bluuebunny/crossref_metadata_2025_split huggingface dataset:
161. Assessing Trends in 1,3-β-D Glucan and Aspergillus Galactomannan Antigen Ordering to Improve Use
Authors: Poplin Victoria , Liesman Rachael , Bahr Nathan C 
Published: December 2022

Abstract

Background
1,3-β-D Glucan (BDG) and Aspergillus galactomannan antigen (GM) are commonly ordered. Overutilization of these tests increases the incidence of false positive results, potentially leading to unnecessary follow up testing, procedures, and treatment. The aim of this quality improvement (QI) study was to improve our understanding of BDG and GM utilization at our institution.

Methods
The test orders for BDG and GM were modified within our electronic medical record (EMR) to provide education and require selection of ordering reason from a list of criteria. Educational sessions were provided to non-transplant provider groups who order BDG and GM frequently. Total number of tests, test results, patient immunosuppressed status, ordering location, and provider specialty were compared for a 3-month period pre/post intervention. Ordering criteria was collected post-intervention. SPSS software was used for chi square tests comparing groups.

Results
BDG and GM ordering practices were compared in the pre- and post-intervention timeframes (Table 1). There were no significant differences in the total number of tests, immune status of patients, ordering location or test results for BDG or GM. A significant decrease in hospitalist ordering was found (n=79 (pre), n=48 (post), p=0.006). Positive GM tests were rare in both periods (1.96%, 6/306 and 3.34%, 10/299). Ordering criteria for both tests were also evaluated in the post-intervention period (Table 2). The most common ordering criteria selected for BDG and GM were disseminated fungal infection 275/435 (63%) and invasive aspergillosis 241/299 (81%), respectively.

Conclusion
Most BDG and GM tests were ordered utilizing appropriate ordering criteria and were among immunosuppressed patients. However, selection of an appropriate reason does not necessarily correlate to obtaining in the appropriate clinical setting. This QI project improved our understanding of how BDG and GM are utilized, and by whom. In the future, these results will be used to provide more targeted education to specific provider groups. In addition, further EMR order entry modifications will focus on potential false positive results to further optimize BDG and GM test utilization.

Disclosures
All Authors: No reported disclosures.
162. Assessment of Guideline-Concordant Testing for Legionella pneumophila and Streptococcus pneumoniae in Community-Acquired Pneumonia
Authors: Malik Waleed , Fisher Ann , Kotansky Brian , Dembry Louise , Datta Rupak 
Published: December 2022

Abstract

Background
Urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila is only recommended in patients with severe pneumonia according to the 2019 guidelines from the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA). Unnecessary testing for these organisms may increase antibiotic utilization. This quality improvement project evaluated whether patients who received a Streptococcus pneumoniae or Legionella pneumophila urine antigen met criteria for testing.

Methods
We conducted a cohort study of patients who received a urinary antigen test for Streptococcus pneumoniae or Legionella pneumophila within 3 days of admission to the Veterans Affairs Connecticut Healthcare System between September 1, 2018 and September 1, 2021. We determined whether patients had clinically defined pneumonia per National Healthcare Safety Network criteria. Among patients that met criteria for clinically defined pneumonia, the subset with severe pneumonia according to the ATS/IDSA guidelines was identified. We used the ATS/IDSA guidelines to determine whether patients received guideline-concordant choice of therapy.

Results
We identified 352 patients who received a urinary antigen test within 3 days of admission. Mean age was 72.6 years, 97% (n=278) were male sex, and 86% (n=301) were White race. Common comorbidities included heart disease (76%, n=268), lung disease (58%, n=203), and diabetes (30%, n=106). Overall, 36% (n=127) of patients met criteria for clinically defined pneumonia, and 7% (n=25) met criteria for severe pneumonia. 9 patients had a positive Streptococcus pneumoniae antigen test and 1 patient had a positive test for Legionella. Among patients with clinically defined pneumonia, 74% (n=75) received guideline-concordant choice of therapy and 74% (n=75) received an antibiotic duration &gt;5 days
Diagnostic and Therapeutic Characteristics of Veterans According to Presence of Pneumonia

Conclusion
Only 7% of patients who underwent urine antigen testing for Streptococcus pneumoniae or Legionella pneumophila met criteria for testing per ATS/IDSA guidelines, and length of therapy was prolonged in the vast majority of patients. These data support the need for a clinical decision-making tool to reduce unnecessary testing and treatment for pneumonia at our institution.

Disclosures
All Authors: No reported disclosures.
164. BioFire FilmArray Pneumonia Panel Implementation: Examining Appropriate Usage and Opportunities for Diagnostic Stewardship
Authors: Zelus Casey S , Van Schooneveld Trevor C 
Published: December 2022

Abstract

Background
The BioFire FilmArray Pneumonia Panel (PnaP) is a novel diagnostic tool for rapid diagnosis of lower respiratory tract infections. However, appropriate usage and optimal implementation strategy in the clinical setting remain poorly characterized. The PnaP assay was introduced along with institutional guidance restricting use to intensive care units (ICUs) and Infectious Disease and Pulmonary consultative services. Examining guideline compliance and clinically appropriate PnaP usage highlights the role of diagnostic stewardship in improving management of pneumonia in hospitalized patients.

Methods
PnaP testing was obtained retrospectively from hospitalized adults over a 6-month period (January 1 - June 30, 2021). Outpatient and pediatric (&lt; 18 years of age) testing was excluded. Appropriate use criteria based on institutional guidance are defined in Figure 1. Primary outcomes included PnaP results with respect to utilization appropriateness. Statistical analyses included chi squared testing with p-value &lt; 0.05 considered statistically significant.

Results
PnaP testing was performed on 574 respiratory samples from 440 patients (Table 1). Overall compliance with institutional guidance was 84% (n=482/574) but varied with respect to level of care (ICU 89% vs non-ICU 72%, p &lt; 0.001) and location (Table 2). Repeated testing was the most common reason for non-compliance, accounting for 59% of inappropriate use. Positivity rates varied significantly respect to guideline compliance and level of care, with distinct pathogen isolation profiles seen among ICU and non-ICU patients. Pathogen isolations was not significantly impacted by respiratory sample type (Table 3).

Conclusion
Multiplex panels can isolate significant more pathogens compared to traditional diagnostic testing, with the potential to identify additional variables that factor into pneumonia pathology. PnaP assay results and appropriateness of use appear intertwined, with criteria compliance significantly impacting positivity rates, with distinct pathogens isolated among ICU and non-ICU patient groups. Our study highlights specific target areas for intervention, with the potential to promote clinically appropriate diagnostic testing by adjusting ordering restrictions at our hospital.

Disclosures
Trevor C. Van Schooneveld, MD, bioMerieux: Advisor/Consultant|bioMerieux: Grant/Research Support|Insmed: Grant/Research Support|Merck: Grant/Research Support|Thermo-Fischer: Advisor/Consultant.
166. Bring your boots: wading through GI PCR panel diagnostic stewardship applications
Authors: Bennett Nicholas , Boyd Sarah E , Sattler Jeffrey , Boos Ginny , Johnston Cara , Humphrey Matt , Aragon Laura , Aragon Laura , Essmyer Cynthia 
Published: December 2022

Abstract

Background
Infectious diarrhea is a common cause of emergency department (ED) visits and hospital admissions. Polymerase chain reaction (PCR) testing allows for quick and expansive pathogen identification and facilitates earlier targeted treatment. We implemented a multiplex gastrointestinal (GI) PCR panel in 2014. In collaboration with the Antimicrobial and Diagnostic Advisement Program (ADAP), post-launch optimization strategies have changed test use. We evaluate the impact of diagnostic stewardship initiatives.

Methods
GI PCR testing was initially unrestricted for ED or inpatients within 72 hours of admission. After fielding many questions regarding interpretation, the ADAP developed a guidance document in June 2019 regarding treatment considerations for all potential organisms detected. In January 2020, organism-specific treatment considerations were embedded in the test results real-time treatment guidance (figure 1). A pre-post quality improvement assessment of the changes was performed. In August 2021, individual GI PCR panel orders were replaced with an order set containing a decision tree to provide passive guidance evaluating acute vs chronic diarrhea, assessing recent antibiotic use (to consider C. difficile testing), no testing scenarios, and avoiding repeat testing (figure 2). Figure 1Example of templated comments for Norovirus embedded within GI PCR panel results.
Figure 2 GI PCR panel order set

Results
GI PCR panel use peaked in 2019 with 3,142 tests processed. The guidance document was less helpful, requiring an external site link. Embedding organism-specific GI PCR guidance significantly improved appropriate antibiotic prescribing (77.9 vs 89.1%, p=0.001). A precipitous drop off in GI PCR test orders occurred after the COVID-19 pandemic began (1,774 in 2020), partly attributed to supply chain issues. When comparing intra-pandemic years (2020 vs 2021), implementation of a smart order set was associated with a 51.3% reduction in orders (1,774 vs 864) and $131,000 in savings despite significant patient volume increases in 2021. Low use rates have persisted into the first quarter of 2022 (n=229).

Conclusion
Diagnostic stewardship changes should be proactive and contextually relevant at the time of result interpretation. Antimicrobial stewardship programs are uniquely positioned to lead optimization initiatives and drive clinical and cost-effective solutions.

Disclosures
All Authors: No reported disclosures.
170. Comparison of Traditional Stool Culture and Targeted Testing Using Multiplex PCR to Diagnose Infectious Diarrhea at the Atlanta VA Medical Center (AVAMC): A Diagnostic Stewardship Initiative.
Authors: Molinari Alexander H , Epstein Lauren H , Darius Nicole , Goolsby Tiffany , Webster Andrew S 
Published: December 2022

Abstract

Background
Multiplex PCR panels have become common for diagnosing infectious diarrhea; however, indiscriminate use of multiplex PCR panels may identify common pathogens that do not require treatment.
To optimize laboratory workflow and improve diagnostic stewardship, we developed a targeted algorithm to optimize multiplex PCR testing at the AVAMC. We retroactively applied the targeted algorithm to historical stool cultures to assess the potential impact on diagnosis, inappropriate test ordering, and cost. Figure 1Targeted Algorithm for Testing Infectious Diarrhea

Methods
In March 2022, multiplex PCR testing (Biofire) was initiated at AVAMC; we developed a targeted algorithm to inform testing of patients at highest risk from infectious bacterial diarrhea (Figure 1). We retrospectively reviewed all clinical information among patients with bacterial stool testing, which included cultures and antigen tests, obtained from January 1, 2019 to December 31, 2021. In our analysis, we included all patients with a positive stool culture and a random sample of patients with a negative stool culture. We applied the targeted algorithm to both retrospective cohorts in order to evaluate potentially missed cases, outcomes, and overall differences in costs and labor between traditional stool cultures and targeted multiplex PCR testing.

Results
We identified 1027 patients with bacterial stool testing. Among 27 patients with a positive stool test, the targeted algorithm missed testing among 6 (22%) patients with mild, self-limited disease that resolved within 7 days. Among 100 patients with negative stool cultures, the targeted algorithm excluded testing among 75 (75%) patients. Among the remaining 25 (25%) negative patients who would have been tested using the targeted algorithm, 14 (56%) were high-risk and 16 (64%) had severe illness. Eliminating unnecessary stool testing using a targeted algorithm would have saved an estimated $50,000 and 750 laboratory labor hours.

Conclusion
At our facility, the implementation of algorithm-guided infectious diarrhea testing by multiplex PCR is estimated to reduce laboratory time and materials costs while eliminating 75% of unnecessary testing. Algorithm-guided testing would capture the majority of bacterial diarrhea at our institution but could lead to missed diagnoses in lower-risk populations.

Disclosures
All Authors: No reported disclosures.
176. Evaluation of the Predictive Value of Methicillin-Resistant Staphylococcus aureus (MRSA) Nares Polymerase Chain Reaction (PCR) Screening within Hospitalized Patients
Authors: Alilaen Nicole , Vu Catherine , Burke Victoria , Bellfi Lillian 
Published: December 2022

Abstract

Background
While MRSA nares PCR screening utilization has established evidence for de-escalation of anti-MRSA agents in pneumonia, its utility in other sites of infection is not well studied. The purpose of this study was to evaluate the utility of MRSA nares PCR screening within a wide range clinical specimens and its impact on antimicrobial stewardship.

Methods
This retrospective study was conducted at a 446-bed academic medical center. Patients ≥ 18 years old with an in-house MRSA nares PCR ordered between 1 November 2021 and 1 February 2022 were included in the primary analysis. Negative predictive value (NPV), positive predictive value (PPV), sensitivity, and specificity were calculated using cultures obtained within 7 days of nares screening. Vancomycin duration, de-escalation, and incidence of acute kidney injury were collected pre- and post- implementation of the in-house MRSA PCR screening. The pre-intervention cohort observed patients admitted from 1 November 2020 to 1 February 2021 screened by send out MRSA nares PCR.

Results
At baseline, patients were a mean age of 55 years old, 55% black, and required ICU care in 50% of cases. A total of 665 cultures from 308 patients were included in the primary analysis (131 respiratory, 282 blood, 154 urine, 61 wound, 22 sterile fluid, 15 bone, and 12 spinal fluid specimens). The overall NPV of the MRSA nares PCR screening was 99.8% and the PPV was 21.1%. The sensitivity and specificity were 96.8% and 81.67%, respectively. Duration of vancomycin was a median of 3 days in both the pre- and post- intervention cohorts. However, rates of vancomycin de-escalation increased at day 3 from 31.5% to 48.1% and at day 5 from 69.9% to 80.0% post implementation on an in-house MRSA PCR screening. Incidence of acute kidney injury decreased from 45.2% to 21.6%.

Conclusion
Based on its high NPV among cultures of different sites, MRSA nares PCR screening may be utilized to de-escalate anti-MRSA agents within tertiary care facilities.

Disclosures
All Authors: No reported disclosures.
185. Implementation of Multiplex Polymerase Chain Reaction in Clinical Practice: Impact on Antimicrobial Management In Infectious Diarrhea
Authors: Kelly Gillean , Iordanov Roumen , Franklin Alex , Ahmed Amna , Srinivasan Krithia , Hayon Jesica , Lasco Todd M , Amini Rosie , Shay Sabra , Kulkarni Prathit A , Mohajer Mayar Al 
Published: December 2022

Abstract

Background
Stool culture and stool polymerase chain reaction (PCR) panels are both used to evaluate patients with suspected infectious diarrhea. Stool PCR panels are especially advantageous because of their ability to detect a broad array of infectious pathogens in less than one hour. Our study assessed how the use of stool PCR panels instead of stool culture impacted antibiotic days of therapy (DOT) and length of therapy (LOT) in hospitalized patients with suspected infectious diarrhea.

Methods
In December 2021, an intervention was implemented in our hospital in which all electronic orders for stool cultures were automatically switched to stool PCR testing. The pre-intervention group was comprised of 75 hospitalized adult patients who had a stool culture obtained from September to November 2021. The post-intervention group was comprised of 81 adult patients who had a stool PCR obtained from December 2021 to February 2022. The DOT and LOT for antibiotics prescribed specifically for infectious diarrhea were determined for each patient; DOT and LOT were compared between the pre- and post- intervention groups.

Results
The median DOT in the pre- and post-intervention groups was 0 with a range of 0-10 and 0-8, respectively. The median LOT in the pre- and post-intervention groups was 0 (range 0-5 for both groups). No significant difference in the median DOT (Wilcoxon rank sum test, p-value = 0.967) or LOT (Wilcoxon rank sum test, p-value = 0.993) was found between the pre- and post-intervention groups (Figure 1). After adjusting for patient days present, no significant change in DOT or LOT incidence rate was found between the pre- and post-intervention groups. The DOT incidence rate ratio (RR) was 0.71 (95% CI 0.42, 1.22), and the LOT incidence RR was 0.67 (95% CI 0.36, 1.24). Figure 1.DOT and LOT Comparisons between Pre- and Post-Intervention Groups
Antibiotic days of therapy (DOT) stratified by study period (top) and antibiotic (LOT) stratified by study period (bottom).

Conclusion
An intervention of automatically changing stool culture testing to stool PCR testing did not result in a significant change in median DOT or LOT in hospitalized adult patients, nor did it result in a significant change in DOT or LOT incidence rate. These findings could be explained by an insufficient sample size (n = 156), limiting the study’s power. Additionally, most patients in the pre-intervention group received no antibiotics for infectious diarrhea, resulting in a short DOT and LOT at baseline.

Disclosures
Sabra Shay, BSN, MPH, Premier Inc.: Employee Prathit A. Kulkarni, M.D., Vessel Health, Inc.: Grant/Research Support.
188. Opportunities for antimicrobial stewardship: Time to optimal therapy and vancomycin use in gram-positive and contaminated blood cultures before and after implementation of rapid blood culture diagnostic testing
Authors: Olion Kelsey , Hamann Laura , Jennemann Rebecca , Shapiro-Schere Julie A , Burnett Yvonne J 
Published: December 2022

Abstract

Background
Rapid molecular diagnostic tests improve time to organism identification and may expedite antimicrobial de-escalation. Through faster detection of contaminated samples, rapid blood culture identification (BCID) should also reduce unnecessary antibiotic use. BioFire FilmArray BCID was implemented in July 2019 at a community hospital. This study compared antimicrobial use for gram-positive blood cultures before and after BCID implementation to identify areas for further antimicrobial stewardship intervention.

Methods
This retrospective cohort study evaluated adult patients at a 450-bed community hospital with gram-positive blood culture results between February and June 2018 and 2019 (pre-and post-BCID). Patients were excluded for polymicrobial bacteremia, pregnancy, or expiration/hospice status before blood culture positivity. The primary outcome was time to optimal therapy (TTOT) for bacteremia, defined as time to antimicrobial de-escalation, discontinuation, or result for untreated contaminated cultures. Time to organism identification, receipt of optimal therapy, and vancomycin duration were also evaluated, in addition to subgroup analysis of contaminated cultures (identified by microbiology comment or physician note).

Results
Of the 232 patients, median age was 70 years and 54.3% were male. Coagulase-negative staphylococci was most commonly isolated (n=104, 45%) and contamination rate was 53.4%. Median TTOT improved from 53.3 vs 28 hours, p&lt; 0.001 in pre- vs post-groups, respectively, and optimal therapy selection increased from 83% to 93%, p=0.028. Median time to organism identification was 60.2 vs 23.5 hours, p&lt; 0.001. Median duration for vancomycin (35.1 vs 25.2 hours, p=0.231) and overall antimicrobial duration did not differ between groups. Among contaminated blood cultures, TTOT improved (54 vs 27.3 hours, p&lt; 0.001) and vancomycin median duration decreased (27.5 vs 16.6 hours, p=0.253).

Conclusion
Rapid BCID significantly improved TTOT, resulting in improved rates of optimal therapy and an observed reduced vancomycin duration. High rates of contaminated blood cultures identified opportunities for coordination with antimicrobial stewardship to reduce contamination rates and improve antimicrobial use.

Disclosures
All Authors: No reported disclosures.
192. Predictors of Actionable Results on Gastrointestinal Panel Testing for Children Hospitalized with Acute Diarrheal Illnesses
Authors: Ho Erin , Dominguez Samuel R , Cotter Jillian , Thomas Jacob 
Published: December 2022

Abstract

Background
Among hospitalized children with acute diarrheal illnesses, multiplex PCR gastrointestinal panels (GIP) are commonly overused. GIPs are most likely to impact management and outcomes if an actionable (bacterial or parasitic) result is obtained. To inform future diagnostic stewardship, we evaluated which clinical factors, including provider-reported test indications and stool frequency, were associated with actionable results.

Methods
This is a multicenter cross-sectional study of children ≤ 18 years old hospitalized at any Children’s Hospital Colorado site between 2015-2018 with a diarrheal illness and at least one GIP performed. We used multivariable logistic regression to determine associations between actionable GIP results and testing indication, stool frequency, and demographics. We evaluated these findings in two subgroups - patients with at least one complex chronic condition (CCC) and non-CCC patients.

Results
There were 1,124 GIPs performed for 967 encounters. Yield of actionable results was higher for non-CCC than CCC patients (30% vs. 21%, p &lt; .001) (Image 1), and test indications differed between the two groups (Table 1). For non-CCC patients, we found positive associations between actionable results and “Diarrhea with blood or pus” test indication (relative risk (RR) 1.5, confidence limits (CL) 1.09-2.07, p = .01), summer season (RR 1.69, CL 1.14-2.5, p =.01), and age ≥1 yr (RR 2.88, CL 1.82-4.54, p&lt; .001). Male gender was negatively associated (RR 0.75, CL 0.58-0.96, p=.02). For CCC patients, age ≥1 yr was positively associated with actionable results (RR 3.17, CL 1.59-6.32, p = .001). ≥4 stools per day (RR 0.73, CL 0.54-.99, p=0.04) and ICU admission (RR 0.69, CL 0.5-0.95, p=0.2) were negatively associated with actionable results (Table 2).

Conclusion
For both cohorts, age ≥1 was positively associated with actionable GIP results. For otherwise healthy children, bloody diarrhea and summertime were positively associated with actionable results. CCC patients had less frequent actionable results, and no GIP indications were predictive of actionable results. A higher stool burden did not statistically increase the probability of an actionable result in either cohort. These results may guide diagnostic stewardships efforts for GIP ordering in pediatric patients.

Disclosures
Samuel R. Dominguez, MD PhD, Biofire DIagnostics: Advisor/Consultant|Biofire DIagnostics: Grant/Research Support|DiaSorin Molecular: Advisor/Consultant|Karius: Advisor/Consultant|Pfizer: Grant/Research Support.