bluuebunny/crossref_metadata_2025_split huggingface dataset:
545. Real-world use of a novel host-response test to aid physicians in distinguishing between bacterial and viral infections at outpatient urgent care centers
Authors: Ben David Shirley Shapiro , Rahamim-Cohen Daniella , Kalmovich Boaz 
Published: December 2022

Abstract

Background
Uncertainty in the diagnostic process of an acute infection may cause antibiotic overuse and underuse. MeMed BV® (BV) is an FDA cleared test designed to differentiate between bacterial and viral infections based on computational integration of the blood levels of three proteins (TRAIL, IP-10, CRP) into a score. Here we describe the impact of its real-world use on the uncertainty physicians face in the diagnostic process.

Methods
A retrospective study was conducted at three Maccabi Healthcare Services outpatient urgent care centers in Israel between December 2020 and May 2021. Physicians could use BV in real time whenever they felt uncertain regarding the cause of the infection -bacterial or viral. The BV result is based on pre-defined score thresholds: 0 ≤ score &lt; 35 viral (or other non-bacterial) infection, 35 ≤ score ≤ 65 equivocal and 65 &lt; score ≤ 100 bacterial infection (or co-infection). Physicians were asked to answer a questionnaire composed of two parts: The first part included the suspected etiology and likelihood of prescribing antibiotic (AB) treatment before ordering the test. The second part included questions regarding the tool's impact on their decision-making process, completed after receiving the BV results.

Results
A total of 152 questionnaires were filled out. Of them, 58% of the patients were children under the age of 18, and 51% were female. The average number of days from fever onset was three in children and 2.3 in adults. Out of the 131 cases with either bacterial or viral scores, in 86 (66%) of the questionnaires the physicians confirmed that the BV result supported their overall impression and management. In 28 (21%) cases the BV results altered their decision. In 39 (30%) cases the physicians marked high likelihood for prescribing ABs, of them 22 (50%) received a viral score and in 8 (36%) of them physicians altered their decision and withheld ABs. In 63 (41%) cases the physicians marked low likelihood for prescribing ABs of which 8 (15%) received a bacterial score and in 6 (75%) cases physicians altered their decision and prescribed ABs.

Conclusion
BV contributed greatly to physicians’ decision-making process in the management of patients with acute infection. These preliminary results demonstrate the test’s clinical utility with regard to AB overuse and underuse.

Disclosures
Shirley Shapiro Ben David, MD, pfizer: Grant/Research Support.
546. Resolution of a Cluster of Travel-Associated Leptospira santarosai Infection in Four Adolescents by Plasma Microbial Cell-Free DNA Detection with the Karius Test®
Authors: Nguyen-Tran Hai D , Erdem Guliz , Laufer Marcelo , Patterson Lori , Ahmed Asim A , Bower William A , Galloway Renee , Saporta-Keating Sara 
Published: December 2022

Abstract

Background
Leptospira can cause severe infections but their diagnosis can be challenging. Diagnosis is limited by nonspecific, protean clinical symptoms; the fastidious nature of Leptospira; and poor specificity, sensitivity, and long turnaround times of serologic testing. Given these limitations, identifying epidemiological clusters of leptospirosis can be challenging. Rapid, non-invasive diagnosis of leptospirosis by microbial cell-free DNA (mcfDNA) next-generation sequencing (NGS) of plasma offers a means to overcome these limitations in individual diagnosis and public health epidemiological surveillance.

Methods
The Karius Test® (KT) detects and quantifies mcfDNA in molecules/µL (MPM) in plasma from a curated genomic database of &gt;20,000 organisms reporting on &gt;1000 pathogens through the Karius CLIA certified/CAP accredited lab (Redwood City, CA). Four KT detections of Leptospira santarosai were identified April - August 2021 across four independent United States institutions. Clinical review was performed by pediatric infectious diseases consultants.

Results
KT detected L. santarosai in four adolescents with travel to Costa Rica or Belize (Table). A broad work-up was performed in all patients. McfDNA NGS was the first test to identify L. santarosai as the diagnosis in all cases with an average time to diagnosis of 2.5+/- 0.58 days from sample collection, enabling narrowed, targeted antibiotic treatment. L. santarosai mcfDNA was positive in three patients despite pretreatment; average L. santarosai mcfDNA concentration was 173.5+/- 186.1 MPM. Leptospira serologies were confirmatory in three patients, potential epidemiological exposures were identified in all patients, and all recovered.

Conclusion
KT enabled rapid, non-invasive diagnosis of diverse manifestations of L. santarosai against a competing broad differential in four adolescent travelers returning from Costa Rica or Belize. The resolution of the etiology of this cluster of patients with leptospirosis demonstrates the potential utility of mcfDNA to quickly diagnose and support case definitions of reportable diseases and the potential importance of plasma mcfDNA NGS in public health and epidemiological surveillance.

Disclosures
Asim A. Ahmed, MD, Karius: Employee|Karius: Stocks/Bonds Sara Saporta-Keating, MS, MD, Pfizer: Co-investigator in investigator-driven study sponsored by Pfizer.
551. Antibiotic Use Among Surgical Patients in the Neonatal Intensive Care Unit (NICU): The NO-More-AntibioticS and Resistance in Surgery (NO-MAS-R-S) Study
Authors: Dixit Himangini Singh , Drews Joseph D , Nwomeh Benedict , Sanchez Pablo J , Goff Debra A , Medoro Alexandra K , Magers Jacqueline , Prusakov Pavel 
Published: December 2022

Abstract

Background
Although antibiotic exposure among infants in the NICU is associated with short- and long-term adverse effects, the burden of antibiotic use in neonatal surgical patients has not been well described. The pediatric surgical team at Nationwide Children’s Hospital (NCH) provides all surgical consultations for central Ohio in the level 4 outborn referral NICU at NCH. Our objective was to quantify the total use of antibiotics in surgical NICU patients and thus inform antimicrobial stewardship opportunities.

Methods
This was a prospective observational study of all infants in the NCH NICU who underwent pediatric surgical evaluation and received antibiotic therapy from 1/3/2022 to 4/29/2022. The pediatric surgery fellow informed the neonatal clinical pharmacist about all consultations and provided qualitative data on antibiotic prescribing (diagnosis, indication and reasoning for antibiotic selection, dosing, and duration) using a set questionnaire. Pertinent demographic maternal/infant data were obtained from the electronic health records.

Results
During the 4-month study period, 59 infants (median gestational age, 35 wks, IQR 28-35 wks; median birth weight, 2275 g, IQR 1085-3107 g) underwent surgical evaluation at a median postnatal age of 2 days (IQR, 1-12 d). 33 (56%) infants were male; 9 (22%) had antibiotic exposure for &gt;48 hours before surgical consultation. Of the 59 infants, 28 (47%) had a surgical procedure performed (Figure 1) with indications for antibiotic use provided in Figure 2. 34 (58%) infants had antibiotics started by surgical team for a median treatment duration of 7 days (IQR, 5-14). Surgeons considered 74% (20/27) of antibiotic initiation courses to be evidence-based. Of the 59 infants, the most commonly used antibiotics were gentamicin (32%), ampicillin-sulbactam (29%), cefazolin (19%), and piperacillin-tazobactam (14%). The most frequent blood isolate was E. coli (n=4). Mortality was 2% (n=1) and was not infection-related. Figure 1Surgical procedures performed in 28 of 59 infants who underwent surgical evaluation.
Figure 2 Indications for antibiotic use in 59 infants who underwent surgical evaluation

Conclusion
Antibiotics were utilized in the majority of infants who had surgical consultation. Surgical prophylaxis was the main indication and may serve as a potential opportunity for ongoing surgical stewardship efforts.
(Supported by Merck & Co research grant)

Disclosures
Debra A. Goff, Pharm.D, FIDSA, FCCP, Merck Sharp & Dohme (MSD): Grant/Research Support Alexandra K. Medoro, MD, Merck: Grant/Research Support Pavel Prusakov, PharmD, Merck Sharp & Dohme: Grant/Research Support.
555. Early Outcomes of Penicillin and Cephalosporin Allergy Assessment Tool
Authors: Norton Laura E , Grothe Lily Y , Oliver Meredith B , Thielen Beth K 
Published: December 2022

Abstract

Background
Penicillin allergy is reported in approximately 10% of the US population and is one of the most frequent medication allergies in children. Penicillin allergy labels are associated with more expensive care and adverse outcomes, such as MRSA and C. Diff infection. Studies suggest up to 90% of these patients could safely tolerate this class of drugs. Our team at M Health Fairview University of Minnesota Masonic Children’s Hospital (UMMCH) implemented an allergy assessment tool for inpatient use in January of 2020 to create an effective and accessible path for delabeling pediatric patients with penicillin and cephalosporin allergies.

Methods
Our pharmacists conducted the allergy assessment on inpatient pediatric patients with penicillin/cephalosporin allergies. Those deemed low to moderate risk for having a true IgE-mediated allergy by our assessment were recommended for outpatient allergy testing. Those deemed no risk were recommended for immediate delabeling. We performed manual chart reviews to describe pediatric patient risk stratification, allergy label status after assessment, outpatient allergy follow-up, and status and results of allergy testing.

Results
From January, 2020 to present, 140 patients received a pharmacist allergy assessment. During the 2020 calendar year, 51 allergy assessments were performed on 49 patients. 58 allergies were recorded, with penicillins as the most common (62%), followed by cephalosporins (24%), and penicillin combination drugs (14%). 1.9% of allergies were high risk, 68.8% moderate, 15.7% low, 9.8% no risk, and 3.8% difficult to determine. Of 42 patients deemed low to moderate risk, 8 (17%) were seen by an outpatient allergist. Of these, 5 proceeded with allergy testing and were found to be not allergic. Out of 58 allergy labels, 9 (15.5%) were removed, 5 after allergy testing, 2 immediately due to no risk, and 2 after further history review.

Conclusion
Our preliminary data show allergy assessments can inform pediatric allergy risk prior to outpatient allergy testing and assist with imminent delabeling. Next steps include analysis of our 2021 assessments as well as patient caregiver surveys to assess perception of the allergy assessment process and to elucidate on barriers to testing/delabeling.

Disclosures
Beth K. Thielen, MD, PhD, Horizon: Advisor/Consultant|Horizon: Honoraria|Merck: Grant/Research Support.
557. Improving Surgical Antimicrobial Stewardship with Quarterly Audit and Feedback Scorecards
Authors: Downey Rachel , Bhakta Kavita , Sapozhnikov Julia , Grethel Erich , Fernandez Marisol 
Published: December 2022

Abstract

Background
Adherence to national surgical antimicrobial prophylaxis (SAP) is of utmost importance to prevent antimicrobial resistance. Guideline development does not always confer compliance with changes. This report describes an ongoing process of quarterly SAP audit and feedback using individualized scorecards.

Methods
Our hospital participates in local data collection for the National Surgery Quality Improvement Program- Pediatric (NSQIP-P). We implemented changes to local SAP guidance to better align with national recommendations and collected data regarding baseline SAP beginning in January 2019. Using these data, we initiated an audit and feedback program of quarterly scorecard reports beginning in January 2020 regarding surgical adherence to national SAP guidelines at our children’s hospital.
This scorecard gives each surgeon a quarterly, private, individual report, allowing them to review cases that deviated from SAP guidance, and compare their scores to the surgical team as a whole. NSQIP-P cases are adjudicated manually for SAP adherence. The program aimed to improve adherence to SAP guidance, promote collaborative discussion, and identify areas for improvement in prescribing practices and local guidelines. The goal was to reach &gt;90% compliance with SAP guidance.

Results
Baseline adherence to SAP guidance was 50-85%. After introducing the audit and feedback program in January 2020, SAP compliance rates increased overall. In the most recent 3 quarters (2021 Q1-3), adherence was 95%, 89%, and 95%, respectively. Figure 1.Antimicrobial stewardship report by quarter among the pediatric surgery teamFigure 2.Example of individual audit & feedback scorecard

Conclusion
We have seen an improvement overall in SAP compliance and have reached the goal of &gt;90% compliance. One drawback to this program is the need for manual case review. Feedback using scorecards has led to better communication regarding process changes for SAP prescribing.

Disclosures
All Authors: No reported disclosures.
562. Multipronged Approach to Recruitment of Pediatric Patients with Beta-Lactam Allergies for Evaluation and De-labeling
Authors: Ewing Anne , Patel Malina , Stephen Ellen D , Keizur Erin , Vu Betty N , Nash Colleen B , Bandi Sindhura 
Published: December 2022

Abstract

Background
Penicillin allergy is the most commonly reported drug allergy in the pediatric population. However, most reports do not represent true IgE-mediated or late-onset severe hypersensitivity reactions. False allergy labels can lead to unnecessarily broad and/or non-first line antibiotic utilization, the development of antibiotic resistance, adverse drug side effects, and have implications for the use of antimicrobials in adulthood. In an effort to decrease inappropriate allergy labeling, we have implemented a multipronged approach for the evaluation of documented beta-lactam allergies in pediatric patients and potential “de-labeling” of inaccurate or outdated allergies.

Methods
We performed retrospective chart review of pediatric patients (0-18 years) with a documented beta-lactam allergy who were seen in clinic at a single tertiary medical center between 2014-2019. Prospective telephone screening then began to further characterize reaction symptoms and timing to determine patient candidacy for allergy testing (Fig. 1). Inpatient screening began in April 2022. If amenable to referral, eligible patients are then referred for outpatient Allergy and Immunology (A/I) assessment. Figure 1Process map for pediatric beta-lactam allergy risk-stratifying algorithm.

Results
A total of 1160 eligible pediatric patients were identified, and initial results are summarized (Fig. 2). Of those screened, 48 (57%) patients were referred. 5 (6%) patients were de-labeled via screening, of which 3 had received and tolerated repeat dosing. 11 (33%) patients have attended allergy appointments; 4 (36%) were tested and all were de-labeled (ages 6-11 years) from mostly non-IgE-mediated reactions. Additionally, 16 patients have upcoming appointments, and recruitment efforts are ongoing to include increased inpatient recruitment.

Conclusion
Use of an inpatient and outpatient algorithm can help identify pediatric patients less likely to have a true or persistent beta-lactam allergy (delayed-onset mild symptoms, or IgE-mediated reaction &gt;5 years ago) and who could benefit from formal allergy testing to potentially remove their allergy label. In the future, algorithm implementation within the electronic medical record may assist clinicians in thorough documentation of beta-lactam allergies and expeditious referral for allergy testing when appropriate.

Disclosures
All Authors: No reported disclosures.
563. Nationwide Trends in Antibiotic Selection for the Treatment of Pediatrics Acute Sinusitis, 2003-2020
Authors: Savage Timothy J , Kronman Matthew , Lee Su Been , Oduol Theresa , Huybrechts Krista F 
Published: December 2022

Abstract

Background
Acute sinusitis is a common diagnosis associated with outpatient antibiotic prescribing for children. Infectious Diseases Society of America guidelines (published in 2012) and American Academy of Pediatrics guidelines (published in 2013) for the management of acute sinusitis recommend amoxicillin with or without clavulanate as empiric therapy. Nationwide trends in antibiotic treatment of sinusitis have not been described since guideline publication.

Methods
We evaluated trends in antibiotic prescriptions for new acute sinusitis diagnoses among commercially insured patients &lt; 18 years old between January 1, 2003 and December 31, 2020 using the MarketScan Research Database. Subjects were identified via an outpatient encounter with an ICD code for acute sinusitis along with an oral antibiotic prescription dispensed on the day of the visit. New diagnoses were defined as having no sinusitis diagnosis in the preceding 180 days. Patients were excluded if they had a diagnosis code for chronic sinusitis or cystic fibrosis in the 6 months prior to the acute sinusitis diagnosis or had a same-day ICD code for another infection that would influence antibiotic selection (acute otitis media, cellulitis/abscess, community acquired pneumonia, Group A Streptococcal pharyngitis/tonsillitis, or urinary tract infection).

Results
3.3 million patients met the inclusion and exclusion criteria (Table 1). From 2003-2012, about 50% of patients received amoxicillin with or without clavulanate (Figure 1). Since 2013, the proportion of patients receiving first line antibiotics increased by 13%. The proportion receiving two or more antibiotics was unchanged. Approximately 80% of patients were prescribed 10-13 days of antibiotics (Figure 2). The proportion of patients receiving 14 or more days decreased by 67% over the study period.

Conclusion
In a nationwide cohort of commercially insured children with acute sinusitis, prescriptions for amoxicillin with or without clavulanate increased after publication of society guidelines. About 40% of patients are prescribed a non-first line antibiotic or multiple antibiotics and nearly 90% of patients are prescribed 10 or more days of antibiotics, presenting important opportunities for antimicrobial stewardship interventions.

Disclosures
Timothy J. Savage, MD, MPH, MSc, UCB: Contract to Brigham and Women's Hospital.
567. The Quality & Management of Penicillin Allergy Labels in a Pediatric Birth Cohort
Authors: Taylor Margaret G , Joerger Torsten , Anvari Sara , Li Yun , Gerber Jeffrey S , Palazzi Debra 
Published: December 2022

Abstract

Background
Penicillin allergy labels (PALs) influence antibiotic prescribing, yet little is known about the quality and management of PALs placed in the pediatric outpatient setting.

Methods
We performed a retrospective chart review of 500 randomly selected children with PALs from a ten-year birth cohort (n=18,015) from Texas Children’s Pediatrics and Children’s Hospital of Philadelphia Primary Care Networks. PALs were classified as “not allergy” (family history, isolated diarrhea), “low risk” (maculopapular rash &gt;24 hours into antibiotic course, no hives or pruritis), “moderate or high risk” (hives or pruritis, maculopapular rash &lt; 24 hours into antibiotic course, anaphylaxis, swelling, or respiratory symptoms), “severe cutaneous reaction” (erythema multiforme, serum sickness), or “unable to classify” (information not available or unspecified rash characteristics or timing) based on 1) information in the allergy tab and 2) encounter notes. We used kappa-statistic measure-of-agreement to determine allergy classification agreement between the allergy tab and notes.

Results
The median age of PAL placement was 1.4 years (IQR 0.9, 2.2). Most (n=303, 63%) PALs were placed by physicians. Half of PALs were categorized as “unable to classify; physicians were just as likely to place ambiguous PALs as other providers (48 vs 53%, p=0.31). Most (80%) children were evaluated at a primary care office within 1 week of their reaction. There was fair agreement between the allergy tab and encounter note documentation (Table 1). Of 54 (11%) children evaluated by an allergist, 25/25 passed an oral amoxicillin challenge. Only 69 (14%) children were de-labeled during the study period, more by an allergist (48%) than in the community (9.6%, p&lt; 0.001). Table 1.Risk stratification by penicillin allergy label and notes.

Conclusion
PAL classification was ambiguous in half of labeled children; there was fair risk classification agreement between the allergy tab and notes. Children with PALs were rarely referred to allergists or de-labeled in the community. Future quality improvement efforts should seek to improve PAL documentation and access to allergy services.

Disclosures
Debra Palazzi, MD, MEd, AAP: Board Member|AHRQ: Grant/Research Support|AMA: Board Member|Elsevier: Honoraria.
568. Using Machine Learning to Predict Place-Based Risks for Staphylococcus aureus Infections in Children
Authors: Lin Xiting , Ali Fatima , Edelson Michael R , Jerris Robert C , Leong Traci , Baltrus Peter T , Immergluck Lilly 
Published: December 2022

Abstract

Background
Community-onset Staphylococcus aureus (CO-S. aureus) pediatric infections, methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) continue to contribute to the burden of infections seen in the ambulatory setting in the US. Individual risk factors have been identified, but place-based factors and specific geographic locality have not been well-studied. The purpose of this study is to predict place-based factors that contribute to the spread of CO-S. aureus in a major urban area using maximum entropy (MaxEnt), a machine learning technique.

Methods
Electronic medical records from two pediatric hospitals (2002 to 2016) were retrospectively reviewed. Inclusion criteria: a confirmed S. aureus infection within 48 hours of hospital admission (CO-S. aureus), &lt; 19 years old, and a geo-referenced address within Atlanta’s metropolitan statistical area (MSA). Fourteen place-based factors, at the US Census block group level, were included in the MaxEnt models: &lt; 18 years old, Caucasian, African American, ethnicity, poverty, education attainment, crowding, daycare, kindergarten enrollment, distance to K-12 school, distance to a children’s hospital, distance to a daycare center, and population density. A total of four models (CO-MRSA early, CO-MSSA early, CO-MRSA later, and CO-MSSA later) were run using the MaxEnt software. For each model, 75% and 25% of data was randomly assigned to training and testing groups, respectively. Models were assessed by jack-knife tests.

Results
16,124 records met eligibility criteria for MaxEnt models. The training Area Under the Curve (AUC) ranged from 0.771 to 0.837 and the test AUC ranged from 0.769 to 0.804. Population density had the highest contribution in predicting CO-MRSA and CO-MSSA locations, which was confirmed by jack-knife tests.

Conclusion
By applying MaxEnt to pediatric CO-S. aureus infections in the Atlanta MSA, it was found that higher risks of CO-S. aureus infections may exist in more densely populated areas. MaxEnt can be utilized to identify potential future areas of CO-MRSA and CO-MSSA infections based on estimated or predicted changes to the place-based factors used to build these models.

Disclosures
Lilly Immergluck, MD, MS, GSK: Clinical Trial- PI|Merck: Vaccine Trial Site- serve as PI|Moderna: Board Member|Novavax: Part of CoVID-19 Phase 3 Trial through US Covid Prevention Network.