 31 (72.1%) were continued on anti-PsA abx for an average of 11 days [IQR 5-14] despite no PsA in Bcx. 30-day all-cause mortality was not significantly different between those who continued on anti-PsA abx versus those in whom anti-PsA abx was stopped when PsA was not isolated [5/31 versus 3/13, p=0.5]. All cases of PsA bacteremia had at least one risk factor for nosocomial acquisition, e.g. hospitalization and/or abx exposure ≤ 90 days.Figure 1:Frequency of Isolated OrganismsFigure 2:Breakdown of Organism ClassificationsFigure 3:Sources of Bacteremia

Conclusion
The most common organism causing bacteremia in FN was Enterobacterales. The prevalence of PsA bacteremia was low, yet most were continued on anti-PsA abx despite Bcx showing a different organism. Continuation of anti-PsA abx did not make a difference in all-cause 30-day mortality when PsA was not isolated. Even when neutropenic, the risk factors for PsA bacteremia was the same as that for other patients; thus, as an abx de-escalation strategy, patients can be risk stratified. Further stewardship efforts can be focused on de-escalating anti-PsA abx in FN when PsA is not isolated.

Disclosures
All Authors: No reported disclosures
2219. Guiding stewardship interventions through tracking of bone cultures in diabetic lower extremity infections
Authors: Ketema Pawlose , Adenew Ayne , McKnight Angela Y , Thompson Janette , Liappis Angelike P 
Published: November 2023

Abstract

Background
Lower extremity infections (LEIs) of diabetic patients poses a challenge to addressing over-utilization of broad spectrum antibiotics (BSA). To guide the development of educational and behavioral initiatives, we employed ASP quality improvement surveillance practices to explore podiatric-surgery collected bone cultures (BC), pre-procedural tissue cultures (PTC) and results of resection margin pathology.

Methods
Washington DC VAMC is an urban medical center with 220 acute and LTC beds with acute and outpatient surgical Podiatry Service and supported by an active ASP (PharmD/MD/NP). Between 2020-2022 positive BCs collected in podiatric LEI procedures for presumed osteomyelitis were reviewed by ASP with CDSS (TheraDoc, Inc) and EMR (VISTA_CPRS). A positive post-resection margin (Margin+), empiric antibiotic selection and microbiology including regimen altering organisms such as MRSA and P. aeruginosa (PSAR) were collected.

Results
Diabetic individuals had 94 positive BCs in 296 procedures among nearly 2,000 total cultures. Subjects were predominately male (97%), mean age 68 ± 8.7 (45-93y); and nearly a third had &gt; 1 BC. Intraoperative BCs made up 79% of episodes and half were Margin+. Subjects had high rates of PVD (45%), insulin-dependence (49%) and HbA1c &gt; 10 mg/dL (21%). Empiric BSA selection consisted mainly of MRSA and PSAR coverage with no deaths &lt; 30d from BC. Among BC with PTC, 61% had partial or complete correlation in microbiology; MRSA and PSAR incidence were the same if PTC:BC findings were concordant or not. PTC:BC microbiologic non-concordance vs concordance for Margin+ was not significantly different between the groups (45.8% vs 59.4%, P=NS) and among PTC:BC concordant samples, PSAR rates trended higher (12.9% vs 4.8%, P=NS) with no difference in MRSA incidence.

Conclusion
Providers have limited information in predicting LEI results in advance of path and micro. Empiric BSAs remains a challenge for ASPs. Less than half of patients had a BC finding that would have been predicted by the PTC and for those with a concordant prior to procedure sample, the finding of organisms that directed the empiric selection were not reflective of final cultures. There are opportunities for ASP interventions that address empiric selection in diabetic LEIs.

Disclosures
All Authors: No reported disclosures
2223. Evaluation of the Microbiology and Clinical Outcomes of Spontaneous Bacterial Peritonitis (SBP) within a US Academic Health System
Authors: Chris Parish P , Taylor Alex D , Stone Tyler J , Luther Vera , Ohl Christopher , Beardsley James R 
Published: November 2023

Abstract

Background
2021 SBP treatment guidelines recommend empiric therapy with spectra broader than 3rd generation cephalosporins (TGC) in patients (pts) at risk for multidrug-resistant organisms (MDOs), including those admitted to ICUs, with nosocomial infections, or with recent hospitalization. This study aimed to characterize the microbiology and clinical outcomes of SBP in our health system to determine the applicability of these guidelines.

Methods
Setting: 5-hospital academic health system with &gt; 1500 beds. Design: retrospective, observational study. Adult pts from 2010-2022 with ICD 9/10 codes for SBP & liver dysfunction were screened. Pts with concomitant secondary peritonitis were excluded. Study included all pts with culture-positive (CX-pos) SBP and randomly screened pts with culture-negative (CX-neg) SBP to provide a total sample of 80 pts. Primary outcome was % of peritoneal fluid CX with organisms non-susceptible to ceftriaxone (CRO) in CX-pos pts. Secondary outcomes included mortality & effect of MDO risk factors (hospitalization in prior 90 days, ICU admission, or nosocomial infection) on microbiological & clinical outcomes.

Results
49 pts with CX-pos and 31 pts with CX-neg SBP were included. Median age was 59; median MELD score was 25; 26 (33%) were admitted to the ICU. 67 of 80 (84%) total pts had ≥ 1 MDO risk factor; 40 of 49 (82%) in the CX-pos cohort. 8 (16%) isolates were CRO-non-susceptible, 7 in the 40 CX-pos pts with MDO risk factors (17.5%) vs. 1 in the 9 CX-pos pts without risk factors (11%) (p=NS). 49 (61%) pts received initial TGC therapy. Mortality at 30 days & 90 days was 29 (43%) & 40 (60%) and 3 (23%) & 6 (46%) for pts with and without MDO risk factors, respectively. Outcomes based on empiric therapy are summarized in Table 1.

Conclusion
In our facilities, 16% of isolates in CX-pos SBP pts were not susceptible to CRO. There was no significant difference in the number of non-susceptible isolates in pts with and without MDO risk factors. Treatment with broader therapy was not associated with improved outcomes. Within our health system, giving all SBP pts with MDO risk factors broad empiric therapy may not be necessary. Evaluating local microbiologic data may help health systems assess the local applicability of national treatment guidelines.

Disclosures
Tyler J. Stone, PharmD, ViiV Healthcare: Employee
2238. Effect of Cefazolin Breakpoint Update in Susceptibility Reports on Antimicrobial Use
Authors: Buckley Valerie , Scott Ferren R , Zaidan Noor , Britt Rachel S , Reynoso David 
Published: November 2023

Abstract

Background
The Clinical Laboratory Standards Institute updated the breakpoints for cefazolin in the treatment of E. coli, Klebsiella, and Proteus (EKP) infections in 2011 to reflect doses used in clinical practice and achievable therapeutic concentrations in different body sites (urine vs. non-urine). The UTMB clinical microbiology laboratory adopted this update in January 2022 with the introduction of MicroScan™ technology. Our objective was to evaluate the effect of the cefazolin breakpoint update on antimicrobial use in EKP bloodstream infections.

Methods
This was a retrospective, multicenter, pre-post, study conducted at four UTMB hospitals. Pre-intervention data was collected from January 2021 to December 2021 and post-intervention data was collected from February 2022 to March 2023. Patients ≥ 18 years old were included if they were admitted to a UTMB hospital and received antibiotics for EKP bacteremia. Texas Department of Criminal Justice patients, those with beta-lactam anaphylaxis, polymicrobial bacteremia, immunocompromised patients, and Klebsiella aerogenes isolates were excluded. The primary outcome was cefazolin days of therapy (DOTs) for EKP bacteremia. Extended-spectrum beta-lactamase (ESBL)-producing isolates and Clostridioides difficile (C. difficile) infection six months after the index admission, and in-hospital and 28-day mortality were also assessed.

Results
There were 50 and 48 patients included in the pre- and post-intervention periods, respectively. Most patients were female (59%) with a mean age of 67.8 years (standard deviation [SD] 14.9). The most isolated gram-negative pathogen was Klebsiella pneumonia (81%) followed by Proteus mirabilis (13%) from urinary sources of infection (59%). There was no significant difference in median cefazolin DOTs before (0 days; interquartile range [IQR] 0,0) and after (0 days; IQR 0,0) the breakpoint update (p=0.35). There was no difference in ESBL-producing pathogens (2 vs. 3, p=0.67), C. difficile infection (1 vs. 2, p=0.61), in-hospital (3 vs. 7, p=0.20), or 28-day mortality (0 vs. 0, p=1) between the pre- and post-breakpoint update groups.

Conclusion
Updating the breakpoint to a lower value for EKP isolates in the blood did not have an effect on cefazolin use.

Disclosures
All Authors: No reported disclosures
2239. Antibiotic Sensitivity Spectrum Of Acute Bacterial Cholangitis: Trends From A Tertiary Referral Center In Pakistan
Authors: Butt Muhammad Abdurrahman , Khan Maahin Manzoor , Omar Myyra , Rafique Mehwish , Badshah Maaz , Salih Mohammad , Atiq Muslim 
Published: November 2023

Abstract

Background
Acute bacterial cholangitis can result in significant morbidity. Aggressive antibiotic therapy and prompt endoscopic or percutaneous biliary decompression are key to improving outcomes. However, evolving antimicrobial resistance patterns pose a significant challenge to treating these infections especially when deciding about empiric therapy.

Methods
The study was conducted at Shifa International Hospital in Islamabad. All the patients with the diagnosis of Acute bacterial cholangitis between July 2016 and June 2022 were included. The study was approved by institutional IRB. Data was analyzed using the Pearson Chi-Squared test.

Results
In this study, a total of 144 consecutive patients were included, out of which 51 (35.4%) had a growth on blood cultures. The most commonly identified organism was E. Coli found in 30 (58.8%) followed by Pseudomonas in 7 (4.9%), Klebsiella pneumonia in 6 (11.8%), Proteus in 3 (5.9%), and Enterococcus in 1 (2.0%) patients. Other organisms were found in 15 (29.4%) patients. Polymicrobial infection was found in 12 (23.5%) patients. Out of the blood cultures with growth, 10 (19.607%) were identified as multi-drug resistant (MDR) species, while 19 (37.25%) were identified as extended-spectrum beta-lactamase (ESBL) species. Patients who have undergone prior biliary intervention (ERCP, PTBD or both) were more likely to be infected with E.Coli (MDR)(P=0.026), Proteus(P=0.033), or polymicrobial strains (P=0.040). Antibiotic sensitivity was 10.9% for Ceftazidime, 29.5% for Piperacillin/Tazobactam, 31.3% for Ertapenem, 59.4% for Colistin, 71.7% for Meropenem and 72.9% for Imipenem.
Organisms Identified on Culture. (Table 1)
Organisms Identified on Culture. (Table 1)
Antibiotic Sensitivity Spectrum. (Graph 1)
Antibiotic Sensitivity Spectrum. (Graph 1)

Conclusion
Antibiotic resistance poses a major challenge in treating Acute Bacterial Cholangitis. The most effective antibiotics found for treating this condition in our population were Meropenem, Colistin, and Imipenem, while high resistance patterns were observed for Ertapenem, Ceftazidime, and Piperacillin/Tazobactam. A balance in prescribing broad-spectrum antibiotics and avoiding their use without definitive evidence of infection is crucial in mitigating the growing threat of antimicrobial resistance in cholangitis.

Disclosures
All Authors: No reported disclosures
2252. Characteristics and Management of non-ICU Patients with Community-Acquired Pneumonia (CAP)
Authors: Goetz Matthew B , Vaughn Valerie , Graber Christopher J , Kelly Allison , Jones Makoto M 
Published: November 2023

Abstract

Background
Pneumonia is the most common reason for hospitalization and is often associated with excessively broad empiric therapy & long antibiotic duration. To evaluate overuse, we assessed the indications & frequency of MDRO therapy, risk factors & post-admission culture positivity for MDRO, time to stability and duration of therapy in hospitalized persons with CAP not receiving intensive care.

Methods
We identified patients in the VA Corporate Warehouse with discharge ICD-10 codes consistent with pneumonia from 1/2022 to 3/2023. Exclusion criteria included &lt; 2 days of antibiotic therapy, ICU admission, concurrent infections, &gt; 14 days of antibiotic therapy & severe immunocompromise. Per ATS/IDSA guidelines, we allowed anti-MRSA therapy for patients with a prior positive MRSA culture, anti-pseudomonal (PSA) therapy for patients a prior positive PSA culture, and both anti-MRSA & anti-PSA therapy in patients with severe pneumonia (defined by &gt; 1 ATS/IDSA minor criteria [mental status & x-ray data were not evaluable]) and intravenous antibiotics in the prior 3 months. Similarly, we assessed antibiotic duration and considered &gt; 6 days inappropriate if patients were clinically stable (no more than one sign of instability) or discharged by day 5.

Results
The median age of the 19223 patients was 75 (IQR 68,81); 4.6% were women. 42%, 35% & 22% of patients had CURB-65 scores of 0-1, 2 & 3-4. While 32% (6185/19223) of patients received empiric MDRO therapy, per ATS/IDSA guidelines, only 12% (2330 patients) warranted MDRO therapy (593 had severe disease with prior IV antibiotics, 1737 had prior positive MRSA [1381] and/or PSA [457] cultures). Overall, 90% (5600/6185) of patients who received MDRO therapy were potentially overtreated while 6.5% (1213/19233) were potentially undertreated (Figure 1). MDRO were recovered in 6.3% of cases (Table 1). Across all patients, 98% (18870) were stable by day 5, 42% (7997) of whom received &gt;6 days of therapy (Figure 2).
Figure 1
Table 1
Figure 2

Conclusion
We found substantial opportunities to reduce overuse of MDRO antibiotics and the duration of therapy in persons with CAP. Strengths of this analysis include the breadth and depth of the VA EHR. Limitations include the inability to assess selected measures of disease severity and stability (mental status changes and radiographic abnormalities).

Disclosures
All Authors: No reported disclosures
2256. Racial and Socioeconomic Disparities Evident in Inappropriate Antibiotic Prescribing in the Emergency Department
Authors: Klein Eili , Saheed Mustapha O , Irvin Nathan A , Balhara Kamna S , Badaki-Makun Oluwakemi , Poleon Suprena E Z , Kelen Gabor , Cosgrove Sara E , Hinson Jeremiah S 
Published: November 2023

Abstract

Background
Inappropriate antibiotic prescribing for acute respiratory infections is a common source of low-value care in the emergency department. Racial disparities have been noted in episodes of low-value care, particularly in children, but the intersection between race and socioeconomics in inappropriate prescribing has received less attention. Decisions to prescribe antibiotics outside of guideline recommendations may result from underlying bias. We evaluated inappropriate prescribing by race and socioeconomic status in five emergency departments of a large hospital system.

Methods
We conducted an observational analysis of antibiotic prescribing in adult and pediatric EDs at five hospitals between October 2015 and March 2023. We calculated the rate of inappropriate prescribing for ED encounters that had an ICD-10 for an acute respiratory tract infection (ARTI) that did not require antibiotics and that had no secondary ICD-10 code on the record for which antibiotics may be indicated. Multivariable regression analysis controlling for comorbidities and patient-level factors was used to estimate the odds ratio of prescribing.

Results
A total of 147,402 ED encounters were included, of which ∼50% identified as Black, 23% as White, and 15% as Hispanic. Inappropriate prescribing rates were 8.5% overall, 13.6% for White patients, 7% for Black patients and 6% for Hispanic patients. After adjusting for patient-level factors, including socioeconomic status,White patients had 1.39 (95% CI, 1.32-1.47) higher odds of receiving an inappropriate prescription compared to Black patients. Patients residing in areas of greater socioeconomic deprivation, regardless of race, had 0.70 (95% CI, 0.66-0.75) lower odds of receiving a prescription.
Inappropriate Prescribing Rate by Year and Race
The overall rate of inappropriate prescribing did fall over the years, both overall (black line) and by race, but differences in prescribing by race persisted.
Odds ratios of a patient being prescribed an inappropriate antibiotic

Conclusion
Our results suggest that after controlling for patient-level factors, White patients and patients from wealthier areas are more likely to receive inappropriate antibiotic treatment. While likely multifactorial in origin, it is possible that these disparities are driven by clinicians’ implicit biases that lead to overtreatment of White and wealthier patients. Further qualitative and quantitive approaches are needed to elucidate mechanisms and solutions to these disparities in care.

Disclosures
Oluwakemi Badaki-Makun, MD, PhD, Beckman Coulter: Grant/Research Support Sara E. Cosgrove, MD, MS, Debiopharm: Advisor/Consultant|Duke Clinical Research Institute: Advisor/Consultant Jeremiah S. Hinson, MD, PhD, Beckman Coulter: Advisor/Consultant|Beckman Coulter: Grant/Research Support|Beckman Coulter: TriageGO