bluuebunny/crossref_metadata_2025_split huggingface dataset:
High prevalence of antibiotic use in a tertiary-care hospital in Sierra Leone: We need to handle antibiotics with care
Authors: Kamara Ibrahim Franklyn , Fofanah Bobson , Sheriff Bockarie Pharaj , Katawera Victoria , Musoke Robert , Lakoh Sulaiman , Kamara Kadijatu Nabie , Kanu Joseph Sam 
Published: September 2023

Background: Antimicrobial resistance (AMR) is a global public health concern that has the potential to reverse decades of progress aimed at decreasing morbidity and mortality attributed to infectious diseases. In 2019, ~5 million deaths were associated with AMR, of which 1.2 million were attributed to antibacterial-resistant infections. Healthcare facilities where antimicrobials are frequently used are high-risk settings for the selection and spread of resistant bacteria, and they further contribute to the increase in the burden of AMR. We have documented the prevalence and indication of antibiotic use in a tertiary-care referral hospital in Freetown, Sierra Leone. Methods: This point-prevalence survey was conducted at Connaught hospital, a tertiary-care hospital in Sierra Leone, in November 2021. The hospital offers a range of medical and surgical services through 25 units and has 16 wards with >300 beds. Data on patient-level antibiotic use, including indications for use, were extracted from medical records using WHO point-prevalence survey (PPS) forms that had been pretested and validated. Data collection was conducted in all the wards over a 10-day period by trained healthcare personnel. On the day of the survey, only the medical records of patients on admission before 8:00 a.m. on that day were included in the study. Data entry, cleaning, and analysis were conducted using the WHO PPS platform. Ethical approval was obtained. Results: In total, 87 patient records were included in the survey. Most (71%) were women, and the average age was 30.6 years. The prevalence of antibiotic use was 66%, and the average number of antibiotics prescribed to patients since admission was 2. The 5 most prescribed antibiotics were metronidazole, ceftriaxone, amoxicillin and clavulanic acid, ampicillin and cloxacillin, and azithromycin. The parenteral route of drug administration was the mainstay. The most frequent indications for antibiotic prescription were community-acquired infection and surgical prophylaxis. Blood-culture requests were not ordered before the initiation of antibiotic treatment. Conclusions: This study was the first study to be conducted in Connaught hospital using the WHO PPS methodology. The survey reports a high prevalence (60%) of antibiotic use, and most treatment was done empirically. This finding is contrary to the WHO recommendation of <30% antibiotic use. This high prevalence of antibiotic use has the potential to increase the burden of AMR in the country. Therefore, there is an urgent need to strengthen Connaught hospital’s antibiotic stewardship program.Disclosures: None
Implementing a health-system–wide antibiotic stewardship program in ambulatory surgery centers
Authors: Hickman Kasey , Forcade Nicolas , Cooper Mandelin , Bhagwandeen Shivanne , Russell Brandy 
Published: September 2023

Background: In 2016, the CDC released the Core Elements of Outpatient Antibiotic Stewardship, which extended the requirements previously released for hospital facilities and nursing homes to the outpatient setting. Several regulatory agencies focused on outpatient antimicrobial use. However, The Joint Commission and the Ambulatory Surgery Center (ASC) Leapfrog Group excluded ambulatory surgery centers from their medication management standards and questions. Due to the public health and patient safety benefits of implementing an antimicrobial stewardship program (ASP) and increasing regulatory interest in the matter, the Hospital Corporation of America (HCA) Ambulatory Surgery Division formally launched a nationwide ASP for its ambulatory surgery centers in March 2021. Methods: HCA is a large healthcare system with 146 ASCs in 16 states in 2021. The structure of the ASCs are local surgery centers with a medical director, a nurse responsible for infection prevention, and a pharmacist at a regional level. The types of surgeries vary based on location and ASC site. In 2019, a multidisciplinary team formed the corporate planning committee. The program was modeled after the CDC Core Elements and The Joint Commission’s requirements for an ASP. Each ASC was asked to build a local ASP team, led by a local physician and a regionally based pharmacist. In addition, a stewardship goal was established to update all preoperative antibiotic surgical-site infection prophylaxis order sets. The corporate committee provided educational resources, including evidence-based guidelines for appropriate antibiotic selection for surgical-site infections. They collected antibiotic cost per case as a baseline metric to track and analyze. Pediatric, ophthalmic, and gastrointestinal endoscopic procedures were excluded from the program. Results: From January 1, 2020, through December 31, 2021, including only centers that were operational during this period and excluding single specialty endoscopy centers, antibiotic cost per case decreased annually from $2.38 to $1.84 (t = 4.157; P < .005), and the postoperative infection rate also declined from 0.370 to 0.304 (t = 2.079; P = .040). Conclusions: Our findings suggest that implementing a health-system–wide outpatient antibiotic stewardship program in the ambulatory surgery center setting is feasible and may contribute to decreased antibiotic cost per case and improved postoperative surgical site infection rates.Disclosures: None
Understanding clinician perspectives on antibiotic associated adverse events to inform feedback
Authors: Cherian Jerald , Jones George , Helsel Taylor , Virk Zunaira , Salinas Alejandra , Grieb Suzanne , Keller Sara , Tamma Pranita , Cosgrove Sara 
Published: September 2023

Background: Feedback regarding antibiotic-associated adverse events (ABX-AEs) may assist clinicians with antibiotic decision making. We sought to understand how clinicians account for ABX-AEs when prescribing and their preferences for ABX-AE feedback. Methods: We conducted 1-hour virtual focus groups with 3–5 physicians or advance practice practitioners (APPs) per session at Johns Hopkins Hospital. Participants discussed the role of ABX-AEs in antibiotic decision making and feedback preferences. Participants evaluated prespecified categorization (mildly, moderately, or very concerning) of several ABX-AEs. Focus groups were recorded and transcribed. Transcripts were coded inductively by 2 independent reviewers; discrepancies were resolved by consensus. Codes were used to conduct thematic analysis. Results: Overall, 3 focus groups were conducted with 12 participants: 41.6% were house staff, 16.7% were attending physicians, and 41.6% were APPs. Most were female (91.6%) and were white (41.7%) or Asian (41.7%). Clinicians generally agreed with the prespecified categorizations of ABX-AEs based on degree of clinical concern (Table). We identified 5 themes: (1) The risk of ABX-AE is considered during initial prescribing but influences agent selection more than the decision to prescribe antibiotics. (2) The occurrence of an ABX-AE leads to assessment of need for continued antibiotic therapy. (3) The impact of an ABX-AE on other management decisions is as important as the direct harm of the ABX-AE when assessing severity. (4) Feedback must be curated to prevent clinicians from being overwhelmed with data. (5) Clinicians will be more receptive to feedback regarding ABX-AEs if feedback is contextualized (Fig.). Conclusions: The themes identified and assessment of ABX-AEs of greatest clinical concern may help inform the development of effective ABX-AE feedback methods to improve antibiotic safety.Disclosures: None
Pneumonia panel results and antibiotic prescribing in COVID-19 patients in 2020 versus 2022
Authors: Hussain Aysha , Van Schooneveld Trevor , Bergman Scott , Miller Molly , Fey Paul D. , Stohs Erica 
Published: September 2023

Background: Antibiotics are frequently prescribed in patients with COVID-19 infections to treat secondary bacterial pneumonia. The pneumonia panel (PNP) is a molecular diagnostic tool that rapidly detects 33 bacterial and viral targets. The utility of this panel in COVID-19 patients and how it may direct antibiotic use is unknown. We sought to understand the utilization of PNP in patients with COVID-19 pneumonia over time by comparing clinical parameters, microbiologic results, and antibiotic use between May–December 2020 and January–July 2022. Methods: We implemented the PNP in May 2020 with antimicrobial stewardship guidance, provider education, and order restriction to critical care and infectious disease clinicians. From February–July 2021 prescribers received regular structured antimicrobial stewardship feedback regarding PNP results; from August 2021 to January 2022, no antimicrobial stewardship feedback was provided; from February to July 2022, intermittent feedback was provided. We compared PNP and culture results from sputum or bronchoalveolar lavage samples and antibiotic use and modification within 24 hours of PNP result from patients with confirmed COVID-19 pneumonia between May–December 2020 and January–July 2022. Clinical data and antibiotic use were abstracted through chart review. We excluded patients who died within 72 hours of PNP, those who had concurrent nonpulmonary infections, and those whose COVID-19 test was >30 days prior. Results: We included 114 patients in 2020 and 71 patients in 2022. The overall median age was 61 years, 71% were male, and 66% were mechanically ventilated without statistical differences between the cohorts, including their comorbidities. Acute or worsening hypoxia remained the predominant indication for PNP (77% in 2020 vs 75% in 2022, NS). The median number of days between admission and PNP was 4 (IQR, 1–8) in 2020 versus 3 (IQR, 1–7), and the difference was not significant. PNP and culture results in Table 1 show that Staphylococcus aureus and Hemophilus influenzae were the pathogens most commonly identified. Table 2 describes empiric prescribing and modifications for commonly prescribed antibiotics. Prescribers used empiric cefepime and ceftriaxone more in 2020 and vancomycin more in the 2022 group; however, these were not statistically significant. Cefepime de-escalation was more common in 2022 (53% vs 28%; P = .03). Antibiotic modifications within 24 hours of PNP remained similar in 2020 vs 2022. Although vancomycin cessation was more common in 2020 (78%) versus 2022 (57%), the difference was not statistically significant. Conclusions: With ASP guidance, PNP may be a useful tool to stop or target antibiotics for secondary bacterial pneumonia in COVID-19 pneumonia. Early vancomycin cessation (prior to culture results) may be an enduring consequence of PNP implementation.Disclosures: None
Using state claims data to explore first-line antibiotic prescribing for acute respiratory conditions—Minnesota, 2018–2019
Authors: Freitas Mari , Fell Ashley , Klammer Susan Gerbensky , Lynfield Ruth , Beaudoin Amanda 
Published: September 2023

Background: Nationally, >30% of all outpatient antibiotics are unnecessary or inappropriate, and only 52% of outpatients with sinusitis, otitis media, or pharyngitis receive recommended first-line antibiotics. The Minnesota All Payer Claims Database (MN APCD) collects medical claims, pharmacy claims, and eligibility files from private and public healthcare payers. We analyzed claims to describe overall and firstline antibiotic prescribing for acute bronchitis, adult acute sinusitis, and pediatric patients. Results: We analyzed 3,502,013 respiratory events from 1,612,501 members. Acute bronchitis accounted for 179,723 events (5.1%), acute sinusitis accounted for 236,901 adult events (10%), and otitis media accounted for 232,226 pediatric events (19%). Also, 73,385 bronchitis diagnoses (~40%) had no associated antibiotic. Antibiotics were associated with 199,445 adult sinusitis events (84.2%), of which 89,386 (44.8%) were firstline antibiotics, and 190,962 pediatric otitis media events (82.2%), of which 126,859 (66.4%) were firstline antibiotics. Common antibiotic classes used when a firstline drug was not selected were macrolides (28.9%) and tetracyclines (26.8%) for adult acute sinusitis and cephalosporins (61.4%) and macrolides (30.6%) for pediatric otitis media. Compared to the least vulnerable quartile, the most vulnerable social vulnerability index (SVI) quartile had lower odds of receiving firstline antibiotics for adult acute sinusitis if antibiotics were prescribed (OR, 0.90; 95% CI, 0.87–0.94) and higher odds of receiving firstline antibiotics for pediatric otitis media if antibiotics were prescribed (OR, 1.16; 95% CI, 1.12–1.21). Conclusions: Improvement is needed in avoiding antibiotics for acute bronchitis and selecting firstline drugs for sinusitis and otitis media. Additional analyses adjusting for demographic, geographic, and prescriber factors are planned to better understand differences in prescribing appropriateness among Minnesotans.Disclosures: None
Retrospective data analysis of CLABSI rates at Baystate Medical Center during the COVID-19 pandemic
Authors: Satta Giovanni , Smith Kristin , Smith Jacob 
Published: September 2023

Background: Central-line–associated bloodstream infections (CLABSIs) are an important public health issue. Recent data from the CDC have shown an increase in healthcare-associated infections (including CLABSI) during the COVID-19 pandemic. Therefore, the main aim of this project was to analyze the epidemiology of central-line–associated bloodstream infection during different periods at the Baystate Medical Center (Springfield, MA) before, during, and after COVID-19 peaks of infection. Methods: Two specific periods were considered during the year (quarter January–March and quarter July–September) to consider potential seasonal variations, and the incidence of CLABSI during those 2 quarters was analyzed for 4 different years: 2019 (prepandemic), 2020–2021 (intrapandemic), and 2022 (postpandemic). An analysis of the microbial pathogens causing line infections was also performed to investigate differences described by other authors. Results: In total, 97 CLABSI (all from different patients) were reported into the NHSN website during the 8 periods considered. The average age of the patients was 55 years, with a male:female ratio of 57%:43%, and 14 renal patients were on dialysis. The CLABSI rates ranged from a minimum of 1.11 in Q1 of 2020 (start of COVID) to a maximum of 2 in Q3 of 2021 (SARS-CoV-2 delta variant) (Table 1). A statistical comparison of the pre–COVID-19 period with the respective quarters during the pandemic years (2020, 2021, and 2022) did not show any significant differences (Table 2). In term of microbiological data, of the 97 patients with CLABSIs, most of the patients (n = 70) had only 1 pathogen isolated, 14 patients had 2 pathogens, and 3 patients had 3 pathogens, bringing the total number of bacteria cultured to 117. Candida spp and Enterococcus spp were the most frequently isolated pathogens at 19% and 13%, respectively (Fig. 1). There was no statistically significant difference between the pre–COVID-19 and intra–COVID-19 periods for Candida spp (rate ratio, 1.391; 95% CI, 0.5477–3.533; P = .48) or Enterococcus spp (rate ratio, 2.385; 95% CI, 0.8365–6.798; P = .09). Conclusions: The COVID-19 pandemic did not seem to have an impact on the local epidemiology at Baystate Medical Center in terms of CLABSI rates or type of pathogens causing infections, but the sample size taken into consideration may not have been powerful enough to detect statistical significance.Note. This project was carried out as part of Dr Satta’s MPH requirements at UMass.Disclosures: None
Novel strategies to reduce central-line–associated blood stream infection (CLABSI) events in the neonatal intensive care unit
Authors: Camelo Ingrid , Neshangi Srilatha , Thompson Amy 
Published: September 2023

Background: We describe the components of an improved and easy-to-implement strategy to reduce CLABSI events in the NICU implemented during July–September 2021 in a tertiary-care healthcare center. These strategies were added to an existing institutional protocol created following CDC guidelines. Methods: During the previous timeframe of the implementation of new strategies, CDC insertion-related prevention measures [ie, hand hygiene, use of personal protective equipment (PPE), catheter size selection, standard chlorhexidine gluconate (CHG) antisepsis, maintenance related Curos disinfecting caps, and scrubbing the hub] were part of an existing protocol at our institution. We introduced the following key elements along with the previous ones: decrease length of umbilical vein catheter (UVC) utilization from 14 days to 5–7 days, change of dressing materials from BIOPATCH to 3M Tegaderm CHG chlorhexidine gluconate IV securement transparent dressing, enhanced compliance of an existing artificial nail policy, and restricted blood draw from central lines. Results: After optimization of the previous protocol through these additional strategies, we achieved a significant reduction in the NICU CLABSI rates from 12 CLABSI events between July 2020 and June 2021 to only 3 CLABSI events between July 2021 and June 2022. Conclusions: Revision of CLABSI bundle prevention protocols should be performed frequently to allow improvement opportunities to be added to diminish infection rates. The addition of simple and easy-to-implement key elements interventions to the existing CLABSI bundle had an important impact on the CLABSI rate at our institution.Disclosures: None
The impact of a blood-culture diagnostic stewardship intervention on utilization rates and antimicrobial stewardship
Authors: Zhou Kelvin , Wang Melinda , Shay Sabra , Herlihy James , Siddique Muhammad Asim , Castillo Sergio Trevino , Lasco Todd , Barrett Miriam , Mohajer Mayar Al 
Published: September 2023

Background: Blood cultures are often ordered when an infection is suspected; however, they have a low yield in most cases. The overuse of blood culture is associated with high contamination rates, resulting in excess diagnostics, unnecessary antibiotics, longer hospital stays, and higher hospital costs. We evaluated the safety of a multifaceted intervention, which encompassed education and blood-culture restriction, and its impact on blood-culture utilization and antibiotic use in adult intensive care unit (ICU) patients. Methods: The study was performed between October 2020 and October 2021 in the 12 general medicine and specialty ICUs of a quaternary academic care center. The intervention, implemented in April 2021, included providing education to ICU and infectious disease physicians based on an algorithm adapted from the Johns Hopkins DISTRIBUTE study in addition to restricting blood-culture ordering on these units to these providers. The month of April 2021 was excluded as a washout period. Study outcomes comprised blood-culture utilization, blood-culture positivity, days of therapy (DOT), and length of therapy (LOT), which were compared across the study periods using IRR or the Pearson χ2 test, as appropriate. In addition, 30-day mortality and 30-day ICU readmission were evaluated utilizing multiple COX regression models. Results: In total, 6,303 patients (2,087 MICU, 3,636 SICU, and 580 both) were included in the study, with a median age of 65 years (IQR, 21). Most participants were male (57.5%), with a median length of stay of 175 hours (IQR, 186). After the intervention, blood-culture utilization rates decreased from 15.4% to 12.4% (IRR 0.80, 95% CI, 0.76–0.85) (Fig. 1). There was no difference in blood-culture positivity between the preintervention period (11.05%) and the postintervention period (11.64%; P = .459). Days of therapy decreased from 1,180 to 1,130 per 1,000 patient days (IRR, 0.96; 95% CI, 0.95–0.98), and the length of therapy decreased from 602 to 579 per 1,000 patient days (IRR, 0.96; 95% CI, 0.94–0.99) (Fig. 2). There was no difference in 30-day mortality (P = .241) nor 30-day ICU readmission (P = .888) across the study periods after adjusting for potential confounders (Table 1). Conclusions: Our multifaceted intervention decreased blood-culture and antimicrobial utilization in the ICUs without significantly affecting the positivity rate, mortality, or readmission. This study suggests that educating providers on appropriate blood-culture use along with restriction could safely improve healthcare outcomes. Further studies are warranted to validate our results across various institutions and to evaluate the impact of blood-culture optimization in non-ICU patients.Disclosures: None
Assessment of endotracheal aspirate culture appropriateness among adult ICU patients at an academic medical center
Authors: Chambers Michael , Humphries Romney , Harris Bryan , Talbot Tom 
Published: September 2023

Background: Ventilator-associated pneumonia (VAP) is a significant cause of mortality in intensive care units (ICUs), but minimal research exists regarding the appropriateness of ordering endotracheal aspirate cultures (EACs). We evaluated the diagnostic utility of rationales given for EAC collection in ICUs at an academic medical center to assess potentially inappropriate EAC ordering. Methods: The study population comprised all adult patients admitted to an ICU in 2019 who underwent EAC collection. A random 10% sample from this population, stratified by ICU type, was selected. Clinical and diagnostic characteristics within 24 hours of EAC collection were identified by chart review. Clinical documentation was reviewed to identify ICU provider rationales for ordering EAC. Results: In total, 749 patients underwent EAC collection. Among them, 75 patients comprised the random sample, of whom 7 (9.3%) were excluded due to extubation before culture collection. Figure 1 shows patient distribution by ICU type. From these 68 patients, 105 EACs were collected. Of these, 41 (39%) were positive for potential pathogens, and 59 (56.2%) had explicit rationales for EAC collection, including fever (44.1%), hypoxia (18.6%), leukocytosis (16.9%), secretions (11.9%), shock (10.2%), and radiologic findings (8.5%). Also, 43.8% of EACs had no explicit rationale for collection. Table 1 shows sensitivities, specificities, positive likelihood ratios (LRs), and negative LRs for these rationales and related characteristics. Conclusions: EACs were commonly ordered without clear clinical indications. Of the noted rationales for EAC collections, most performed poorly at predicting positive cultures, which challenged common rationales for ordering EAC. This study could serve as a foundation for diagnostic stewardship interventions for EAC, potentially decreasing unnecessary cultures.Disclosures: None