bluuebunny/crossref_metadata_2025_split huggingface dataset:
959. It Takes a Village: Reducing Empiric Vancomycin Use by Leveraging Primary Team Pharmacist Oversight of a 72-hour Approval Process
Authors: Pettit Natasha N , Nguyen Cynthia T , Lew Alison K , Pisano Jennifer 
Published: December 2022

Abstract

Background
Vancomycin is often initiated empirically in hospitalized patients for broad spectrum gram-positive coverage, however in many cases it is initiated unnecessarily and/or continued empirically for longer durations than necessary. Strategies to facilitate timely discontinuation of vancomycin when unnecessary may reduce antibiotic toxicity (e.g. nephrotoxicity) and the development of bacterial resistance. In large hospital systems, it may not be feasible for stewardship programs to implement prior authorization requirements or prospective audit/feedback for all vancomycin orders. Novel strategies to enlist other clinicians to serve as stewards of antibiotic use are needed.

Methods
On February 1, 2020, we implemented a protocol requiring providers to obtain approval from the primary team pharmacist to continue empiric vancomycin regimens &gt;72 hours. Primary team pharmacists were provided a list of appropriate indications for vancomycin continuation. After 72 hours, the pharmacist placed a note describing the approved indication or if ASP or ID consult was obtained. We evaluated the standardized antibiotic administration ratio (SAAR) for antibacterial agents for resistant gram-positive infections for FY2019 (pre-protocol) and FY2020 (post-protocol) to assess the impact of this intervention. Vancomycin utilization was also evaluated in days of therapy (DOT)/1000 patient days during both time periods.

Results
The SAAR for antibacterial agents for resistant gram-positive infections for FY2019 was 1.17 and FY2020 was 1.04 (95% CI (0.87, 0.91), p-value &lt; 0.001). A significant reduction in SAAR was observed in patients admitted to the ICU and floor (Figure 1). Overall vancomycin utilization according to days of therapy/1000 patient days was reduced from 111.13 (FY2019) to 104.08 (FY2020).

Conclusion
Leveraging the oversight of primary team pharmacists proved to be an effective strategy to reduce empiric vancomycin durations of therapy. Following the implementation of a 72-hour approval protocol with primary team pharmacist oversight, we observed a significant reduction in the SAAR for antibacterials for resistant gram-positive infections with a corresponding reduction in vancomycin utilization.

Disclosures
All Authors: No reported disclosures.
968. The Impact of Film Array Detection of High-risk and Resistant Pathogens on the Time to Optimal Antibiotic Therapy at a Community Health System
Authors: Baumeister Tyler W , Sinclair Emily , Zeigler Dustin , Frens Jeremy J 
Published: December 2022

Abstract

Background
The importance of effective antibiotic therapy for the treatment of bloodstream infections has been well described. Rapid diagnostic testing platforms like the BioFire® FilmArray® blood culture identification (BCID) have the potential to decrease time to effective antibiotics when acted on appropriately. The Cone Health stewardship team has collaborated with clinical pharmacists and infectious diseases physicians to define a process to optimize antibiotic therapy. This process involves microbiology calling a pharmacist with newly positive blood cultures, and the pharmacist notifies the attending physician with the results and evidence-based treatment recommendations. We transitioned from BCID to BCID2 in August, 2021. As CTX-M (marker for extended spectrum beta-lactamase production) was not a target on BCID, we were interested in how the addition of this marker could improve care in this subset of patients.
Procedure for Positive Blood Culture Workup and Notification
Treatment Recommendations for Selected Organisms

Methods
From August 2021 - March 2022, the times to administration of effective and optimal antibiotics were evaluated in patients with the following BCID2 organism and resistance gene targets identified: S. aureus, P. aeruginosa, CTX-M, KPC, OXA-48 like, IMP, VIM, NDM, and vancomycin resistant enterococci. An effective antibiotic was defined as an antibiotic with in vitro activity to the organism, and an optimal antibiotic was defined as the preferred agent based on institutional guidelines. For CTX-M isolates, we compared effective and optimal times to a historical control of ceftriaxone resistant enterobacterales and analyzed by student’s t-test.

Results
The combined mean time from BCID2 to administration of effective antibiotics = 1.2 hours (range 0-7.9 hours) and to optimal therapy =7.6 hours (range 0 – 113.8 hours). Prior to the BCID2 transition, patients found to be growing ceftriaxone resistant enterobacterales had an average time to optimal antibiotic administration of 17.7 hours, which improved to 2.8 hours after BCID2 implementation (p=0.0041).
Time to Effective and Optimal Antibiotics after implementation of BCID2 (August 2021 – March 2022)
Time to Effective and Optimal Antibiotics for Ceftriaxone Resistant Enterobacterales Prior to BCID2 Implementation (January 2021 - July 2021)

Conclusion
BioFire® FilmArray® coupled with antibiotic stewardship team support can help optimize time to effective and optimal antibiotic therapy in bloodstream infection. The addition of the CTX-M target to BCID2 was a helpful addition to the panel which allowed for decreased time to optimal antibiotic therapy.

Disclosures
All Authors: No reported disclosures.
969. The Importance of a Strong Handshake: Expanding Antimicrobial Stewardship to Engage Frontline Providers in Adult Medicine
Authors: Sapozhnikov Julia , Hoff Brian M , Adams Jenna , Santarossa Maressa , Kalathiya Sonali , Albarillo Fritzie S 
Published: December 2022

Abstract

Background
The Joint Commission highlighted handshake stewardship (HS) as a leading practice in antimicrobial stewardship (AMS). However, intervention and outcomes data in adult populations are lacking. Additionally, limited human resources remain a barrier to widespread implementation of HS services. In February 2022, our antimicrobial stewardship program (ASP) expanded to include a HS service supporting adult internal medicine patients managed by hospitalist staff at an academic medical center. Here we aim to describe the interventions made to support and improve care in this population.

Methods
This was a single-center, retrospective quality improvement initiative at a 547-bed academic medical center. Beginning in February 2022, the ASP structure expanded to include 2-week rotations between HS, general infectious diseases (ID) consult rounds, and whole house AMS (a combination of prospective audit and feedback and pre-authorization). During the HS rotation, all prescribed antimicrobials were prospectively reviewed Monday-Friday by the ID pharmacist and recommendations to improve quality, safety, and transitions of care were discussed in-person during daily rounds with hospitalists. Interventions were documented daily and data generated between February 1, 2022 and April 30, 2022 were reviewed to categorize the impact of the expanded service.

Results
A total of 316 interventions were made for 101 unique patients over a 3-month period. We observed 286 accepted interventions (90.5%) during the intervention period. On average, the HS pharmacist reviewed 24 charts per day and spent 68 minutes in chart review, 16 minutes in rounds, and 23 minutes in other direct communication with providers per day. Table 1 and Figure 1 describe the distribution of interventions by type and indication. Table 2 quantifies the number of days broad spectrum antibiotics were avoided directly attributable to interventions. Since implementation, the HS service has contributed to an estimated cost savings of $73,470.19 for our hospital. Table 1.Intervention by TypeFigure 1.Antibiotic Indication for Cases with Interventions

Conclusion
Implementation of HS in two adult internal medicine teams was associated with many interventions with high acceptance by hospitalist staff. Interventions led to tangible reductions in broad spectrum antibiotic days of therapy and cost.

Disclosures
Sonali Kalathiya, PharmD, MPH, BCIDP, Blueprint Medicines: Spouse is employed by Blueprint Medicines|Blueprint Medicines: Stocks/Bonds.
988. Risk of surgical site infection and Clostridioides difficile infection after perioperative clindamycin in patients labeled penicillin and/or cephalosporin allergic
Authors: Jeffres Meghan N , Porter Melissa , Ricco Madison , Norvell Miranda , Koonce Ryan , Bassler Eric , Hogan Craig 
Published: December 2022

Abstract

Background
Perioperative antibiotics reduce surgical site infections after hip and knee arthroplasty. Clindamycin is routinely used as a perioperative antibiotic in patients with beta-lactam allergy labels instead of first-line antibiotics like cefazolin. The purpose of this study is to assess the risk of adverse outcomes associated with the use of clindamycin to prevent surgical site infections (SSI) after total joint arthroplasty.

Methods
This retrospective review included adult patients labeled as allergic to penicillin or cephalosporin antibiotics, who underwent a primary total hip and/or knee arthroplasty between January 2020 through July 2021, and received perioperative antibiotics. The outcomes of SSI and Clostridioides difficile infection (CDI) within 90 days was compared between patients receiving perioperative clindamycin vs. non-clindamycin antibiotics.

Results
A total of 1,121 surgical procedures in 1,047 patients were included. The frequency of SSI for the cohort was 1.6% and CDI was 0.4%. SSI occurred more frequently in the clindamycin group than in the non-clindamycin group (4.3% vs 0.7%, p&lt; .01). The average duration from surgery to SSI was 22.7 ± 11.6 days in the clindamycin group and 24.8 ± 11.1 days in the non-clindamycin group. The frequency of CDI occurrence was greater in the clindamycin group than the non-clindamycin group (1.1% vs. 0.1%, p=.05). The average duration from surgery to CDI was 32.6 + 26.6 days in the clindamycin group and 4.6 days in the non-clindamycin group. Multivariable logistic regression identified clindamycin-containing perioperative antibiotic regimens (odds ratio (OR) 5.5) and opioid use prior to surgery (OR 8.7) as risk factors for 90-day surgical site infection. Staphylococcus aureus was the cultured pathogen in 9 of the 17 SSIs.

Conclusion
This study found a significantly higher frequency of SSI and CDI when clindamycin-based regimens are used perioperatively for primary hip and knee arthroplasty. These results are likely related to decreased activity of clindamycin against Staphylococcus aureus and greater alterations of the microbiome in comparison to beta-lactams.

Disclosures
All Authors: No reported disclosures.
990. Sex-Specific Analysis of Clinical Features and Outcomes in Staphylococcal Periprosthetic Joint Infections Managed with Two-Stage Exchange Arthroplasty
Authors: Higgins Eibhlin , Tai Don Bambino Geno , Lahr Brian D , Suh Gina A , Tande Aaron J 
Published: December 2022

Abstract

Background
There are anatomical, pharmacokinetic, and joint biomechanical differences between males and females. Whether these differences result in differing presentation, treatment tolerability and outcomes in periprosthetic joint infection (PJI) has not been widely evaluated.

Methods
We undertook a retrospective case matched study of patients with staphylococcal PJI managed with two-stage exchange arthroplasty. In order to control for differences other than sex which may influence outcome or presentation, males and females were case-matched for age, causative organism (Coagulase-negative staphylococci vs Staphylococcus aureus) and joint involved. The two matched groups were analyzed for differences in duration of symptoms, inflammatory markers, duration of hospital stay, antimicrobial side effects, post-operative complications and recurrence rate. Recurrence of infection was defined as per Musculoskeletal Infection Society criteria for PJI and included both relapse with original microorganism or with an additional organism.

Results
78 pairs of males and females with staphylococcal PJI were successfully matched. There were no significant baseline differences by sex, except for greater use of chronic immunosuppression among females (16.7% vs. 4.1%; p=0.012). Clinical characteristics and outcomes of the patients are summarized in table 1. We did not detect a statistically significant between the outcomes of the two groups. Overall, 16 recurrent infections occurred during a median follow-up time of 2.9 (IQR: 1.5 - 5.3) years. The 3-year cumulative incidence of treatment failure depicted in figure 1 was 16.1% for females, compared with 8.8% for males (p=0.434).

Conclusion
Success rates for PJI treated with two-stage exchange arthroplasty are high consistent with previously reported literature. A larger cohort of patients may be required to detect differences in relapse rates. This study included only staphylococcal PJI and was thus unable to evaluate the differences in microbiology of PJI between males and females, which could also impact outcomes. This retrospective case-matched study did not detect any significant differences in outcomes between males and females with staphylococcal PJI who underwent two stage exchange arthroplasty.

Disclosures
Gina A. Suh, M.D., Adaptive Phage Therapeutics (APT): Grant/Research Support|Adaptive Phage Therapeutics (APT): Dr. Suh received grants and has an equity and royalty-bearing know-how agreement with Adaptive Phage Therapeutics but is unrelated to project Aaron J. Tande, M.D., Uptodate: Dr Tande has received an honorarium from Uptodate for medical writing unrelated to this project.
991. Single Center, Exploratory, Open-label Prospective Study Using the Minimally Invasive LysinDAIR Procedure (Lysin Administration During an Arthroscopic DAIR Procedure) in Patients with Suspected Relapsing Chronic Coagulase-Negative Staphylococci (CNS) Prosthetic Hip Infection (PHI)
Authors: Ferry Tristan , Conrad Anne , Kolenda Camille , Laurent Frederic , Schmidt Axel , Cassino Cara , Lustig Sebastien , Batailler Cécile 
Published: December 2022

Abstract

Background
Exebacase, a recombinant staphylococcal lysin, has: (i) reported proof-of-concept data in Phase II in S. aureus bacteremia; (ii) demonstrated antibiofilm activity in vitro against S. epidermidis; and (iii) been used as salvage therapy in 4 patients with relapsing multidrug-resistant (MDR) S. epidermidis knee prosthetic joint infection (PJI) using the LysinDAIR (arthroscopic administration of exebacase [Lysin] with Debridement and Antibiotics Implant Retention) procedure. Surgical treatment of recurrent PHIs has high risk of morbidity and loss of function. We now report our experience with the LysinDAIR procedure for PHIs.

Methods
We performed a single center, exploratory, open-label prospective study using LysinDAIR and suppressive antimicrobial therapy (SAT) in patients with recurrent, chronic (inoculation &gt;3 months prior to treatment) CNS PHI. In agreement with the French Health authority, exebacase (2 to 3.5 total mg in 30-50 ml [∼0.067 – 0.075 mg/ml]) was arthroscopically administered directly into the joint.

Results
Three consecutive patients were included (55 to 75 years). All had previous iterative hip prosthesis exchange with a high total number of surgeries (from 6 to 10) and recent persistent or intermittent fistula (Figure). All refused hip prosthesis explantation or surgeon considered explantation too high risk for loss of function and severe post-operative complications. Patients A and B had MDR S. epidermidis; Patient B had P. aeruginosa co-infection at the time of LysinDAIR. Patient C had a prior persistent S. lugdunensis PHI and relapse on arthrocentesis; K. pneumoniae was cultured at the time of LysinDAIR. No adverse events related to exebacase or the procedure were reported. At 2 years follow up, all patients had resolution of fistula and no clinical signs of infection on SAT (tedizolid (+/- ciprofloxacin [Patient B] or cotrimoxazole [Patient C]).
Description of the patients treated with the LysinDAIR procedure
Local signs of infection with discharge of the three patients (A, B and C) with complex relapsing prosthetic hip infection with X-ray before the LysinDAIR procedure and at 2 years of follow-up

Conclusion
The LysinDAIR procedure was easy-to-perform, safe and may have therapeutic potential to facilitate the success of SAT salvage therapy for chronic relapsing CNS PJIs, and potential cure of initial chronic PJI. Randomized clinical trials evaluating the LysinDAIR procedure in these clinical situations are clearly warranted.

Disclosures
Tristan Ferry, MD, PhD, Contrafect: Advisor/Consultant Camille Kolenda, n/a, Contrafect: Research grant frederic Laurent, n/a, Contrafect: Research grant cara cassino, n/a, Contrafect: Employee.
995. Acute Kidney Injury Rates Before and After Implementation of Integrated Bayesian Software for Vancomycin Dosing
Authors: Tigh Jeremy E , Jantrakul Nicholas A , Miller Molly M , Alexander Bryan T , Avedissian Sean , Van Schooneveld Trevor C , Bergman Scott J 
Published: December 2022

Abstract

Background
Therapeutic drug monitoring of vancomycin with Bayesian models is recommended to maximize efficacy and minimize nephrotoxicity by targeting a 24-hour area under the curve (AUC24) of 400-600mg*h/L. Minimal real-world evidence exists on the impact of this strategy. In 2020, we integrated Bayesian software from DoseMeRx into Epic OneChart and converted from trough-based vancomycin to AUC-guided dosing. We assessed the incidence of acute kidney injury (AKI) in patients receiving vancomycin before and after this change and sought to establish an efficient method of assessment.

Methods
This was a retrospective, single-center quasi-experimental study. Patients were divided into pre-Bayesian software (trough guided dosing, Jan-Jun 2018) and post- (Jan-Jun 2021). Preliminary data showed 10% & 6% AKI rates, respectively. Therefore, a sample of 1442 patients was needed to detect a difference. Adults were included with a baseline Scr ≤2 mg/L, who received ≥3 vancomycin doses and had ≥1 vancomycin level measured. The primary outcome was AKI incidence assessed using AKIN criteria. Patients were reviewed in each period until 500 met inclusion criteria. This sample was used to determine the feasibility and accuracy of using EHR-generated reports.

Results
Of the 1,000 patients reviewed, baseline characteristics were similar; however, indications varied as pneumonia was more common in the pre-group and skin and soft tissue infection was more common in the post-group (Table 1). Initial daily dose and duration of vancomycin treatment were not different between groups. Incidence of AKI was decreased in the post-integration group, although this was not significant by bivariate analysis (15.4% vs. 12.6%, p=0.20). Fewer trough concentrations were drawn in the post-group (2 vs. 1.8, p=0.005), with overall lower vancomycin levels (13.2 vs. 12.1 mg/L, p=0.04).

Conclusion
The rate of AKI was numerically lower in patients monitored and dosed with Bayesian AUC-guided dosing software for vancomycin. Trough levels were lower, and vancomycin levels were needed less often. AKI incidence was higher than in our pilot but similar to what is reported in other studies. Further investigation is required to establish statistical significance and whether the assessment process can be automated.

Disclosures
Bryan T. Alexander, PharmD, BCIDP, AAHIVP, Astellas Pharma: Advisor/Consultant Trevor C. Van Schooneveld, MD, bioMerieux: Advisor/Consultant|bioMerieux: Grant/Research Support|Insmed: Grant/Research Support|Merck: Grant/Research Support|Thermo-Fischer: Advisor/Consultant Scott J. Bergman, PharmD, BCIDP, FCCP, FIDSA, Merck & Co., Inc: Advisor/Consultant|Merck & Co., Inc: Grant/Research Support|Merck & Co., Inc: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Honoraria.
997. Burden of Inappropriate Urine Culture Collection and Processing on the Environment
Authors: Farshidpour Leyla , Wilson Tyler E , Hauser Naomi , Desai Angel 
Published: December 2022

Abstract

Background
Healthcare is the second-most energy-intensive commercial sector in the United States. Clinical laboratories make up a large portion of that energy use and contribute significantly to waste production (7, 8, 9, 10). We aimed to estimate the environmental impact of urine cultures and suggest inappropriate culturing as a target for diagnostic stewardship and waste mitigation.

Methods
The total number of urine cultures performed by our facility’s microbiology laboratory was gathered. The plastic components, including bacterial culture plates, urine sample collection cups, and biohazard bags, were weighed.

Results
Between 3/07-03/13/21, 533 urine cultures were processed by our facility. Since the number of bacterial culture plates varies between samples, we calculated a range from 2 cell-culture plates (clean catch sample) to 4 cell-culture plates (in-and-out catheterization sample), with an additional 1-2 plates per isolate for susceptibility testing. This yielded a range of 3-6 total plates (30g for bacterial culture plates, 120g for susceptibility plates) used per processed urine culture. Each sample also requires a collection cup (27.2g or 19.1g) and a biohazard bag (4.1g) yielding a range of 95 - 192kg of plastic waste over the study period. Assuming this week represents an average week, our projected annual waste is between 6.5 to 12 tons for urine culture collection and testing.

Conclusion
In this single-center pilot study, urine cultures produced an estimated 6.5 to 12 tons of plastic waste annually. Prior studies suggest that 58%-68% of urine cultures are not clinically indicated (2, 3). This includes up to 35% of emergency department urine cultures being done in the context of a negative urinalysis, 20% of urine cultures sent without a urinalysis, and a urine culture contamination rate of at least 5% (4). While the effects of inappropriate urine cultures on length of hospital stay, antibiotic stewardship, and healthcare costs have been investigated, the subsequent impact on the environment has not been well studied (5). Although this study was limited by its reliance on estimated numbers, the sizable impact on healthcare’s net waste production suggests that further quantifying inappropriate culturing and how to alleviate it is an important area for further investigation.

Disclosures
All Authors: No reported disclosures.