bluuebunny/crossref_metadata_2025_split huggingface dataset:
892. Clinical Impact of Early Antifungal De-escalation (≤ 2 days) based on Rapid Species Identification in Patients with Azole-susceptible Candidemia
Authors: Lee Sara , Mazur Shawn , Mazur Shawn , Kodiyanplakkal Rosy Priya , Theodore Deborah , Kubin Christine J 
Published: December 2022

Abstract

Background
Echinocandins are first-line therapy of candidemia with an option to de-escalate (DE) to oral azoles based on clinical response and susceptibilities. There are no universally accepted DE criteria but rapid diagnostic testing (RDT) allows for earlier Candida sp. identification. The objective of this study was to compare outcomes between early DE (≤ 2 days) and late DE ( &gt; 2 days) using RDT as an antifungal stewardship strategy.

Methods
This was a retrospective study in adults with candidemia caused by C. albicans, C. tropicalis, and C. parapsilosis from 2017-2021. Patients with neutropenia or deep-seated/uncontrolled source were excluded. Primary outcome was 30-day global response (clinical and microbiological success). Secondary outcomes included clinical and microbiologic success, length of stay after candidemia, development of resistance, infection recurrence, and mortality. Comparisons were performed using Chi-squared or Fischer’s exact test for categorical variables and Student’s t test or Mann-Whitney U for continuous variables. A multivariable logistic regression model was constructed to identify independent factors for global response using DE strategy, ICU status, and considering all variables with a p-value &lt; 0.1 on univariate analysis.

Results
87 patients were included, 34 (39%) in early DE group and 53 (61%) in late DE group. Groups were well matched except early DE patients were less likely to be in the ICU at time of candidemia (18% vs 38%; p=0.079). C. albicans was the most common Candida sp. (54%) and a vascular catheter was the most common source (45%). Overall global response was 93% with an in-hospital mortality of 8%. At the time of DE, 45% were considered hemodynamically unstable. No difference in global response between early and late DE was identified (94% vs 96%, p=1.0). On multivariable analysis, no independent predictors were identified and late DE was not associated with improved global response [OR 0.82 (95% CI 0.08, 8.24)]. No differences were identified in secondary outcomes.

Conclusion
There were no differences in outcomes between early and late DE in the treatment of azole-susceptible candidemia. Early DE within 2 days based on rapid species identification should be considered as an antifungal stewardship strategy based on local susceptibilities.

Disclosures
All Authors: No reported disclosures.
894. Clinical utility of methicillin resistant Staphylococcus aureus (MRSA) nasal PCR to streamline antimicrobial use in the treatment of diabetic foot infection (DFI) with or without osteomyelitis (OM)
Authors: Harb Gaielle , Hopkins Teri L , Yang Linda , Morneau Kathleen , Frei Christopher R , Cadena-Zuluaga Jose , Walter Elizabeth 
Published: December 2022

Abstract

Background
DFI guidelines recommend empiric MRSA-targeted therapy in settings of high prevalence or severe infection; however, they do not provide recommendations for de-escalation. This approach has the potential to increase unnecessary use of broad-spectrum antibiotics; therefore, additional strategies are needed to optimize appropriate antibiotic use. This study evaluates the effect of MRSA nasal PCR testing on MRSA-targeted antibiotic use and clinical outcomes in patients with DFI.

Methods
This was a retrospective quasi-experimental study of patients &gt; 18 years admitted to South Texas VA for DFI, with or without OM, who had an MRSA nasal PCR and culture data. Eligible patients were identified from the Corporate Data Warehouse and reviewed via electronic health record. Patients were allocated into two groups: PRE (5/1/2019-4/30/2020) and POST (12/1/2020-11/30/2021) protocol implementation for de-escalation or avoidance of MRSA-targeted antibiotics. The primary outcome was median (interquartile range [IQR]) days of inpatient MRSA-targeted antibiotic therapy. A Wilcoxon Rank Sum test was used to assess the difference between the groups for the primary outcome. Secondary outcomes included the proportion of patients needing MRSA coverage added back after de-escalation, hospital readmission, length of hospital stay (LOS), patient mortality, and acute kidney injury.

Results
A total of 151 patients were included (83 PRE; 68 POST). Most patients were male (98% PRE; 97% POST) with a median age of 64 (IQR, 56-72) years. There was a significant decrease in MRSA-targeted antibiotic therapy use, from a median of 72 (IQR, 27-120) hours in the PRE group, to 24 (IQR, 12-72) hours in the POST group (p &lt; 0.01). There was also a significant decrease in hospital readmission from 17% in the PRE group to 5% in the POST group (p = 0.02). No significant differences were found for other secondary outcomes.

Conclusion
This study of patients presenting to a VA hospital with DFI identified a statistically significant decrease in median duration of MRSA-targeted antibiotic use post-protocol implementation. This suggests a favorable effect of MRSA nasal PCR for de-escalation or avoidance of MRSA-targeted antibiotics in DFI.

Disclosures
All Authors: No reported disclosures.
899. Evaluation of a Pharmacist-Led Penicillin Allergy Screening Protocol in a Tertiary Care Hospital
Authors: Alzaabi Salma I , El Lababidi Rania M , El Nekidy Wasim S , Hisham Mohamed , Nasef Rama , Salvo Fulvio 
Published: December 2022

Abstract

Background
Although penicillin allergy is commonly reported, less than 1% of the population are truly allergic to penicillin. False penicillin allergy labelling may be associated with suboptimal antibiotic selection, greater costs, and higher prevalence of antibiotic-resistant organisms. The purpose of this study was to evaluate outcomes of implementing a pharmacist-led penicillin-allergy screening protocol on the antibiotic prescribing habits and the appropriateness of selecting first line antimicrobial therapy.

Methods
A retrospective, quasi-experimental study included 97 patients with suspected or confirmed common infections. Data was collected between January 2020 to August 2021 for the pre-protocol implementation group (PPG) and between November 2021 to April 2022 for the post-protocol implementation group (PPI). Adults ( &gt; 18 years) with a documented penicillin allergy were included. Patients with penicillin allergy were identified and interviewed by our Emergency Department (ED) clinical pharmacists using an evidence-based algorithm. Data were analyzed using two-sample Student’s t-test and descriptive statistics.

Results
Fifty-one patients in PPG and 46 in PPI. In the PPG, 60.8% (31/51) had a history of beta-lactam tolerance and 26% (8/31) tolerated at least a penicillin derivative previously. While, twenty-two patients (47.8%) in the PPI tolerated beta-lactams and 50% (11/22) tolerated at least one penicillin derivative. Thirty-eight patients (82.6%) had a documented infection in the PPI and received an antibiotic. The use of Moxifloxacin was significantly lower in the PPI vs the PPG, 0% (0/38) vs 17.6 (9/51) respectively, (P=0.008). However, the use of ciprofloxacin, vancomycin, and aztreonam was lower in the PPI vs the PPG but was not statistically significant (Table 2). Antibiotic therapy appropriateness was higher in the PPI as compared to the PPG, 86.8% (33/38) vs 49% (25/51) respectively, (P=0.0004). In the PPI, documented penicillin allergies were delabeled in 23.9% (11/46) of patients.

Conclusion
We observed higher rates of appropriate first line antibiotic therapy selection post-implementation of the pharmacist led penicillin allergy screening protocol. This could be an effective strategy to optimize antimicrobial therapy in the hospital setting.

Disclosures
All Authors: No reported disclosures.
900. Evaluation of automated blood culture results and subsequent pharmacist intervention on time to targeted therapy in patients with bacteremia
Authors: Spangler Jessica , Gentry Andrew , Bilinskaya Anastasia 
Published: December 2022

Abstract

Background
Bloodstream infections (BSIs) are associated with a high mortality rate and timely administration of empiric broad-spectrum antibiotics is critical. However, prolonged exposure increases the risk of colonization and subsequent infection with resistant bacteria. The use of rapid diagnostics and prospective audit and feedback allows for decreased time to targeted therapy and development of resistance.

Methods
This quasi-experimental study aimed to evaluate changes in time to targeted antibiotic therapy before and after implementation of a real-time pharmacist notification for bacteremic patients. The pre- and post- intervention periods were 9/1/19–12/31/19 and 9/1/21– 12/31/21, respectively. Bacteremic patients that were identified via automated Bruker’s MBT Sepsityper IVD kit reports and admitted for ≥48 hours were included in the study. Patients were excluded if they had ≥ 1 BSI or polymicrobial BSI during hospitalization, treatment of a concurrent infection, or transitioned to hospice. The primary outcome was change in time to targeted antibiotic therapy. Secondary outcomes included change in broad-spectrum antibiotic days of therapy, total duration therapy, hospital length of stay, and in-hospital all-cause mortality.

Results
A total of 132 charts were reviewed, 83 of which were included, with 47 in the pre- and 36 in the post-intervention group. The most common isolates in the study across both groups was E. coli (36.1%), Klebsiella spp. (15.7%), MSSA (15.7%) and MRSA (8.4%). A trend towards decreased time to targeted therapy was seen in the post-intervention group (5.4 hours vs 33.0 hours; p = 0.150). Median duration of anti-MRSA therapy was reduced from 49.4 hours in the pre-intervention group to 27.92 hours in the post-intervention group (p=0.035). There was no significant difference in total duration of therapy, days of anti-pseudomonal therapy, length of stay, or in-hospital all-cause mortality. Of the 22 pharmacist interventions, 18 (81.8%) were accepted. The most common pharmacist intervention was therapy de-escalation (72.7%).

Conclusion
Automated rapid blood culture diagnostic results used in conjunction with real-time notifications to pharmacists, further decreased time to targeted therapy and significantly reduced duration of anti-MRSA therapy.

Disclosures
All Authors: No reported disclosures.
908. Impact of Antimicrobial Stewardship Protocol Mandating Infectious Diseases Consultation Post 72 Hours of Meropenem Usage
Authors: Nguyen Nhi , Britt Rachel S , Reynoso David , Ferren Scott 
Published: December 2022

Abstract

Background
Carbapenem use correlates with the development of carbapenem-resistant organisms, prompting our antimicrobial stewardship program (ASP) to develop a policy mandating infectious diseases (ID) consultation after 72 hours of meropenem use. Our objective was to evaluate the impact of this policy on meropenem utilization and associated clinical outcomes.

Methods
This quasi-experimental, observational study evaluated the impact of the new ASP policy in adult patients across four campuses. Administered meropenem orders were retrieved retrospectively six months before (11/2020-4/2021) and after (6/2021-11/2021) policy implementation. The primary outcome was meropenem days of therapy per 1000 patient-days (DOTs). Secondary outcomes included DOTs of select broad-spectrum antimicrobials, 30-day all-cause mortality, hospital length of stay (LOS), and Clostridioides difficile (C. difficile) infection incidence. All outcomes were assessed in pre- and post-intervention periods.

Results
There were 1493 and 1404 meropenem orders in the pre- and post-intervention periods, respectively. Pre-intervention group patients had slightly higher modified Charlson Comorbidity Index scores (2.1 vs 1.9, p=0.02). Pre-intervention group had more patients with penicillin allergies but less patients with sulfa allergies (p=0.007 and p=0.03, respectively). The most common meropenem indications were bloodstream, respiratory, abdominal, and urinary tract infections. The incidence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales and cefepime-resistant Pseudomonas spp. was similar in both groups (p=0.7 and p=0.1, respectively). ID consultation increased after policy implementation (44.1% vs 51.7%, p=0.001). Meropenem DOTs decreased significantly after intervention (50.3 vs 35.5, p=0.0003). We observed increases in ceftriaxone and cefepime DOTs (94 vs 103.8, p=0.006 and 39 vs 58.5, p=0.0005, respectively). An increase in C. difficile incidence was seen. Hospital LOS was similar pre- and post-intervention (mean 18.5 days, p=0.9).

Conclusion
The ASP policy mandating ID consultation after 72 hours of meropenem use helped decrease meropenem DOT and encouraged use of antimicrobial agents with narrower spectrum.

Disclosures
All Authors: No reported disclosures.
911. Impact of Intensified Clindamycin Stewardship Initiatives in Three Phases: A Quasi-Experimental Study
Authors: Gamble Kelly C , Rose Dusten T T , Mondy Kristin , Thyagarajan Rama , Jaso Theresa , Coats Leslie , Reveles Kelly R 
Published: December 2022

Abstract

Background
Clindamycin utilization has provoked gram-positive and anaerobic bacterial resistance and is associated with Clostridioides difficile infections (CDI). The purpose of this study was to evaluate if implementing local clindamycin-focused stewardship initiatives impacts clindamycin utilization and outcome metrics.

Methods
This multicenter, retrospective quasi-experimental study was conducted in adult hospitalized patients who received clindamycin from 2018 to 2020. Outcomes were compared in three phases between an intervention and control group (Figure 1). The primary outcome was inappropriate utilization: a resistant pathogen, concurrent antibiotic(s) with pathogen activity, a non-necrotizing infection, an alternative agent was preferred, or alternative reasons per expert discretion. Secondary outcomes included clindamycin duration of therapy per 1000 patient hospital days (DOT/1000 PD), 30-day CDI, 30-day readmission, and in-hospital mortality. Outcomes were compared between groups using the chi-square, Fisher’s exact, or Kruskal-Wallis tests as appropriate. Figure 1.Study DesignID: infectious diseases, I: intervention group, C: control group

Results
The study included 481 patients (Table 1). Inappropriate clindamycin use in the intervention group was highest in Phase 1 (94%), then decreased in Phase 2 (72%) and Phase 3 (74%) (p&lt; 0.01). Comparing Phase 1, Phase 2, and Phase 3 between the intervention and control groups, respectively, the primary outcome occurred in 94% vs 93% (p=0.80), 72% vs 88% (p=0.02), and 74% vs 89% (p=0.03). The DOT/1000 PD was 10 in Phase 1, 9.2 in Phase 2, and 6.2 in Phase 3. Initiatives were not associated with significant reductions in 30-day CDI (1% in Phase 1, 0% in Phase 2, 0% in Phase 3, p=0.64), 30-day readmission (18% in Phase 1, 31% in Phase 2, 22% in Phase 3, p=0.13), or in-hospital mortality (0% in Phase 1, 2% in Phase 2, 0% in Phase 3, p=0.33). Table 1.OutcomesI: intervention group, C: control group, DOT/1000 PD: days of therapy per 1000 patient days, CDI: Clostridioides difficile infection

Conclusion
Clindamycin-focused stewardship initiatives reduced inappropriate prescribing patterns by approximately 20% but still remained high in Phase 3. Clindamycin was primarily ordered in the emergency department (ED). Additional initiatives may include formal criteria for use and removing clindamycin from automated dispensing cabinets in the ED. Our initiatives may serve as a model for other institutions to reduce clindamycin utilization and its associated complications.

Disclosures
All Authors: No reported disclosures.
914. Implementation and User Experience with a Mobile Stewardship App: Phase One of a Study on Guideline Concordant Prescribing
Authors: Thumann Alexis , Wankum Michael , Gens Krista 
Published: December 2022

Abstract

Background
The development of facility-specific antibiotic guides to promote the appropriate use of antibiotics is strongly encouraged; however, the inability to access these resources quickly and easily can be a barrier to optimal antimicrobial prescribing. This study phase aims to determine whether providing guidelines in an easy-to-use mobile app increases access to and awareness of these resources available to providers.

Methods
In phase one of this study, our team: migrated facility guidelines over to the Sanford Guide Stewardship AssistTM application, provided education, launched the app (March 14, 2022), and sent out a voluntary pre- and one-month post-implementation REDcap provider survey. Phase two of this study will evaluate antibiotic prescribing for limited indications pre-post app implementation and will include a six-month follow-up survey to assess continued trends in guideline awareness and accessibility. The primary endpoint for phase one is to evaluate the usefulness and effect of the app on provider guideline awareness.

Results
As of May 3, 2022, 409 downloads of the app occurred since launch, with the facility-specific antibiogram being the most viewed page. Thirty-five participants completed the pre-implementation survey, and twenty-three completed the one-month follow-up survey. Respondents included medicine residents (54.3%), hospitalists (17.1%), primary care (11.4%), infectious disease (8.6%), internal medicine (5.7%), and others (2.9%). Statistically significant increases pre-post app implementation for strongly agree/agree responses were seen for the statements, “I feel confident in using an antibiogram” (71.4% vs. 95.7%, p=0.02) and “I can easily access our facility-specific antibiotic guidelines when needed” (68.6% vs. 95.7%, p=0.01). At one month, 73.9% and 91.3% of providers agreed with the statements “I would consider myself a better steward of antibiotics because of the app implementation” and “The app is useful to my practice,” respectively.
Pre-implementation Survey Responses
One-month Post-survey Responses: General
One-month Post-survey Responses: App-specific

Conclusion
Implementing an antimicrobial stewardship app at a large, non-academic health system promoted accessibility to facility-specific guidelines, reinforced antimicrobial stewardship ideals, and was a valuable resource for prescribers.

Disclosures
All Authors: No reported disclosures.
929. A Nationwide Survey on the Role of Antimicrobial Stewardship Programs during the COVID-19 Pandemic: What is restricted and who decides?
Authors: Mena Lora Alfredo J , Herald Fischer , Lindsey Brenna , Burgos Rodrigo M , Borgetti Scott , Chaisson Lelia H , Bleasdale Susan C 
Published: December 2022

Abstract

Background
During the COVID-19 pandemic, evolving literature and emerging therapies have led to significant controversies on what constitutes optimal therapy for hospitalized patients with COVID-19. In addition, multiple guidelines emerged exhibiting variable recommendations in key areas of therapeutic management. Thus, interpreting emerging data and deploying novel therapeutics during the pandemic has been challenging. Antimicrobial stewardship programs (ASP) have been proven to help promote evidence-based practices and are now common the United States (US). We seek to further understand the role of ASP during the COVID-19 pandemic.

Methods
A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, hospital size, facility type, and existence of active ASP. COVID-19 therapeutic restrictions and type of provider who decides on treatment allocation was surveyed.

Results
A total of 92 surveys were completed, representing wide geographic reach within the United States (Figure 1). Hospital size by beds were 14% less than 200 (13), 18.5% 201-300 beds (17), 15.2% 301-400 beds (14), and 52.2% over 400 beds (48). Community hospitals accounted for 31.5% (29), county/public hospital 3.3% (3, 3.3%), University-affiliated Community-Based Teaching Hospitals 10.9% (10), University-based Teaching Hospital 45.7% (42), and 8.7% selected other. ASP were present in 97.2% of hospitals. COVID-19 therapeutic restrictions were common (Figure 2). Infectious diseases (ID) approval was required in 87.9% of facilities (Figure 3). Figure 1Geographic distribution of hospitals represented in the survey
Figure 2. Restricted COVID-19 therapies by medication type (%)
Figure 3 Specialties or providers that are able to order or approve restricted COVID-19 therapies (%)

Conclusion
COVID-19 therapeutics were commonly restricted during the COVID-19 pandemic. Approval by ID clinicians was required almost universally (87.9%). The role of other specialties was significantly lower, representing less than 45% of hospitals. ID clinicians have played a vital role in guiding therapy and supporting ASP during the COVID-19 pandemic. This survey highlights the value of ID clinicians to healthcare systems in allocating resources and promoting evidence-based practices through ASP.

Disclosures
All Authors: No reported disclosures.
932. Analysis of Seasonal Variation of Antibiotic Prescribing for Respiratory Tract Diagnoses in Primary Care Practices
Authors: Serletti Lacey M , Dutcher Lauren , Degnan Kathleen , Cressman Leigh , David Michael Z , Szymczak Julia E , Glassman Lindsay W , Cluzet Valerie , Hamilton Keith W 
Published: December 2022

Abstract

Background
Seasonal fluctuations in antibiotic prescribing for respiratory tract diagnoses (RTDs) have been identified, but characteristics and appropriateness of these variations have not been well described. The objectives of this study were to describe seasonal variations for RTDs and to determine whether seasonal variation in prescribing is associated with inappropriate use.

Methods
From July 1, 2016 through June 30, 2017, antibiotic prescribing was analyzed for 31 primary care practices comparing winter (October-March) and summer (April-September) months. ICD-10 codes for RTDs were described as tier 1, 2, or 3 based on whether antibiotics are almost always, sometimes, or almost never indicated, respectively. Twenty visits from each of 60 providers were randomly selected and manually reviewed to determine a gold standard of antibiotic appropriateness in order to characterize the appropriateness of these seasonal variations. Associations between season and diagnosis tier, season and appropriateness, and individual provider seasonal changes in antibiotic prescribing and provider characteristics were determined.

Results
There was a lower proportion of visits with tier 3 diagnoses in winter months (68% v. 74%, p&lt; 0.01), but a greater proportion of tier 2 diagnoses (29% v. 23%, p&lt; 0.01). There were greater proportions of visits in which an antibiotic was prescribed for both tier 2 (80% vs 74%, p&lt; 0.01) and tier 3 diagnoses (23% v. 16%, p&lt; 0.01) in winter months. Using medical record review, inappropriate antibiotics were prescribed more frequently for RTDs in winter compared to summer months (73% v. 64%, p&lt; 0.01). Greater individual provider difference in proportion of RTD visits in which an antibiotic was prescribed from summer to winter was associated with family medicine v. internal medicine specialty (8.2% v. 5.1%, p&lt; 0.01), nonteaching v. teaching practice (8.1% v. 2.9%, p&lt; 0.01), and nonurban v. urban setting (9.1% v. 3.9%, p&lt; 0.01).

Conclusion
Although there was a greater proportion of tier 2 compared to tier 3 RTDs in winter months, winter months were associated with more inappropriate prescribing than in summer months. More investigation is needed to understand the drivers for seasonal variations in RTDs and inappropriate prescribing.

Disclosures
Kathleen Degnan, MD, Gilead: Grant/Research Support Michael Z. David, MD PhD, Contrafect: Grant/Research Support|GSK: Advisor/Consultant|Johnson and Johnson: Advisor/Consultant.