Length Of Antibiotic Therapy Research Articles

Septic Arthritis of the Acromioclavicular Joint: A Single-Center, 11-Year Retrospective Review.

Septic arthritis of the smaller acromioclavicular joint is uncommon, with only a few reports and case series available in the literature. The aim of this outcomes analysis was to determine the prevalence of shoulder girdle septic arthritis within the authors' institution, with a particular focus on describing the authors' experience with acromioclavicular joint septic arthritis. A retrospective outcomes analysis was conducted of patients admitted to a single tertiary referral center from 2008 to 2018 with acromioclavicular joint septic arthritis. Demographic and clinical data were recorded for each patient; the modified Frailty Index score was calculated for each patient. Nine patients were identified as having acromioclavicular joint septic arthritis, making up 12% of shoulder girdle septic arthritis. Diabetes mellitus was the most prevalent comorbidity, present in 4 (44.4%) patients. Staphylococcus aureus was responsible in 55.6% and Streptococcus species in 44.4%. Seven patients were treated surgically. Mean (SD) length of antibiotic therapy was 6.2 (2.7) weeks. Mean (SD) length of stay was 6 (2.83) days (range, 4-8 days) for patients who received antibiotic therapy only and 12.7 (7.52) days for those who proceeded for operative management. Mean modified Frailty Index score was 1.1. Septic arthritis of the acromioclavicular joint is an uncommon infection that occurs both in patients with impaired immunity and in those with intact immune systems. Tailored antimicrobial therapy in conjunction with surgical intervention, when indicated, appears to result in successful suppression or eradication of infection in the majority of cases. [Orthopedics. 2021;44(4):e493-e497.].

Use of electronic pharmacy transaction data and website development to assess antibiotic use in nursing homes

BackgroundIn 2017, the Centers for Medicare and Medicaid Services required all long-term care facilities, including nursing homes, to have an antibiotic stewardship program. Many nursing homes lack the resources, expertise, or infrastructure to track and analyze antibiotic use measures. Here, we demonstrate that pharmacy invoices are a viable source of data to track and report antibiotic use in nursing homes.MethodsThe dispensing pharmacy working with several nursing homes in the same healthcare corporation provided pharmacy invoices from 2014 to 2016 as files formatted as comma separated values. We aggregated these files by aligning elements into a consistent set of variables and assessed the completeness of data from each nursing home over time. Data cleaning involved removing rows that did not describe systemic medications, de-duplication, consolidating prescription refills, and removing prescriptions for insulin and opioids, which are medications that were not administered at a regular dose or schedule. After merging this cleaned invoice data to nursing home census data including bed days of care and publicly available data characterizing bed allocation for each nursing home, we used the resulting database to describe several antibiotic use metrics and generated an interactive website to permit further analysis.ResultsThe resultant database permitted assessment of the following antibiotic use metrics: days of antibiotic therapy, length of antibiotic therapy, rate of antibiotic starts, and the antibiotic spectrum index. Further, we created a template for summarizing data within a facility and comparing across facilities. https://sunahsong.shinyapps.io/USNursingHomes/.ConclusionsLack of resources and infrastructure contributes to challenges facing nursing homes as they develop antibiotic stewardship programs. Our experience with using pharmacy invoice data may serve as a useful approach for nursing homes to track and report antibiotic use.

92. Successful Scale-up of an Intervention to Decrease Unnecessary Urine Cultures Led to Improvements in Antibiotic Use

BackgroundWe previously conducted a successful single-site intervention to improve compliance with antibiotic stewardship guidelines for asymptomatic bacteriuria (ASB). In this dissemination project we explored whether we could facilitate antibiotic stewardship for ASB at a distance, in four distant VA medical centers.MethodsEach site champion received a decision-aid algorithm, interactive teaching based on actual cases, and support with data collection. The focus of the intervention was on teaching providers in acute and long-term care to avoid ordering unnecessary urine cultures. We measured DOT (days of antibiotic therapy), LOT (length of antibiotic therapy) and urine cultures ordered per 1,000 bed-days monthly in the intervention sites and four matched control sites. Both DOT and LOT captured all systemic antibiotics initiated on day -1 to +2 of a urine culture order. We conducted segmented regression analyses for the three outcomes for the intervention and control sites separately, and difference in differences analysis for urine cultures.ResultsOver the baseline and intervention years, 12,260 urine cultures were ordered in 6823 unique patients in the acute and long-term care wards at the 8 sites. During the baseline year, the average urine-culture related DOT was 45.1 and LOT was 34.7, per 1000 bed-days. Both DOT and LOT decreased significantly over the intervention period in the intervention sites (p < 0.05 for both); a significant decrease was not seen in the control sites (Figures 1 and 2). For urine cultures, at baseline the average number of cultures ordered per month per 1000 bed-days was 13.6. Both intervention and control sites saw a significant decrease in urine cultures over the baseline year. In the intervention year, urine cultures continued to decrease in the intervention sites (p=0.001) but increased in the control sites (Figure 3).Figure 1. Days of Therapy (DOT) per 1,000 bed-days, for antibiotics started within -1 to +2 days of a urine culture Figure 2. Length of Therapy (LOT) per 1,000 bed-days, for antibiotics started within -1 to +2 days of a urine culture Figure 3. Urine Cultures per 1,000 bed-days ConclusionOur externally-facilitated intervention significantly decreased local antibiotic use (both DOT and LOT) and urine cultures. Unnecessary urine cultures are a major driver of unnecessary antibiotic use for ASB, and our focus on diagnostic stewardship for urine cultures led to antibiotic stewardship. Our next step will be to further disseminate our intervention to other VA facilities.Disclosures All Authors: No reported disclosures

62. Factors Associated with 30-Day ED Readmission Following Initial ED Discharge for Suspected Sepsis

BackgroundGiven the increased mortality associated with delayed recognition of sepsis, emergency departments (ED) often use protocols to rapidly identify and treat suspected sepsis. However, screening criteria such as systemic inflammatory response syndrome (SIRS) lack specificity and may over-diagnose sepsis in patients otherwise stable for discharge. Our study describes outcomes and identifies factors associated with ED readmission in those initially discharged directly from the ED who met sepsis criteria.MethodsThis retrospective cohort study evaluated adult patients (≥ 18 years) seen in the ED at UTSW Medical Center from January to June 2018 who met all the following: ≥ 2 SIRS criteria; received ≥ 1 dose of intravenous (IV) broad-spectrum antibiotic(s) in the ED; were discharged home. A multivariable logistic regression model identified factors associated with 30-day re-admission to our ED, using clinically significant variables parsimoniously. A two-sided P value < 0.05 was considered significant.ResultsA total of 179 patients were included. Forty-four patients (25%) returned to the ED within 30 days of their initial visit; of those 44, 63.6% (28) returned for issues related to their prior visit, and 50% (22) were admitted to the hospital. Table 1 compares baseline demographics of patients with suspected sepsis readmitted to the ED with those not readmitted within 30 days after initial ED discharge. In univariable analysis, quick Sequential Organ Failure Assessment (qSOFA), and length of antibiotic therapy (ED plus discharge antibiotics) were associated with ED re-admission (table 1). Receipt of antibiotics on discharge was not significant. In the final multivariable analysis (table 2), initial qSOFA ≥ 2 alone was associated with increased risk of ED re-admission (OR 7.5, p=0.01).Table 1. Baseline demographics of patients readmitted and not readmitted to the ED within 30 days after ED discharge with suspected sepsis Table 2. Multivariable logistic regression of risk factors for patients readmitted and not readmitted to the ED within 30 days after ED discharge with suspected sepsis ConclusionIn this cohort, 25% of patients with suspected sepsis initially discharged from the ED were readmitted to our ED within 30 days. A qSOFA ≥ 2 at the initial ED visit was associated with increased risk of readmission, suggesting a potential use of qSOFA to triage those warranting admission or closer follow-up. Larger prospective studies are warranted in this understudied population of patients who meet screening sepsis criteria but are discharged from the ED.Disclosures All Authors: No reported disclosures

COMPARISON OF SHORT-TERM AND LONG-TERM COURSE OF ANTIBACTERIAL THERAPY FOR INTRA-ABDOMINAL INFECTION CAUSED BY ACUTE GANGRENOUS APPENDICITIS

Intra-abdominal infection and its complications is still remaining a fairly common and urgent global problem. Currently, there are a large number of publications providing guidelines and recommendations for the treatment of infections caused by a certain type of causative agents. However, the appropriate duration of antibiotic therapy is among the most controversial issues. Majority of clinicians tend to prescribe antibiotic therapy until all signs of inflammation disappear, usually for 7-14 days. But, in 1994, Schein M., and co-authors suggested that with adequate treatment of the focus of intra-abdominal infection, the duration of antibiotic therapy can be reduced to 3-4 days that in turn will reduce the resistance to antibacterial drugs. The aim of this study was to investigate the possibility in reducing antibiotic therapy length for patients with intra-abdominal infection caused by acute gangrenous appendicitis. The study included 32 patients aged 18 - 65 years, who were operated on for acute gangrenous appendicitis at the same day when admitted to the hospital at the surgical department of the 3rd Municipal Clinical Hospital of Poltava. The patients were divided into two groups. The first (study) group included 16 patients who received antibiotic therapy within minimum 3 days until the normalization of the leukocytosis and body temperature. The second (control) group included 16 patients who continued to receive antibiotic therapy for at least 2 days following the normalization of these criteria. Based on the results obtained in studying the effect of the length of antibiotic therapy course on intra-abdominal infection in the patients with acute gangrenous appendicitis during the postoperative period, we revealed the duration of antibiotic therapy for 3 ± 0.25 days showed similar results compared to the results of traditional and longer antibiotic therapy. The comparable values included periods of recovery and discharge following the surgery, the incidence of complications in the early and remote postoperative period. Our data confirm the concept that adequate surgical treatment of the infection focus in the abdominal cavity results in the reduction of antibiotic therapy length for several days after the operation without the risk of developing postoperative complications and recurrence of the infectious process.

Antibiotic Use Among Residents Receiving Skilled Nursing Care in 29 U.S. Nursing Homes.

Data describing antibiotic use in U.S. nursing homes remain limited. We report antibiotic use among skilled nursing facility residents from 29 U.S. nursing homes and assessed correlations between antibiotics prescribed to residents in skilled care and nursing home characteristics. Retrospective cohort study. Twenty-nine U.S. nursing homes in the same healthcare corporation. Residents receiving skilled care in 2016. We used pharmacy invoice and nursing home census data to calculate the days of antibiotic therapy per 1,000 days of skilled care (1,000 DOSC), the rate of antibiotic starts per 1,000 DOSC, the length of antibiotic therapy, and the average antibiotic spectrum index. We also assessed correlations between antibiotic use and nursing home characteristics. Antibiotics accounted for an average of 9.6% (±0.6%) of systemic medications prescribed among residents receiving skilled care. On average, 26.8% (±2.9%) of antibiotics were intravenous. Fluoroquinolones were prescribed at the highest rates (19% across all facilities), followed by beta-lactam/beta-lactamase inhibitors (11%), first- and second-generation cephalosporins, sulfonamides, and oral tetracyclines (each at 9%). Both the proportion of residents using enrolled in Medicare and number of unique prescribers responsible for systemic prescriptions positively correlated with the rate of antibiotic starts. Our study demonstrates that pharmacy invoices represent a useful and preexisting source of data for assessing antibiotic prescriptions among individuals receiving skilled nursing care. The correlation between the number of unique prescribers and antibiotic starts suggests that prescribers are central to efforts to improve antibiotic use in nursing homes.

Outcomes of Extended-Spectrum Beta-Lactamase Gram-Negative Bacteremia Cases Treated With Carbapenem Versus Noncarbapenem Antibiotics

Background: The rising prevalence of infections caused by extended-spectrum β-lactamase (ESBL)–producing bacteria increases reliance on carbapenems, which intensifies selection pressure for the emergence of carbapenem-resistant Enterobacteriaceae (CRE). Whether noncarbapenem (nC) antibiotics can be safely used in this setting remains incompletely understood. Objective: To examine the safety of carbapenem stewardship in this population, we compared outcomes of uncomplicated ESBL bacteremia treated with a carbapenem to those treated with a noncarbapenem regimen. Methods: A retrospective chart review of patients with ESBL bacteremia from 2014 to 2018 in a 5-hospital regional health system was conducted. Patients aged &lt;18 years, with polymicrobial bacteremia, whose infections required a prolonged length of antibiotic therapy (LOT), or who died on antibiotic treatment or transitioned to hospice, were excluded. Groups were stratified based on the antibiotic regimen with the highest number of treatment days during the treatment course. Outcome measures included empiric and definitive length of therapy (LOT), 30-day all-cause mortality, 90-day readmission, recurrence of ESBL bacteremia, hospital length of stay (LOS), incidence of Clostridioides difficile infection (CDI) and adverse drug events, obtained by Wilcoxon rank-sum testing, χ2 test, and Fisher exact test, as applicable. Results: In total, 112 unique patients had ESBL bacteremia; 42 were excluded, leaving 70 for analysis. Of these, 57 were treated with a carbapenem regimen and 13 patients were treated with a noncarbapenem regimen: 9 ciprofloxacin, 3 gentamicin, 1 TMP-SMX. Patient baseline and antibiotic regimen characteristics were similar (Table 1). The most common organism was E. coli, and the most common source was urinary. A similar proportion of each group received ESBL-active empiric antibiotics. There were no significant differences in total effective antibiotic LOT, 30-day all-cause mortality, 90-day readmission, or recurrence of ESBL bacteremia (Table 2). A nonsignificant trend in hospital LOS was observed in the noncarbapenem group (11 vs 6 days; P = .055). Conclusions: Although the sample size was small, these multicenter data suggest that noncarbapenem treatment of ESBL bacteremia may be safe and effective. Pending confirmatory studies, ESBL bacteremia may be an important target for carbapenem stewardship.Funding: NoneDisclosures: None

S0254 Factors Influencing Clostridium difficile Infection Amongst African Americans in a Community Hospital

INTRODUCTION: Clostridium difficile infection (CDI) poses a significant health concern amongst hospitalized patients in the United States. Underlying comorbidity significantly increases the burden of this infection especially in vulnerable populations. However, we have shown that the severity and infection rates are lower in African Americans treated at our community hospital. Unnecessary isolation protocols increase length of stay and overall cost of healthcare. The aim of this study is to determine factors that could predict CDI amongst African Americans at Harlem Hospital in an effort to avoid unnecessary isolation of patients. METHODS: Information was collected from hospital charts of patients who were isolated for clostridium infection between January 2016 and December 2018. A total of 251 patients were isolated for suspected infection during this time. Baseline socio-demographic information, immune compromising comorbidities, days on antibiotic therapy, and length of hospital stay were extracted from clinical records. Descriptive, bivariate and multivariate logistic analysis was done. RESULTS: 251 patients were isolated for CDI of which 48% were females and 52% male. 56 patients (22%) were confirmed positive and the median age was 61 with an IQR [20–92]. Average length of hospital stay varies from one to 80 days with the average length of antibiotic use being 14 days [range 1–44]. There was no significant difference between the length of antibiotic therapy in those with CDI compared with those without. The average length of hospital stay for those with CDI was 33 days and for those without the infection was 34. Older patients were more significantly affected with CDI (P < 0.05). CDI increases by age 3% [OR (1.01–1.05)], Male 28% [OR (0.67–2.41)], days on antibiotics 1% [OR (0.99–1.02)], immune compromising status 48% [OR (0.79–2.810)]. CONCLUSION: A large percentage of our hospital patients with diarrheal illness suspected of having CDI in fact test negative for the disease. Strict adherence to Centers for Disease Control and Prevention (CDC) guidelines may likely decrease unnecessary isolation protocols. The prevalence of CDI was influenced by the age of the patient as the risk increases with age. This might be attributed to a weaker immune response as shown.

Identifying targets for antibiotic stewardship interventions through analysis of the antibiotic prescribing process in hospitals - a multicentre observational cohort study

BackgroundIn order to change antibiotic prescribing behaviour, we need to understand the prescribing process. The aim of this study was to identify targets for antibiotic stewardship interventions in hospitals through analysis of the antibiotic prescribing process from admission to discharge across five groups of infectious diseases.MethodsWe conducted a multi-centre, observational cohort study, including patients with lower respiratory tract infections, exacerbation of chronic obstructive pulmonary disease, skin- and soft tissue infections, urinary tract infections or sepsis, admitted to wards of infectious diseases, pulmonary medicine and gastroenterology at three teaching hospitals in Western Norway. Data was collected over a 5-month period and included antibiotics prescribed and administered during admission, antibiotics prescribed at discharge, length of antibiotic therapy, indication for treatment and discharge diagnoses, estimated glomerular filtration rate (eGFR) on admission, antibiotic allergies, place of initiation of therapy, admittance from an institution, patient demographics and outcome data. Primary outcome measure was antibiotic use throughout the hospital stay, analysed by WHO AWaRe-categories and adherence to guideline. Secondary outcome measures were a) antibiotic prescribing patterns by groups of diagnoses, which were analysed using descriptive statistics and b) non-adherence to the national antibiotic guidelines, analysed using multivariate logistic regression.ResultsThrough analysis of 1235 patient admissions, we identified five key targets for antibiotic stewardship interventions in our population of hospital inpatients; 1) adherence to guideline on initiation of treatment, as this increases the use of WHO Access-group antibiotics, 2) antibiotic prescribing in the emergency room (ER), as 83.6% of antibiotic therapy was initiated there, 3) understanding prescribing for patients admitted from other institutions, as this was significantly associated with non-adherence to guideline (OR = 1.44 95% CI 1.04, 2.00), 4) understanding cultural and contextual drives of antibiotic prescribing, as non-adherent prescribing differed significantly between the sites of initiation of therapy (between hospitals and ER versus ward) and 5) length of therapy, as days of antibiotic therapy was similar across a wide range of diagnoses and with prolonged therapy after discharge.ConclusionsAnalysing the process of antibiotic prescribing in hospitals with patient-level data identified important targets for antibiotic stewardship interventions in hospitals.

2103. Emergency Department (ED) Stewardship: Stratifying ED Sepsis Order Sets by Penicillin (PCN) Allergy Severity

BackgroundThe Surviving Sepsis Campaign Guidelines recommends administration of broad-spectrum antibiotics within 1 hour of sepsis diagnosis; electronic order sets drive antibiotic selection with pre-populated regimens based on the suspected infectious indication. Given the low rate of cephalosporin cross-reactivity in patients with a PCN allergy, we modified our ED sepsis order set (Images 1 and 2) to include cephalosporin options in patients with reported mild-to-moderate PCN reaction histories. This was a single-center, retrospective analysis evaluating the impact of this change on antibiotic prescribing and associated outcomes.MethodsAn electronic medical record (EMR) report identified patients ≥18 years of age with a documented PCN allergy that received antibiotics via the ED sepsis order set from December 30, 2012 to September 28, 2013 (pre-intervention) and January 3, 2014 to July 18, 2015 (post-intervention). The primary objective was to compare antibiotic days of therapy (DOT) and length of therapy (LOT) between the pre- and post-groups. The secondary objectives included 30-day readmission and mortality, hospital length of stay (LOS), incidence of C. difficile within 6 months and documented hypersensitivity reactions. Bivariate analyses, with chi-square, Mann–Whitney U, and Poisson means test, were used.ResultsA total of 180 patients (90 pre- and 90 post-intervention) were included. Demographics were similar between groups, with the exception of congestive heart failure (CHF) which was more prevalent in the post-intervention group (P = 0.039). Aztreonam, vancomycin, aminoglycoside, and fluoroquinolone DOTs were significantly reduced (P < 0.001) while cephalosporin DOTs significantly increased (P < 0.001) in the post-intervention group. There were no statistical differences in antibiotic LOT, 30-day readmission and mortality, hospital LOS, or incidence of C. difficile infection. For those patients that received cephalosporin antibiotics, there were no hypersensitivity reactions documented in the EMR.ConclusionStratifying ED sepsis order sets by PCN allergy history severity is a safe and effective intervention that reduces second-line antibiotics in PCN allergic patients presenting to the ED with suspected sepsis. Disclosures All authors: No reported disclosures.

2006. Evaluation of Rapid Blood Culture Identification with Antimicrobial Stewardship Treatment Recommendations at a Community Health System in Patients with Gram-negative Bacteremia: Adequacy, Adherence, and Outcomes

BackgroundSepsis mortality is greatly affected by the timely receipt of appropriate antibiotics. FilmArray Blood Culture Identification (BCID) is used at Cone Health to identify organisms in blood cultures within one to 2 hours after growth detected. The Cone Health antimicrobial stewardship (AMS) team has created treatment recommendations for each organism and resistance mechanism identifiable by BCID. Results and antibiotic recommendations are communicated in real time to providers by clinical pharmacists. The purpose of this evaluation was to validate the adequacy of antibiotics recommended by the BCID treatment algorithm for Gram-negative rods (GNR); assess proper implementation of the BCID notification procedure; and evaluate its effect on AMS.MethodsPatients with GNR BCID results in January and April 2018 were retrospectively identified. Information collected for each patient included: demographics, location, organism, admission antibiotics, pharmacist compliance with BCID procedure, recommendation acceptance rate, organism susceptibility, changes to antibiotics post-BCID and final cultures, extended-spectrum β-lactamase (ESBL) incidence, length of antibiotic therapy, and patient outcome.ResultsA total of 101 patients were evaluated. The BCID treatment algorithm recommendations covered 97% of identified organisms (Figures 1–4). Resistant isolates were ESBL producers. Pharmacist antibiotic recommendations matched the treatment algorithm 66% of the time. Providers accepted 90% of pharmacist recommendations. Twenty-two percent of antibiotics were not de-escalated after BCID results without identifiable reason.ConclusionThe BCID treatment algorithm provided adequate coverage for nearly all identified organisms, except ESBLs. However, patients with ESBL organisms all survived to hospital discharge. Pharmacists are following the BCID protocol in a majority of cases. One-third of recommendations deviated from the algorithm but only 17% did not have documented reasoning. Providers are very receptive to pharmacist input, with only 8% of recommendations rejected without documented reasoning. Finally, nearly a quarter of empiric antibiotics were not de-escalated despite organism identification, which represents opportunity for improvement. Disclosures All authors: No reported disclosures.

First outbreak of Clostridium difficile infections in Serbia: An experience of the department for orthopedic surgery

Objectives: Increased C. difficile infection rates were observed during the last decade, as well as the onset of complicated forms of the disease. The primary objective of this study was to report the first outbreak of C. difficile in a Serbian hospital, aiming to determine clinical and environmental factors associated with the outbreak. The secondary objective was to describe outbreak control measures taken.Design: The retrospective cohort study conducted from 18 April to 22 May 2013 in Serbian healthcare. Ninety-five patients hospitalized at the Department for orthopedic surgery during the CDI outbreak.Results: Prophylactic antibiotic therapy was identified among 93.3% patients with and 87.9% without C. difficile infection. The multivariate logistic regression analysis has shown that the independent risk factors for C. difficile infection incidence are the age beyond 70 (OR = 4.5; 95%CI = 1.1-18.2; p = .031) and the length of antibiotic therapy (OR = 1.5; 95%CI = 1.1-2.1; p = .017).Conclusion: The length of antibiotic prophylaxis is linked with the incidence. Orthopedic departments have a risk of C. difficileinfection. Infection control measure, antimicrobial stewardship programs and compliance to guidelines for the prescribing of antibiotics play important role in the prevention of C. difficile infection burden.

519. Longer Length of Antibiotic Therapy for Community-Acquired Pneumonia and Risk of Clostridium difficile Infection

BackgroundWe previously observed a median 9.5 days length of antibiotic therapy (LOT) among patients with community-acquired pneumonia (CAP) requiring hospitalization (Clin Infect Dis. 2018;66:1333–41). Treatment guidelines for CAP, however, suggest LOT >7 days is rarely necessary. In this study, we evaluated the risk of Clostridium difficile infection (CDI) as a potential harm of longer LOT.MethodsThis retrospective cohort study included Medicare beneficiaries with parts A, B, and D coverage hospitalized for uncomplicated CAP in 2012–2013 for 2–10 days, home discharge, and no hospitalizations 30 days before or 3 days after index hospitalization. The main exposure was total LOT, represented by the sum of estimated inpatient and observed outpatient LOT, and defined as “longer” if >9.5 days and “shorter” if ≤9.5 days. The outcome, post-discharge CDI, was defined using ICD-9-CM diagnosis code 008.45 in inpatient, skilled nursing, or outpatient claims within 6 months after index hospitalization. CDI 12 months before or during index hospitalization was excluded. CDI risk was assessed through a multivariable logistic model stratified by outpatient antibiotic class and adjusted for confounders including comorbidities, severity via ICU status, demographics, and hospital characteristics.ResultsThe cohort consisted of 99,883 patients. Median total LOT was 9.5 days (IQR: 7.4–11.4). Antibiotics filled at discharge included quinolones (40%), none (20%), multiple (14%), cephalosporins (10%), macrolides (7%), and β-lactam/β-lactamase inhibitor combinations (5%). CDI risk was 1.2%. Overall adjusted risk among those with longer LOT was 1.2 (95% CI: 1.1–1.4) times that of those with shorter LOT. Increased risk was observed among those prescribed quinolones at discharge, for whom adjusted CDI risk for longer LOT was 1.4 (95% CI: 1.2–1.7) times the risk of those with shorter LOT. We observed no difference in risk between longer and shorter LOTs for other antibiotic categories.ConclusionThese findings suggest that decreased LOT, which can be achieved with better adherence to current treatment guidelines, could reduce risk of subsequent CDI among patients hospitalized with CAP, particularly among those treated with fluoroquinolones at discharge.Disclosures All authors: No reported disclosures.

Infections in Older Adults: A Case-Based Discussion Series Emphasizing Antibiotic Stewardship.

Compared with younger populations, adults 65 years and older are more likely to suffer infection-related morbidity and mortality, experience antibiotic-related adverse events, and acquire multidrug-resistant organisms. We developed a series of case-based discussions that stressed antibiotic stewardship while addressing management of common infections in older adults. Five 1-hour case-based discussions address recognition, diagnosis, and management of infections common in older adults, including those living in long-term care settings: urinary tract infections, upper respiratory tract infections, lower respiratory tract infections, skin and soft tissue infections, and Clostridium difficile infection. The education was implemented at the skilled nursing centers at 15 Veterans Affairs medical centers. Participants from an array of disciplines completed an educational evaluation for each session as well as a pre- and postcourse knowledge assessment. The number of respondents to the educational evaluation administered following each session ranged from 68 to 108. Learners agreed that each session met its learning objectives (4.80-4.89 on a 5-point Likert scale, 5 = strongly agree) and that they were likely to make changes (2.50-2.89 on a 3-point scale, 3 = highly likely to make changes). The average score on the five-question knowledge assessment increased from 3.6 (72%) to 3.9 (78%, p = .06). By stressing recognition of atypical signs and symptoms of infection in older adults, diagnostic tests, and antibiotic stewardship, this series of five case-based discussions enhanced clinical training of learners from several disciplines.

A Collaborative Approach to Improve Consistent Use of Procalcitonin in Lower Respiratory Tract Infections

Procalcitonin (PCT) is a biomarker that can help differentiate bacterial from viral infections and has been extensively studied in patients with sepsis and pneumonia to guide antibiotic therapy. However, there is poor adherence to prescribed algorithms when used to discontinue antibiotics in the real world. A quality improvement project was implemented to increase consistent use of PCT. To evaluate use of PCT and impact on antibiotic length of therapy (LOT) preimplementation and postimplementation of a quality improvement initiative. This was a single-center retrospective cohort study in patients with lower respiratory tract infections (LRTIs). In all, 330 patients were included in this study. Following implementation of the quality improvement initiative, ordering PCT in the first 24 hours increased from 59.6% to 75.5% ( P = 0.011). Documentation to discontinue antibiotics in patients with low initial PCT values increased from 13.2% to 28.6% ( P = 0.100). Increased PCT use correlated with an overall mean reduction of 1.05 antibiotic days between cohorts (6.82 ± 3.88 vs 5.77 ± 3.43, P = 0.028). There was no difference in incidence of antibiotic-associated adverse effects or 30-day hospital readmission rates attributed to pneumonia. Consistent use of PCT was achieved through a collaborative effort with the clinical pharmacy and hospitalist staff. Increased use of PCT was associated with a significant reduction in antibiotic LOT among patients with LRTIs. When controlling for other factors, low initial PCT values had the strongest influence on discontinuing antibiotics within 72 hours in the intervention group.

A Hybrid Form of Telemedicine: A Unique Way to Extend Intensive Care Service to Neonates in Medically Underserved Areas.

More than 90% of neonatal intensive care units (NICUs) in the United States are in urban areas, denying rural residents' easy NICU access. Telemedicine use for patient contact and management, although studied in adults and children, is understudied in neonates. A hybrid telemedicine system, with 24/7 neonatal nurse practitioner coverage and with a neonatologist physically present 3 days per week and telemedicine coverage the remaining days, was recently implemented at Comanche County Memorial Hospital's (CCMH) Level II NICU. To compare outcomes of moderately ill infants between 32-35 weeks gestational age (GA) managed by our hybrid telemedicine program with outcomes of similar neonates receiving standard care in a Level IV NICU at Oklahoma University Medical Center (OUMC). This was a retrospective, noninferiority study comparing outcomes of neonates receiving hybrid telemedicine versus standard care. All 32-35 weeks GA infants admitted between July 2013 and June 2015 were included. OUMC infants came from areas geographically comparable with CCMH. Infants requiring prolonged mechanical ventilation or advanced subspecialty services were excluded. Outcome variables were length of stay, type and duration of respiratory support, length of antibiotic therapy, and time to full enteral feedings. Eighty-seven neonates at CCMH and 56 neonates at OUMC were included in the analysis. Compared with neonates at OUMC, neonates at CCMH had shorter hospitalizations, fewer days of supplemental oxygen, and fewer noninvasive ventilation support days, and reached full enteral feeds sooner. The hybrid telemedicine system is a safe and effective strategy for extending intensive care to neonates in medically underserved areas.

Infants With Febrile Urinary Tract Infections and Length of Antibiotic Therapy: A Commentary.

Although the American Academy of Pediatrics provides evidence-based recommendations for the management of infants and neonates between 2 months and 2 years of age with febrile urinary tract infections (UTIs),1,2 there is a paucity of data regarding the evaluation and treatment of febrile UTIs in infants <2 months of age. In their study, Joshi et al3 attempt to use this lack of data to reveal variability in treatment and diagnostic plans among physicians with regard to the management of UTIs in this age group. The investigators presented pediatricians of different subspecialties with a clinical vignette of a 2-week-old neonate with a febrile UTI without bacteremia who had received 2 days of intravenous (IV) antibiotics. They then stratified respondents by, among other things, subspecialty (pediatric infectious diseases [IDs], neonatology, and “general pediatricians,” the latter included inpatient and outpatient physicians) and asked questions regarding preferred length of IV antibiotic therapy, desire to obtain a voiding cystourethrogram, and prophylactic antibiotic therapy. The study had a reasonable survey completion rate (64%), although it had a low participation rate (13%), and was well designed. The investigators identified significant variability in physician preference for length of IV antibiotic courses between specialties. …

Duration of Antibiotic Use Among Adults With Uncomplicated Community-Acquired Pneumonia Requiring Hospitalization in the United States.

Previous studies suggest that duration of antibiotic therapy for community-acquired pneumonia (CAP) often exceeds national recommendations and might represent an important opportunity to improve antibiotic stewardship nationally. Our objective was to determine the average length of antibiotic therapy (LOT) for patients treated for uncomplicated CAP in US hospitals and the proportion of patients with excessive durations. Records of retrospective cohorts of patients aged 18-64 years with private insurance and aged ≥65 years with Medicare hospitalized for CAP in 2012-2013 were used. Inpatient LOT was estimated as a function of length of stay. Outpatient LOT was based on prescriptions filled post discharge based on data from outpatient pharmacy files. Excessive duration was defined as outpatient LOT >3 days. Inclusion criteria were met for 22128 patients aged 18-64 years across 2100 hospitals and 130746 patients aged ≥65 years across 3227 hospitals. Median total LOT was 9.5 days. LOT exceeded recommended duration for 74% of patients aged 18-64 years and 71% of patients aged ≥65 years. Patients aged 18-64 years had a median (quartile 1-quartile 3) 6 (3-7) days outpatient LOT and those aged ≥65 years had 5 (3-7) days. In this nationwide sample of patients hospitalized for CAP, median total LOT was just under 10 days, with more than 70% of patients having likely excessive treatment duration. Better adherence to recommended CAP therapy duration by improving prescribing at hospital discharge may be an important target for antibiotic stewardship programs.

Implementation of a Pragmatic Biomarker-Driven Algorithm to Guide Antibiotic Use in the Pediatric Intensive Care Unit: the Optimizing Antibiotic Strategies in Sepsis (OASIS) II Study

BackgroundAntibiotic overuse in the pediatric intensive care unit (PICU) is common and reliable approaches are needed to promote safe antibiotic discontinuation. In prior work we developed a biomarker-based algorithm that identified children with suspected sepsis at low risk of bacterial infection. We evaluated the effectiveness of this algorithm to reduce broad-spectrum antibiotic use in the PICU.MethodsWe conducted a quasi-experimental study focused on patients in whom antibiotics were initiated for presumed bacterial sepsis. Antibiotics were given per usual practice during the nonintervention period (T1: Aug 2012 – May 2015). From June 2015 – May 2016 (T2) PICU clinicians were encouraged but not required to stop antibiotics in “low-risk” patients: CRP <4 mg/dL and procalcitonin <1 ng/mL at SIRS onset (day 0) and no pathogen or signs of bacterial infection identified by day 2. The primary outcome was antibiotic length of therapy (LOT) from day 3 through 9, hospital discharge, or death. CDC NHSN definitions were used to define bacterial infections days 0–2. We reviewed all children ≤18 years with SIRS; those with immune compromise, DNR, or recent SIRS (within 30 days) were excluded. Time series analyses adjusting for significant covariates and confounders compared LOT from T1 to T2 in patients with no identified bacterial infection. We also calculated the incidence rate ratio (IRR) of LOT in the subset of patients who met our low-risk criteria.Results525 eligible episodes of suspected sepsis occurred during T1 and 212 during T2. Bacterial infections were detected in 34% of T1 episodes and 39% in T2 (P = 0.16). Patients in T2 had fewer cardiovascular conditions but were otherwise similar to T1 patients. Broad-spectrum LOT remained unchanged in all patients without bacterial infections following implementation of our algorithm (OR 0.72, 95% CI 0.46 – 1.13; Figure 1). Among the subset who met low-risk criteria, LOT decreased from T1 to T2 (197 v. 104 antibiotic days per 1000 patient-days, IRR 0.53, 95% CI 0.30–0.93).ConclusionImplementation of a biomarker-based algorithm did not affect broad-spectrum antibiotic prescribing overall in patients without bacterial infections in our PICU, although LOT declined in those defined by our algorithm to be low-risk.Disclosures K. Downes, Merck, Inc.: Grant Investigator, Research grant; Pfizer, Inc.: Grant Investigator, Research grant

LO47: Use of C-reactive protein can safely decrease the number of emergency department patients with sepsis who require blood cultures

Introduction: Sepsis protocols call for the acquisition of blood cultures in septic emergency department (ED) patients.However, the criteria for blood cultures are vague, they are costly, only positive 8-12% of the time, with up to half of these being false positives. The objective of this study was to establish if positive blood cultures could be excluded in low-risk sepsis patients with levels of CRP below 20 ml/L. Methods: This was a multicenter prospective cohort study of 765 ED patients at St Paul’s and Mount St Joseph’s hospitals in Vancouver with sepsis (2 or more SIRS criteria and infection) and none of: immuncompromised, injection drug use, indwelling vascular device or septic shock (SBP&amp;lt;90 mmhg). Consecutive patients with sepsis had CRP and blood cultures obtained at the same time.OUTCOMES. True positive blood cultures, false positive blood cultures, positive blood cultures that changed patient management. True and false positive blood cultures were based on Infectious Disease Society of America Guidelines, and change in management was defined as change in type or length of antibiotic therapy and was blindly adjudicated by a medical microbiologist. Results: 765 ED patients with sepsis met inclusion criteria. Mean age was 48.3 years and 57% were male. Blood cultures were positive in 99/765 (12.9%) subjects, of which 19 were false positive (19.2%). CRP was &amp;gt;20 mg/L in 595/765 (77.8%) of patients. Of 170 subjects with a CRP&amp;lt;20 mg/L, 3 had a positive blood culture (1.8%; 95% CI 0.1%- 5%). Management was not changed in any patient with a positive blood culture and CRP level&amp;lt;20 mg/L. Of 19 subjects with a false positive blood culture, CRP was &amp;lt;20 mg/L for 6 (31.6%). Conclusion: In this cohort of low-risk sepsis patients, based on a CRP of &amp;lt;20 mg/L, acquisition of blood cultures could be safely avoided in 22.2% of patients, at significant savings to the health care system.