bluuebunny/crossref_metadata_2025_split huggingface dataset:
912. Impact of Rapid Identification and Stewardship Intervention on Coagulase-negative Staphylococcus Bloodstream Infection (BSI)
Authors: Goshorn Eli S , Viehman Alex , Ryan Bariola J , Khadem Tina , Potoski Brian , Shields Ryan K 
Published: December 2022

Abstract

Background
Coagulase-negative staphylococci (CoNS) are commonly isolated from blood cultures (BCx). Most do not require treatment (tx), yet antibiotics are frequently initiated. Workup of CoNS BSI consumes significant resources. We aimed to demonstrate the safety and efficacy of an early algorithm-based rapid diagnostic testing (RDT) plus antimicrobial stewardship (ASP) intervention.

Methods
BCx with CoNS were captured in 3 time periods to represent pre-RDT, RDT-only, and RDT+ASP. GenMark ePlex RDT was implemented for all Gram-positive BCx, identifying S. epidermidis and other non-aureus/lugdunensis Staphylococcal species. Results were called to ASP in both RDT-only and RDT+ASP periods. In the latter, a prospective algorithm was implemented to standardize ASP recommendations (Fig 1) for cases classified as simple, uncomplicated, and complicated BSI. The primary outcome was receipt of &lt; 24h of antibiotic tx. Safety outcomes included rates of recurrent BSI and hospital readmission.

Results
184 patients were included (Fig 2). The median age was 62, 54% were male, and the median Charlson comorbidity index was 5. 41% had a central venous catheter at time of BSI. Overall, 67%, 19%, and 12% of cases were classified as simple, uncomplicated, or complicated BSI, respectively (Fig 3). BSI class and patient demographics did not vary between periods. During pre- and post-RDT periods, median days of antibiotic tx did not vary significantly for patients with simple BSI (1.1 vs 1.2). In contrast, median days of tx were reduced to 0 (P=0.005) for simple BSI in the RDT+ASP period. Overall, 54% of patients with CoNS BSI received &lt; 24h of tx in RDT+ASP time period compared to 34% (P=0.009) in the combined pre-RDT and RDT-only periods. Tx was entirely avoided in 28% of CoNS BSI cases in the RDT+ASP period compared to 16.5% of cases in other periods (P=0.07). 7 cases classified as simple were reclassified as uncomplicated or complicated after further work up. Rates of recurrent BSI and 30-day readmission were comparable across time periods.

Conclusion
Our algorithm-based ASP + RDT intervention reduced antibiotic tx for CoNS BSI, an effect not realized with RDT alone. These data attest to the safety and efficacy of early ASP intervention for patients with CoNS BSI identified by RDTs at the time of positive BCx.

Disclosures
J Ryan Bariola, MD, Infectious Disease Connect: Salary support|Merck: Grant/Research Support Tina Khadem, PharmD, Infectious Disease Connect: Salary support|Merck: Grant/Research Support Brian Potoski, PharmD, BCPS-AQ ID, Merck Group: Grant/Research Support Ryan K. Shields, PharmD, MS, Infectious Disease Connect: Advisor/Consultant|Merck: Advisor/Consultant|Merck: Grant/Research Support|Roche: Grant/Research Support.
922. Promotion of antimicrobial stewardship after issuing antimicrobial resistance national action plan in Japan: a systematic review of the literature from 2016 to 2020
Authors: Honda Hitoshi , Takamatsu Akane 
Published: December 2022

Abstract

Background
Antimicrobial resistance (AMR) is a global threat, potentially causing a significant healthcare burden. In 2016, the Japanese government issued the national action plan for AMR. Since the issuance of the Japanese AMR action plan in 2016, several ASP studies have been published in Japanese institutions. We, therefore, performed a systematic review of the literature on ASP studies conducted in Japanese institutions to elucidate the current ASP activities and understand the impact of the AMR action plan on the current state of ASPs in Japan.

Methods
We searched literature based on two databases, including Medline (PubMed) and EMBASE, from January 2016 through September 2021. The risk of bias for interventional studies was assessed using ROBINS-I, and Newcastle-Ottawa Scale was used to determine the quality of cohort studies, case-control studies, and cross-sectional studies.

Results
We identified 80 studies subsequently included in the systematic review. The proportions of each type of studies were following: 30 (37.5 %) interventional studies, 15 (18.8 %) database-oriented studies, 9 (11.3 %) analytical studies (1 case-control study, 6 cohort studies, and 2 cross-sectional studies), 12 (15.0%) descriptive studies (3 cohort studies, and 9 cross-sectional study). All interventional studies were a before-after trial and interrupted time series analysis for assessing the changes in antimicrobial consumption by interventions. The subsequent targeted or overall antimicrobial use has significantly decreased (changes in a proportion ranging from 19.0 to 99.4 % in oral agents and 33.0 to 76.2 % in intravenous agents). In database-oriented studies, five studies demonstrated decreasing antimicrobial consumption after issuing AMR national action plan.

Conclusion
The present systematic review revealed that increasing numbers of ASP studies were published after issuing the AMR action plan and showed the promotion of successful interventions of ASP studies. A few database-oriented studies showed a positive impact of AMR action plan on antimicrobial activity consumption. However, further development of high-quality studies, especially interventional studies using appropriate methodology and standardized data collection, is continuously needed.

Disclosures
All Authors: No reported disclosures.
930. Weakening the waves: Impact of a syndrome-based antimicrobial stewardship intervention during COVID-19
Authors: Mena Lora Alfredo J , Herald Fischer , Lindsey Brenna , Echeverria Stephanie , Ali Mirza , Burgos Rodrigo M 
Published: December 2022

Abstract

Background
Lower respiratory tract infections (LRTIs) from SARS-CoV-2 are difficult to distinguish from other viral or bacterial etiologies. This has led to increased antimicrobial use (AU) during the pandemic and concerns for concomitant rise in antimicrobial resistance (AMR). It is crucial for antimicrobial stewardship (ASP) to develop strategies to mitigate excess AU and curve AMR. We leveraged a syndrome-based ASP intervention targeting LRTIs and the use of anti-Pseudomonal beta lactams (APBL) during the COVID-19 pandemic.

Methods
We incorporated COVID-19 elements into a syndrome-based prospective audit and feedback (PAF) at an urban community hospital. Elements included EMR order sets (Figure 1) that discouraged routine AU for COVID-19 and PAF targeting LRTIs and COVID-19 therapies. Empiric selection discouraging APBL was incorporated during the first COVID-19 wave. Order sets and PAF were then modified to reflect novel COVID-19 therapeutics and AU was strongly discouraged in subsequent waves. Data on AU and AMR from 2018-2022 was reviewed. Figure 1.Electronic medical records COVID-19 antimicrobial order set

Results
Average quarterly AU increased during the first pandemic year by 8.7%, from 359.5 to 391 days of therapy per 1000 patient days (DOT/1000), with peaks 22.5% above the pre-pandemic average during COVID-19 surges. AU increased each COVID-19 surge, with smaller peaks each subsequent wave. DOT/1000 declined 29% from the first wave to the Omicron wave. AU decreased the second year to 318, an 18.6% decrease from the first pandemic year. Ceftriaxone use increased during surges, reflecting our LRTI guidelines (Figure 2). Peaks declined each subsequent wave, from a peak of 239 in the first wave to 75 during Omicron, a 68% decrease. The average monthly DOT/1000 for APBL decreased from 73.51 to 63.21 (Figure 3). Incidence rate of ESBL and CRE initially rose and then declined (Figure 4). Figure 2.Antimicrobial use (DOT/1000) before and during the COVID-19 pandemicFigure 4.Antipseudomonal beta lactam use before and during the COVID-19 pandemic
Figure 5. Incidence of multidrug resistance organisms before and during the COVID-19 pandemic

Conclusion
ASP successfully incorporated COVID-19 elements and steered AU during the pandemic. Though total AU increased, APBL use declined and AU peaks decreased with each COVID-19 wave, reflecting adherence with ASP recommendations. AMR increased during the first year and subsequently declined. ASP can play a vital role guiding AU during respiratory pandemics.

Disclosures
All Authors: No reported disclosures.
971. Antibiotic Prophylaxis for Grade III Open Fractures: A Retrospective Comparison of Ceftriaxone plus Vancomycin versus Cefazolin plus Gentamicin
Authors: Shifko Carlee R , Bremmer Derek N , Jenniches Daniel , Holmberg Kyle , Andreini Derek , Philp Allan , Altman Daniel T 
Published: December 2022

Abstract

Background
Owing to the established path of bacterial entry and contamination-associated mechanisms, grade III open orthopedic fractures represent a substantial infection risk. Historically, the EAST Guidelines recommended covering Staphylococcus aureus and adding aminoglycoside gram negative coverage. Incorporating newer evidence, the Allegheny Health Network local guidelines rely on ceftriaxone to cover gram-negatives and add methicillin-resistant S. aureus coverage with vancomycin.

Methods
The electronic health records of adults admitted for a grade III open fracture between January 1, 2016, and October 31, 2021 were retrospectively reviewed. Patients who received cefazolin and gentamicin (CZ+GM) or ceftriaxone and vancomycin (CRO+VA) as their prophylaxis were included. We recorded rate of a composite treatment failure outcome of receipt of antibiotics for suspected infection, infection-related hospitalization, or subsequent debridement for injury site skin and soft tissue infection or osteomyelitis. Presence of acute kidney injury (AKI) within 7 days was also evaluated. Categorical variables were compared using the Chi-square or Fisher’s exact tests, and continuous variables by t-test or Wilcoxon Rank Sum.

Results
Patients in the CZ+GM group were younger, with a mean age of 42.6 years compared to 50.6 years in the CRO+VA group (p = 0.02). Otherwise, there were no significant differences between groups in demographics, mechanism and site of injury, timeline of care, or total number of surgical interventions. More patients in the CZ+GM arm met the composite primary treatment failure outcome, but it was not statistically significant (45% vs 32%, p = 0.2). There were similar rates of treatment failure at 30 days (21% vs 26%, p = 0.5) and for only osteomyelitis (8% vs 9%, p = 1). Patients receiving CZ+GM trended towards higher rates of AKI, but this was not statistically significant (26% vs 19%, p = 0.4).

Conclusion
The trend in numerically lower treatment failure rates in the CRO+VA group across all outcomes studied supports the current recommendations in the local institutional guidelines. Given our sample size, type II error may have occurred, and larger studies with greater power should analyze this question.

Disclosures
Derek N. Bremmer, PharmD, BCPS-AQ ID, Thermo Fisher Scientific: Honoraria.
972. Bone and Joint Infections : Looking Beyond Gram Positive Bugs, A Case Series from Mumbai, India
Authors: Kaneria Mala V , Kothari Manish , Vishwanath Jashan , Jain Reetu , Raut Indraneel , Mashru Puneet , Gohel Tejash , Bhabhor Anand , Nagral Aabha , Wadia Pettarusp , Savardekar Abhijeet , Pispati Ameet , Palekar Gaurav , Goleria Dhimant , Ladkat Kiran , Tandon Shruti , Bhandare Sonal , Narula Sonar , Shah Samir , Bhat Ganapathi , Afzal Fahad 
Published: December 2022

Abstract

Background
Bone and joint infection (BJI) is a dreadful complication of arthroplasties and orthopaedic trauma. Infection with non traditional organisms is a trade off for medical advances such as newer immunosuppressants and implants.
Complex BJIs, may be complicated by longer hospitalizations and higher costs due to the virulence of organisms, growing resistance to antibiotics and patient comorbidities, especially immunocompromised status. The purpose of this study was to analyse the various characteristics of BJIs with emphasis on the organisms cultured.

Methods
21 consecutive patients of BJIs were prospectively included from June 2021 to March 2022. Demographic features, comorbidities, anatomic site involved, previous surgical intervention, presence of implant, infecting organism, their susceptibility patterns, inflammatory markers, surgical procedure performed, antibiotics given , their route, duration and the outcome were noted.

Results
12/21 (57.14 %) had spondylodiscitis ; 4/21 (19.04 %) knee joint involvement ; 3/21 (14.29 %) orthopaedic trauma ; 3/21 (14.29 %) hip involvement ; 1 ankle joint involvement (diabetic foot) and 1 sternal osteomyelitis. 17/21 (80.95 %) had comorbidities. 7/21 (33.33 %) were immunosuppressed . 14/21 (66.67 %) had undergone recent surgery.
11 gram positive, 8 gram negative organisms and 3 fungi were isolated . 2 were culture negative and 4 had mycobacterial infection. Histopathology revealed pyogenic inflammation in bacterial and granulomatous inflammation in fungal and mycobacterial infections. CRP and ESR were elevated in all bacterial infections and were used to guide antibiotic route switchover. All bacterial infections were treated with 6 weeks of antibiotics .14/21 (66.67 %) underwent surgery, whereas the rest underwent diagnostic aspiration and biopsy only. 3/21 (14.29 %) had relapse on stopping antibiotics and responded after restarting.

Conclusion
Though staphylococcus is thought to be the culprit in most cases of BJIs, gram negative organisms, mycobacteria and fungi are gaining centrestage. Histopathology can give important clues in the absence of positive cultures. Surgical interventions, implant presence and immunosuppressed states are implicated in a majority of the infections. CRP guided therapy is a valuable strategy.

Disclosures
All Authors: No reported disclosures.
979. Eligibility for and Use of Oral Antibiotic Therapy among Veterans with Osteo-articular Infections: A Retrospective Study across Eight Medical Centers
Authors: Mareau Jacquelyn , Alexander Bruce , Egge Jason , Heintz Brett , Suzuki Hiroyuki , Livorsi Daniel J 
Published: December 2022

Abstract

Background
Osteoarticular infections are commonly treated with intravenous antibiotics even though oral antibiotics may be as effective. In this multicenter study, we evaluated how often patients with osteoarticular infections qualified for oral antibiotic therapy and how often oral antibiotics were prescribed.

Methods
We randomly selected 2 high-complexity Veterans Affairs (VA) hospitals from each of the 4 US Census regions. Next, we randomly selected patients admitted to these 8 facilities during 2018-2020 who had a discharge diagnosis of an osteoarticular infection, received ≥5 days of inpatient antibiotics, and had an Infectious Disease consult. Manual chart reviews were performed to confirm the diagnosis and to exclude patients who received &lt; 4 weeks of total antibiotics or had infection of the skull, sacrum or pelvis. Eligibility for oral therapy was defined by the inclusion criteria used in a recent randomized controlled non-inferiority trial. Oral antibiotic stepdown was defined as starting an exclusively oral regimen within 2 weeks of antibiotic initiation. The chi-square test was used to compare categorical variables.

Results
After excluding 76 cases, the final cohort included 145 patients (median age 65, 98% male, 72% white). The most common types of osteo-articular infections were peripheral osteomyelitis (66%) and septic arthritis (14%). The most common isolated pathogen was Staphylococcus aureus (53%). Surgical debridement was performed in 104 (72%) patients, and the median antibiotic duration was 47 days (IQR 43-72). One hundred eight (74%) patients were eligible for oral step-down, but only 18 (17%) of these patients received it (Figure 1). Fourteen (78%) patients treated with oral step-down were from the same hospital. Among patients eligible for oral stepdown therapy, peripheral osteomyelitis was present in 15 (83%) of those who received oral therapy versus 58 (64%) of those who were eligible but did not receive it (p=0.12).

Conclusion
In this retrospective study across 8 geographically-diverse VA hospitals, three-quarters of patients with osteoarticular infections qualified for oral antibiotics but only 1 of 6 eligible patients actually received them. Oral antibiotics may be under-utilized for treating osteoarticular infections in routine practice.

Disclosures
Daniel J. Livorsi, MD, Merck & Co.: Grant/Research Support.
980. Enterobacter: An Early-Onset Pathogen of Prosthetic Hip and Knee Infections with Poor Prognoses
Authors: Prado Isabel P , Kim Billy I , Schwartz Andrew , Wixted Colleen M , Polascik Breanna , Hendershot Edward , Jiranek William A , Seidelman Jessica , Seyler Thorsten M 
Published: December 2022

Abstract

Background
Enterobacter sp. is a gram-negative, often drug-resistant bacillus that is classically identified from mucosal surfaces, such as pulmonary or urinary tracts. Despite its virulence, Enterobacter represents a less common pathogen in prosthetic joint infections (PJI). This study aims to resolve the current paucity of described clinical characteristics and treatment success of Enterobacter PJI.

Methods
Thirty-three patients with Enterobacter aerogenes-, cloaecae/asburiae-, or hormachei-positive PJIs were identified at a single institution. Infection clearance was defined as absence of infection or repeat surgery at one year and off all adjunct antibiotic therapy. Patient demographics, PJI characteristics, treatments, and clinical outcomes were compared between patients with and without clearance.

Results
In this cohort, mean age was 66.8 years (SD: 11.6), mean BMI was 31.0 (SD: 7.1), and mean Elixhauser Comorbidity Score was 9.1 (SD: 4.5). 54.5% had a prior PJI in the same joint, and 87.9% had more than one prior surgery in that joint. Median time of PJI diagnosis after surgery was 22 days [IQR: 18-60]. Patients initially treated with debridement antibiotics and implant retention (n=11) had a 45.5% clearance rate, compared to 23.1% for 2-stage exchange (n=13) and 44.4% for those requiring resection arthroplasty or amputation (n=9). With a median follow-up of 2.9 years, final joint outcomes included resection arthroplasty in 9 (27.3%), above-knee amputation in 7 (21.2%), definitive treatment with an articulating spacer in 6 (18.2%), and arthrodesis in 2 (6.1%) patients.

Conclusion
Enterobacter PJI often presents acutely and is a difficult pathogen to treat. The outcomes of our cohort reflect the virulence of Enterobacter, with high rates of failure and ultimate joint- or limb-sacrificing procedure. Despite being a less common cause of PJI, prognosis is exceptionally poor with traditional treatment algorithms when compared to historical cohorts of more common pathogens.

Disclosures
William A. Jiranek, MD, Biomech Holdings LLC: Stocks/Bonds|DePuy, A Johnson & Johnson Company: IP royalties Thorsten M. Seyler, MD, PhD, Heraeus: Paid consultant|Pattern Health: IP royalties|Restor3d: IP royalties|Smith & Nephew: Paid consultant|Total Joint Orthopedics: Paid consultant|Zimmer: research.
1005. Financial and clinical impact of ceftolozane/tazobactam global recall on the treatment of multi-drug resistant Pseudomonas in a large health system
Authors: Carpio Brandon Del , Dillon Michelle , Hurtado Dahlia , VanDenberg Taylor , Hayes Jillian E , Carr Amy L , Minor Sarah B 
Published: December 2022

Abstract

Background
In December 2020, ceftolozane/tazobactam (CT) was voluntarily recalled due to failed sterility tests. With this recall, clinicians were forced to utilize alternatives for multi-drug resistant (MDR) Pseudomonas (PSA) infections until CT returned in late December, 2021. While many studies have examined the impact of medication shortages, few have evaluated the impact of antimicrobial shortages. We evaluated the impact of the CT recall by assessing cost, clinical outcomes, and utilization of novel alternative agents.

Methods
This multi-site retrospective cohort study compared patients treated for MDR PSA prior to the CT recall (Jan-Jul 2020) to patients treated during the CT recall (Jan-Jul 2021) across seven AdventHealth Central Florida (AHCF) adult hospitals. The primary outcome was percentage of patients treated with novel therapies (CT, ceftazidime/avibactam, or cefiderocol). Secondary outcomes included length of therapy (LOT), inpatient mortality, 30-day readmissions, length of say (LOS), pharmacy expenditures, and average cost per case.

Results
A total of 203 patients with MDR PSA were evaluated: 100 in the pre-recall cohort and 103 in the post-recall cohort. The majority (58%) of patients were male with an average age of 64 years. The most common source of infection in both cohorts was pneumonia, followed by complicated urinary tract infection. Significantly more patients were treated with novel agents as definitive therapy in the post-recall cohort (65% vs. 29%, p&lt; 0.0001). Average LOT for all anti-PSA therapy was 12 days in the pre-recall cohort compared to 14 days in the post-recall cohort (p=0.1753). Inpatient mortality and 30-day readmissions were not statistically different between groups. Hospital LOS was significantly different between the two groups (18 days vs. 25 days, p=0.006). Significantly higher pharmacy expenditures were found in the post recall cohort (Figure 1) and the average cost per case was significantly higher in the post-recall cohort ($125,254 vs. $62,249). Figure 1:Pharmacy Expenditures for Novel Agents
Novel agents: cefiderocol, ceftazidime/avibactam, ceftolozane/tazobactam

Conclusion
The CT recall had a significant impact on both economic and clinical outcomes, particularly increased length of stay, length of therapy, and cost to both the patient and health system. Higher utilization of novel agents is concerning given rising rates of PSA resistance.

Disclosures
Amy L. Carr, PharmD, BCIDP, Shionogi: Advisory Board.