Lower Antibiotic Use Research Articles

Characterization of respiratory illness surge (April-June 2021) post-COVID-19 lockdown.

Following the opening of lockdown and relaxation of public health restrictions, an unusual surge of respiratory illness occurred during the spring/summer (Q2) 2021 season. We aimed to characterize this surge compared to previous years. Children discharged from a single tertiary hospital for respiratory illness or selected noncommunicable diseases (NCDs) between 2015 and 2021 were included, and hospitalization rates were compared. To evaluate whether the current respiratory surge resembles a typical winter, characteristics of the second quarter (Q2, April-June) of 2021 were compared to parallel seasons and to autumn/winter (Q4, October-December) of the previous years. Respiratory illness showed a seasonal peak, while the pattern of NCDwas consistent throughout the study period. Respiratory illnesses showed a delayed surge in Q2 2021 (389 patients), with a missing seasonal peak in Q2 and Q4 2020 (135 and 119 patients, respectively). There were more cases of croup in Q2 2021 compared to Q2 and Q4 2015-2019(26.2 vs. 12.5% and 15.8%, p < 0.001), fewer cases of pneumonia (5.9 vs. 15.9% and 11.7%, p < 0.001), lower admission rates (22.4 vs. 36.3% and 31.5%, p < 0.001), and fewer hypoxemia during hospitalization (6.3 vs. 11.7% and 10%, p < 0.001). Additionally, lower use of antibiotics (6.2 vs. 12.3% and 10.3%, p = 0.001 and 0.012, respectively) and higher use of steroids (33.7 vs. 24.8% and 28.3%, p < 0.001 and 0.034, respectively). The postponed increase in respiratory morbidity after lockdown had unique characteristics, with upper respiratory illness predominating and fewer hospitalizations. Follow-up is needed to assess the altered epidemiological patterns of respiratory diseases in the post-COVID era.

CORRECCIÓN DEL DESPLAZAMIENTO ABOMASAL IZQUIERDO POR VIDEOLAPAROSCOPÍA

Correction of left abomasal displacement by video laparoscopy. This article reviews the benefits of the laparoscopic abomasopexy used for correction and fixation of the left abomasal displacement in dairy cows. The first steps are similar to the conventional technique, with sedation, analgesia and antisepsis. Two small flank incisions were made, the first one is about 10 centimeters ventral to the lumbar transverse processes in the cranial aspect of the left paralumbar fossa, and the second one, more cranial than the other and is located 7 cm ventral to the transverse processes of the lumbar vertebrae in the left 11th intercostal space, these two are the entry points of instruments and optics. This technique allows us to shorten the surgical time, reducing the tissue exposure time, the possibility of intra and post-surgical infections and iatrogenic injuries. Therefore, we saw that the recovery time was shorter; and a quick return to production is guaranteed due to the low use of antibiotics.

145. Comparing Antibiotic Use Across Inpatient Facilities with Different Antibiotic Stewardship Typologies using Machine Learning and Joint Modeling Approach

BackgroundHospital antibiotic stewardship programs (ASP) aim to promote the appropriate use of antimicrobials (including antibiotics) and play a critical role in controlling antibiotic costs and antibiotic-resistant bacterial infection risk, and improving patient outcomes. However, unlike other health care quality improvement intervention programs, the ASP implementation strategies vary among healthcare facilities, and little is known about whether different types of ASP implementation will lead to the shifting of antibiotic drug use from one class to another. MethodsWe proposed an analytical framework using unsupervised machine learning and joint model approach to 1) develop a typology of ASP strategies in facilities from the Veterans Health Administration, America’s largest integrated health care system; and 2) simultaneously evaluate the impacts of different ASP types on the annual antibiotic use rates across multiple drug classes. The unsupervised machine learning method was used to leverage the structural components in the surveys conducted by the Veteran Affair (VA) Healthcare Analysis and Information group and the Consolidated Framework for Implementation Research experts from Boston University, and reveal the underlying ASP patterns in the VA facilities in 2016. ResultsWe identified 4 groups in the VA facilities in terms of enthusiasm and implementation level of antibiotic control in our ASP typology. We found the facilities with high implementation level and high enthusiasm in ASP and those with high implementation level but low enthusiasm had statistically significant 30% (p-value=0.002) and 22% (p-value=0.031) lower antibiotic use rates in broad-spectrum agents used for community infections, respectively than those with low implementation level and low enthusiasm. However, the facilities with high implementation and high enthusiasm also marginally increased antibiotic use rates in beta-lactam antibiotics (p-value=0.096). ConclusionThe developed analytical framework in the study provided an approach to the granular assessment of the impact of the healthcare intervention programs and might be informative for future health service policy development.Disclosures Matthew B. Goetz, MD, Nothing to disclose

Risk Factors Influencing Tolerance and Clinical Features of Food Protein-Induced Allergic Proctocolitis

To examine the clinical course and risk factors of food protein-induced allergic proctocolitis (FPIAP).A total of 257 infants who presented to 5 outpatient pediatric allergy or gastroenterology clinics with rectal bleeding and were given a diagnosis of FPIAP were included in the study.After enrollment, infants had serum immunoglobulin E testing, skin-prick testing (SPT), and complete blood cell count. Clinical characteristics were prospectively managed. Patients with other known gastrointestinal illnesses were excluded. Cow’s milk elimination was trialed first in both the infant’s diet as well as the mother’s diet if breastfeeding, and, if no improvement, egg was eliminated next. Combined elimination of wheat, nuts, and soy followed, if no improvement. Eliminated foods were then reintroduced after 2 to 4 weeks, and a worsening of symptoms confirmed diagnosis.There was no sex predominance, with 50.2% being female (n = 129). The vast majority were breastfed at diagnosis (97.2%), with 66.5% exclusively breastfed. Blood in stool was present in every case, and other common complaints were mucous in stool (n = 224) and loose stool (n = 168). Cow’s milk was the most common causative food, accounting for 99.2% of cases. Comparing those with only 1 food allergy (75.9%) versus those with multiple food allergies, children with a single-food allergy more often were exclusively breastfeeding at diagnosis, had a longer duration of breastfeeding, had less antibiotic use in the first 6 months, and had higher tolerance development (P = .003, < 0.001, < 0.001, and < 0.001, respectively). Immunoglobulin E (IgE) sensitization was assessed in 239 patients, and 55 (23%) had positive test results. Sensitized children less often developed tolerance to the offending allergen compared with nonsensitized children (52.4% versus 81.2%). Only 16 patients underwent endoscopy and were continued to be treated as having FPIAP.Most patients with FPIAP resolve within a year. Infants with colic, IgE sensitization, and multiple food allergies may be at risk for delayed tolerance. Cow’s milk should be the first excluded food in infants and breastfeeding mothers, and elimination should resolve symptoms in most patients. Breastfeeding and lower antibiotic use was associated with a decrease in the development of multiple food allergies. The role of SPT and IgE testing is still unclear and may not add benefit to most cases. Endoscopy did not change management, even in severe cases.This is an important study that characterizes a common condition. The prospective nature of this study is a strength, along with high retention of subjects throughout the study. The involvement of multiple centers and specialties introduced some variability in practice. More severe cases of FPIAP are likely represented in this study because subjects had referral to allergy or gastroenterology specialists. Also, the high prevalence of breastfeeding in this cohort may limit its generalizability to other communities; regional food preferences and breastfeeding prevalence may have a large effect on the development of allergies and food sensitization.

Large-size fattening calves’ lots fed with automatic milk feeders may have an increased risk for Mycoplasma bovis infection spread and for antibiotic use

Bovine respiratory disease is the leading user of antibiotics (AB) in calf production. Mycoplasma (M.) bovis could lead to greater use of AB as it is a persistent and AB resistant causative agent for respiratory diseases. Two cross-sectional studies were set up to assess the effects of lot size and feeding system on M. bovis infection and the effects of M. bovis seroconversion, lot size and feeding system on AB use in calves’ feedlots. Twenty-six lots in 22 fattening farms were monitored for 41–81 days, from all-in entry of calves until three consecutive weeks without using any collective antibiotics. M. bovis spread was estimated by measuring seroconversion at entry and at the end of study period in 10–15 calves randomly sampled in each lot. All AB treatments used in the meanwhile were recorded. The lots were selected according to feeding system, i.e. individual bucket (n = 7) vs. automated milk feeder (AMF, n = 19), and lot size (30–519 calves), less than 50 calves (n = 9) vs. more than 50 calves (n = 17). Statistical analysis was performed using multivariable generalised linear models with fattening farms as random effect. M. bovis spread increased with lot size (odds ratio (OR) 2.9[1.4; 5.8] per two-fold increase in lot size). This proportion of seroconverted calves was lower in bucket-fed lots compared to lots fed with the AMF using a shared nipple (OR = 0.03[0.003; 0.41]). The main risk factor for AB use was the lot size, with an increase of 1.5[0.94; 1.98] treatments per two-fold increase in lot size. For same size lots, the use of bucket can decrease AB consumption by up to 1.03[−2.18; 0.14] treatments per calf compared to AMF. Analysis of the association between seroconversion to M. bovis and AB use was inconclusive. We found that bucket feeding in small-size lots, i.e. up to a maximum of 50 calves in the same space, limits seroconversion to M. bovis and enables lower use of AB in veal calf production.

Effects of the affinity to the Mediterranean diet pattern together with breastfeeding on the incidence of childhood asthma and other inflammatory and recurrent diseases.

There is an increasing amount of data relating the dietetic pattern to health variables, although data concerning the child population are scarce. The aim of the study was to assess the effects of affinity to the Traditional Mediterranean Diet (TMD) pattern, together with breastfeeding, on the incidence of childhood asthma and other inflammatory and recurrent diseases (IRD) in children under 2 years of age. Single-group intervention study evaluating differences in results according to degree of adherence to TMD recommendations. According to their adhesion to the TMD-Breastfed Test, patients were classified into two groups: Group 1 (with greater adherence) and Group 2 (with less adherence). The incidence of childhood asthma and IRD was evaluated and compared with both groups. The score of the TMD-Breastfed Test was optimal in Group 1 and good in Group 2. It shows a marked reduction in both consultation groups "on request" compared with "planned," with low morbidity and low use of antibiotics. The incidence of infectious diseases and recurrent bacterial complications shows a clinically relevant difference between both groups. The incidence of childhood asthma was greater and statistically significant in Group 2, with less adherence to breastfeeding. In these cohorts of breastfed patients with good adherence to TMD patterns, there was evidence of a low incidence of childhood asthma and the IRD, more pronounced in the highest adherence Group 1. Some non-TMD foods have been linked to the occurrence of childhood asthma and IRD, as their dietary limitations have contributed to decreasing morbidity.

Side Effects and Supportive Care in Relapsed or Refractory Classical Hodgkin Lymphoma Patients Treated in Later Lines of Therapy: A Pilot Analysis Conducted in 4 Countries

Introduction: Most patients with classical Hodgkin lymphoma (cHL) can be cured with first-line multiagent chemotherapy. However, up to 20% require second-line (2L) therapy, including autologous hematopoietic cell transplantation (auto-HCT); 50% of those will develop relapsed/refractory cHL (R/R HL) after 2L therapy. The introduction of brentuximab vedotin (BV) in 2011 has changed the management of patients with R/R HL. The European Medicines Agency approved programmed death-1 (PD-1) inhibitor nivolumab (nivo) in 2016 for the treatment of patients with R/R HL who failed auto-HCT and BV and pembrolizumab (pembro) in 2017 for the treatment of R/R HL patients who failed auto-HCT and BV or who are transplant-ineligible and have failed BV. Both agents have improved clinical outcomes for indicated patients. As a pilot analysis, we assessed side effects and supportive care to manage side effects in patients with R/R HL who were treated with BV, nivo, or pembro in third- (3L) or later lines of therapy in real-world practice.Methods: The study was designed as a multicenter, cross-sectional survey of R/R HL patients receiving 3L or later-line systemic drug treatment, and was administered between June and September 2016 in Canada and 3 European countries (France, Germany, and UK). The study consisted of 2 components, a physician survey and a medical chart review; data captured included demographics and patient characteristics, treatment and disease management, clinical outcomes, and resource utilization. Side effects and supportive care were assessed during treatment. Summary statistics were reported and difference between treatment cohorts assessed using t -tests and Kruskal-Wallis tests for continuous variables and chi-square/Fisher exact tests for categorical variables. P value <0.05 (2-sided test) was considered significant.Results: A total of 116 physicians (Canada, 16; France, 31; Germany, 44; UK, 25) provided information on 955 patients with R/R HL who were treated in 3L or later-line therapy. Among these, 452 patients received exclusively BV, nivo, or pembro in 3L or later lines (median age 52 years; 58% male) and there was no overlap in utilization of the 3 agents. The 452 patients were divided into 3 treatment cohorts: 336 (74%) on BV, 90 (20%) on nivo, and 26 (6%) on pembro; these were mutually exclusive. Patients in the 3 cohorts were similar in terms of age, sex, most recent cancer stage, and performance status at study enrollment (Table). There was no statistically significant difference between cohorts in proportion of patients with bulky disease. Compared with those on BV, patients on nivo or pembro were more likely to be tested for Epstein-Barr virus (EBV)-specific antibodies (p=0.0003); among those tested, the proportions of patients with positive results were similar across cohorts (Table).The data suggest that nivo may generally result in fewer side effects than pembro and BV (Table). Pairwise comparisons between nivo and pembro show that nivo was associated with lower incidence of anemia (3.3% vs 15.4%, p=0.0438), diarrhea (2.2% vs 23.1%, p=0.0015), fatigue (3.3% vs 15.4%, p=0.0438), nausea (4.4% vs 26.9%, p=0.0024), vomiting (1.1% vs 26.9%, p<0.0001), and weight loss (1.1% vs 15.4%, p=0.0088). The fraction of patients using supportive care antibiotics, antidiarrheals, granulocyte colony-stimulating factor (G-CSF), and analgesics appears lower for nivo than for pembro or BV (Table). Patients on nivo used erythropoiesis-stimulating agents (ESAs) and corticosteroids slightly more than those on BV or pembro, although the difference was not statistically significant (Table). Pairwise comparison shows that the use of anti-emetics was significantly lower for patients on nivo than for those on pembro (6.7% vs 26.9%, p=0.0088). When compared with BV, nivo was associated with significantly lower use of antibiotics (7.8% vs 17.0%, p=0.0303) and anti-emetics (6.7% vs 14.9%, p=0.0405). P value from pairwise comparison is not shown in Table.Conclusions: The sample size of patients receiving nivo or pembro in this analysis is small, but preliminary analysis indicates that patients treated with nivo may have fewer side effects and require less supportive care than those receiving BV or pembro. Further analysis may be necessary to validate these findings.Study support: Bristol-Myers Squibb. [Display omitted] DisclosuresChen:Bristol-Myers Squibb: Employment. Byrne:Adelphi Real World: Employment. Hallworth:Adelphi Real World: Employment. Yasenchak:Bristol-Myers Squibb: Consultancy; Seattle Genetics: Consultancy.

Emergence and dissemination of antimicrobial resistance in Escherichia coli causing bloodstream infections in Norway in 2002–17: a nationwide, longitudinal, microbial population genomic study

The clonal diversity underpinning trends in multidrug resistant Escherichia coli causing bloodstream infections remains uncertain. We aimed to determine the contribution of individual clones to resistance over time, using large-scale genomics-based molecular epidemiology. This was a longitudinal, E coli population, genomic, cohort study that sampled isolates from 22 512 E coli bloodstream infections included in the Norwegian surveillance programme on resistant microbes (NORM) from 2002 to 2017. 15 of 22 laboratories were able to share their isolates, and the first 22·5% of isolates from each year were requested. We used whole genome sequencing to infer the population structure (PopPUNK), and we investigated the clade composition of the dominant multidrug resistant clonal complex (CC)131 using genetic markers previously reported for sequence type (ST)131, effective population size (BEAST), and presence of determinants of antimicrobial resistance (ARIBA, PointFinder, and ResFinder databases) over time. We compared these features between the 2002-10 and 2011-17 time periods. We also compared our results with those of a longitudinal study from the UK done between 2001 and 2011. Of the 3500 isolates requested from the participating laboratories, 3397 (97·1%) were received, of which 3254 (95·8%) were successfully sequenced and included in the analysis. A significant increase in the number of multidrug resistant CC131 isolates from 71 (5·6%) of 1277 in 2002-10 to 207 (10·5%) of 1977 in 2011-17 (p<0·0001), was the largest clonal expansion. CC131 was the most common clone in extended-spectrum β-lactamase (ESBL)-positive isolates (75 [58·6%] of 128) and fluoroquinolone non-susceptible isolates (148 [39·2%] of 378). Within CC131, clade A increased in prevalence from 2002, whereas the global multidrug resistant clade C2 was not observed until 2007. Multiple de-novo acquisitions of both blaCTX-M ESBL-encoding genes in clades A and C1 and gain of phenotypic fluoroquinolone non-susceptibility across the clade A phylogeny were observed. We estimated that exponential increases in the effective population sizes of clades A, C1, and C2 occurred in the mid-2000s, and in clade B a decade earlier. The rate of increase in the estimated effective population size of clade A (Ne=3147) was nearly ten-times that of C2 (Ne=345), with clade A over-represented in Norwegian CC131 isolates (75 [27·0%] of 278) compared with the UK study (8 [5·4%] of 147 isolates). The early and sustained establishment of predominantly antimicrobial susceptible CC131 clade A isolates, relative to multidrug resistant clade C2 isolates, suggests that resistance is not necessary for clonal success. However, even in the low antibiotic use setting of Norway, resistance to important antimicrobial classes has rapidly been selected for in CC131 clade A isolates. This study shows the importance of genomic surveillance in uncovering the complex ecology underlying multidrug resistance dissemination and competition, which have implications for the design of strategies and interventions to control the spread of high-risk multidrug resistant clones. Trond Mohn Foundation, European Research Council, Marie Skłodowska-Curie Actions, and the Wellcome Trust.

Addressing Antibiotic Overuse in the Outpatient Setting: Lessons From Behavioral Economics

Addressing Antibiotic Overuse in the Outpatient Setting: Lessons From Behavioral Economics

Consumer preferences for reduced antibiotic use in Danish pig production

Denmark has a large and intensive pig production sector which accounts for around half of the total use of antimicrobials in Demark. The economic feasibility of alternative strategies involving reduced use of antibiotics depends not only on their effects on productivity but also on consumers’ demand, and willingness-to-pay (WTP), for pork from pigs with no or lower antibiotic treatment. This study investigates the various concerns that consumers might have about the use of antibiotics in pig production, and how they affect demand and WTP. We used data from an online questionnaire survey of approximately 1000 Danish consumers. WTP estimates were obtained using payment card data analysed in an ordered probit regression. We found that 41 % of the respondents wanted antibiotic use to be reduced substantially, and that they linked reduced use of antibiotics in pig production primarily with reduced risk of antibiotic residues in pork and a lowered risk of resistant bacteria developing. A considerable share of the consumers we sampled also linked reduced antibiotic use with improved animal welfare, and with price increases for pork. Two thirds of the consumers stated a positive WTP for reduced use of antibiotics, but only one in five were willing to pay more than 10 % for pork produced using antibiotics 20 % less than average. The WTP estimates differed with socio-demographic variables (education, geography, gender and age). In addition, the respondents’ perceptions of the effects of reducing antibiotic use and of externalities associated with the pig industry, and the frequency of their pork consumption, were found to affect their WTP for pork produced with lower antibiotic use. As the vast majority of the Danish pork is exported, future studies should examine consumer perceptions of antibiotic use in pig production in importing countries.

Contribution of facility level factors to variation in antibiotic use in long-term care facilities: a national cohort study.

To examine national variation in systemic antibiotic use in long-term care facilities (LTCFs) and identify facility characteristics associated with antibiotic utilization. This retrospective cohort study included 312 375 residents of 2536 Australian LTCFs between 2011 and 2016. LTCFs were categorized as low, medium or high antibiotic use facilities according to tertiles of DDDs of systemic antibiotics dispensed per 1000 resident-days. Multivariable logistic regression estimated the associations between facility characteristics (ownership, size, location, medication quality indicator performance, prevalence of after-hours medical practitioner services) and antibiotic use (low versus high). LTCFs in the lowest and highest antibiotic use categories received a median of 54.3 (IQR 46.5-60.5) and 106.1 (IQR 95.9-122.3) DDDs/1000 resident-days, respectively. Compared with not-for-profit LTCFs in major cities, government-owned non-metropolitan LTCFs were less likely to experience high antibiotic use [adjusted OR (aOR) 0.47, 95% CI 0.24-0.91]. LTCFs with 69-99 residents were less likely to experience high antibiotic use (aOR 0.69, 95% CI 0.49-0.97) than those with 25-47 residents annually. Greater prevalence of medical practitioner services accessed after-hours was associated with high antibiotic use [aOR 1.10 (per 10% increase in after-hours services), 95% CI 1.01-1.21]. South Australian LTCFs (aOR 2.17, 95% CI 1.38-3.39) were more likely, while Queensland (0.43, 95% CI 0.30-0.62) and Western Australian (aOR 0.34, 95% CI 0.21-0.57) LTCFs were less likely to experience high antibiotic use than New South Wales LTCFs. Considerable facility level variation in systemic antibiotic use was observed across Australian LTCFs. Identification of facility characteristics associated with antibiotic use provides a basis for targeted stewardship initiatives.

Predictors of failure after fecal microbiota transplantation for recurrent Clostridioides difficile infection: a systematic review and meta-analysis.

Fecal microbiota transplantation (FMT) is a highly effective therapy for recurrent Clostridioides difficile infection (CDI), with ~15% 1-year recurrence rate. Small studies have identified variable risk factors associated with FMT failure. We, therefore, performed a systematic review and meta-analysis to evaluate the predictors of FMT failure. A systematic search of Medline, Embase, and Web of Science was performed from January 2013 up to June 2020. Meta-analyses were performed using random-effects models and pooled adjusted odds ratios for risk factors reported in ≥2 studies were calculated. Overall, 2671 patients with recurrent CDI who underwent FMT in 12 studies were included. FMT failure occurred in 454 patients (16.9%) with median follow-up of 3months (range 2-7.7months). A total of 9 risk factors were identified in ≥2 studies. Meta-analysis showed that use of non- CDI antibiotics, presence of inflammatory bowel disease, poor quality of bowel preparation, CDI-related hospitalization before FMT, inpatient FMT, and severe CDI were associated with statistically significant increased risk of failure after FMT. Increasing age, female gender, and immunocompromised status were not associated with increased risk for FMT failure. Several risk factors (both modifiable and non-modifiable) are associated with FMT failure. Lower use of antibiotics in the post-FMT period and good bowel preparation at the time of FMT are associated with lower risk of failure after FMT. Additionally, patients with non-modifiable risk factors should be counseled to be particularly alert about recurrent symptoms after FMT.

Animal Production With Restrictive Use of Antibiotics to Contain Antimicrobial Resistance in Sweden-A Qualitative Study.

Antibacterial resistance (ABR), is a growing global threat to human and animal health. Efforts to contain ABR are urgently needed. This qualitative interview study explored perceptions of work to contain ABR among stakeholders in food animal production in Sweden, with focus on broiler production. Semi-structured interviews were carried out with a strategic sample of 13 stakeholders in different parts of production, from professionals at policy level, veterinary authorities, to poultry farmers and poultry veterinarians. Conventional inductive content analysis was used for data analysis. A latent theme, “Working in unison,” emerged, based on the consistency expressed by the informants when they discussed ABR, use of antibiotics, and animal health management. This theme was built on four domains representing the content of the interviews: Knowledge and engagement; Cooperation; Animal health concept; and Development in balance with economic prerequisites. According to the informants, ABR has not been an isolated issue in Sweden but has been included in a tradition of animal health and welfare, and actions have been driven by the industry or by government regulations. Veterinarians described how they worked closely with farmers. Farmers felt involved in the development of animal health management methods. The One Health concept was well-known among stakeholders at national level but not at farm level. Close cooperation between stakeholders seems to facilitate development of animal production with low use of antibiotics.

1676. Evaluation of Antibiotic Overuse for Asymptomatic Bacteriuria in a Hospital with Low Baseline Antibiotic Use

BackgroundIn 2019, the Infectious Diseases Society of America published guidelines for the management of asymptomatic bacteriuria (ASB) with recommendations to avoid antimicrobial therapy in most patients. Denver Health has existing guidance for the management of patients with a urinary tract infection (UTI) and in August of 2019, implemented specific guidance for the management of ASB. As an institution, Denver Health has a Standardized Antimicrobial Administration Ratio (SAAR) of 0.8-0.9, suggesting a strong antimicrobial stewardship program with a ratio of < 1. The purpose of this study is to assess if signs and symptoms were present in patients prescribed an antibiotic for UTI.MethodsWe retrospectively identified hospitalized patients at least 18 years old who were prescribed an antibiotic with “UTI” as the indication from March 1st to August 31st, 2019. Patients with catheter-associated UTIs were excluded. A random sample of 50 cases was manually reviewed for signs and symptoms of infection. Signs were considered fever, defined as at least 38oC or leukocytosis, defined as at least 10 k/uL WBC. Symptoms collected were based on documentation of patient reported dysuria, frequency, or urgency, or findings of hematuria. The primary outcome was proportion of patients prescribed an antibiotic for UTI in the absence of signs or symptoms. Prescribing patterns for choice and duration of antimicrobials were also surveyed.ResultsA total of 382 antibiotics were prescribed for UTI during the study period. Of the 50 cases reviewed, median age was 65.8 years, with 11% being male. Overall, 29 patients (58%) had no documented symptoms while being treated for UTI. Additionally, 22 patients (44%) had no documented fever, leukocytosis, or urinary symptoms. The most commonly prescribed antibiotics were cefdinir, fosfomycin, and nitrofurantoin. Tables 1 and 2 include additional findings.Table 1 Symptomology and Type of UTI Table 2 Antimicrobial Choice and Duration ConclusionDespite a well established stewardship program, nearly half of patients prescribed an antibiotic for UTI did not have signs or symptoms consistent with infection. This suggests many patients were treated for ASB, without necessity. Among hospitals with comparatively low antibiotic use, ASB may be a high-yield opportunity to reduce unnecessary antibiotic use.Disclosures All Authors: No reported disclosures

724. Gastrointestinal (GI) PCR vs Stool Cultures: Impact on Length of Hospital Stay (LOS) and Antibiotic Use

BackgroundGI PCR can detect 22 pathogens (bacteria, parasites and viruses) from a single stool sample. Stool cultures are labor intensive and only target the most common diarrheal pathogens (such as Campylobacter, E. coli and a few parasites). We hypothesized that implementation of GI PCR would result in decreased LOS and lower antibiotic use.MethodsThis retrospective study utilized data from review of electronic medical records and included patients aged > 18 years old who were admitted with diarrhea over a 3-year period from 2016 to 2019. LOS and antibiotic use data was collected for patients who had GI PCR from 2017–2019 (GIP arm) and compared with data from patients who had stool cultures from 2016–2017 (SC arm). Differences were assessed using Chi-square or Fisher’s exact test for categorical variables and the Mann Whitney Rank Sum test for continuous variables.ResultsThe analysis included a total of 338 patients, 225 (66.6%) in the GI PCR arm and 113 (33.4%) in the SC arm. A significantly higher proportion of patients in the GIP arm had a positive result compared with the SC arm (26.2% vs. 9.7%, P < .0001; Table 1). Table 2 shows the most frequently isolated organisms. Median LOS was 6 days (IQR: 4–13) for the GIP arm and 5 days (IQR: 3–7) for the SC arm (p=.060); 8 patients in the GIP arm had average LOS of 75 days due to comorbidities and disposition issues. However, within the GIP arm, median LOS was much shorter for patients detected with viruses by PCR vs. those with non-viral pathogens (3.5 days (IQR: 3-7) vs. 6 days (3-12)) There was no difference in antibiotic use between the GIP and SC arms (84.9% vs. 84.1%, P=.844). Patients in GIP arm were more commonly given Piperacillin-tazobactam and Carbapenems, whereas patients in the SC arm received metronidazole more often. Within the GIP arm, antibiotic use was lower among patients detected with viruses vs. those detected with non-viral pathogens (73.1% vs. 81.8%).Table 1 Table 2 ConclusionLOS was longer in patients in GIP arm vs SC arm, which may have been influenced by the presence of outliers in the GIP arm. No differences in antibiotic use was observed between the two groups. However, within the GIP arm, detection of viruses by GI PCR significantly shortened LOS and lowered antibiotic use.Disclosures All Authors: No reported disclosures

Penggunaan Ventilasi Mekanik non Invansif Untuk Mengatasi Kegagalan Pernafasan pada Pasien dengan Edema Pulmo Akut Kardiogenik

Background: Cardiogenic Pulmo edema can cause a heterogeneous syndrome with a mortality rate of up to 9.5% (Aliberti et all., 2018).Objective: The purpose of this paper was to explain how effective the use of non-invasive mechanical ventilation in patients with acute pulmonary edema with respiratory failure.&#x0D; Methods: The literature review was compiled by synthesizing and comparing various relevant scientific articles from the literature search results using the online database of Proquest and Clinicalkey Elsevier that have significance related to the management of acute cardiogenic pulmo edema.&#x0D; Result: Compared with conservative therapy, noninvasive mechanical ventilation has been shown more effective in improving oxygenation in patients with acute cardiogenic pulmo edema Non-invasive ventilation can reduce dyspnea, acidosis and hypercapnea faster than standard oxygen therapy. Studies show that compared to endotracheal intubation, non-invasive mechanical ventilation is associated with a lower risk of nosocomial infection, lower antibiotic use, shorter length of stay in intensive care units and lower mortality. Study found that there were no differences betwen the two setting of non-invasive mechanical ventilation used, Bilevel positive Airway Pressure (BiPAP) and Continues positive Airway Pressure (CPAP) in patients outcomes. However, there are absolute and relative contraindications that must be considered, including the effectiveness of the therapy being insignificant when given too late&#x0D; Conclusion: Noninvasive mechanical ventilation can be considered as the first choice in the management of acute cardiogenic pulmonary edema because of its high clinical effectiveness representing a rescue action for patients not improving with conventional oxygen therapy.

Significant Regional Differences in Antibiotic Use Across 576 US Hospitals and 11,701,326 Million Admissions, 2016–2017

Background: Reducing inappropriate antibiotic use is critical for fighting antibiotic resistance. Quantifying the amount and diversity of antibiotic use in US hospitals is foundational to these efforts but hampered by limited national surveillance. The current study aims to address this knowledge gap by examining adult inpatient antibiotic usage, including regional, facility, and case-mix differences, across 576 hospitals and nearly 12 million encounters in 2016–2017. Methods: We conducted a retrospective cohort study of patients aged ≥18 years discharged from hospitals in the Premier Healthcare Database, a repository of nearly 1 of every 4 annual US hospitalizations, between January 1, 2016, and December 31, 2017. Detailed hospital- and patient-level data were extracted for each admission. Facilities were classified geographically by census division. Using daily antibiotic charge data, we mapped antibiotics to 18 mutually exclusive classes and to categories based upon spectrum of activity. Patient-level data were transformed into hospital case-mix variables (eg, hospital mean patient age), and relationships between antibiotic days of therapy (DOTs), and these and other facility-level variables were evaluated in negative binomial regression models. Results: The study included 11,701,326 adult admissions, totaling 64,064,632 patient days across 576 US hospitals. Overall, antibiotics were used in 65% of all hospitalizations, at a rate of 870 DOTs per 1,000 patient days. The most commonly used classes per patient days wereβ-lactam/β-lactamase inhibitor combinations (206 DOTs), third- and fourth-generation cephalosporins (128 DOTs), and glycopeptides (113 DOTs) (Fig. 1). By spectrum of activity, antipseudomonal agents (245 DOTs) were the most common. Crude usage rates varied by geographic region (Fig. 2). In multivariable analyses, teaching hospitals, and/or larger bed sizes were independently associated with lower use across a range of antibiotic classes (adjusted IRR ranges, 0.90–0.94 and 0.96–0.98, respectively). Significant regional differences also persisted. Compared to the South Atlantic region (chosen as the reference category because it had the largest representation in the cohort), rates of total antibiotic use were 6%, 15%, and 18% lower on average in the Pacific, New England, and the Middle Atlantic regions, respectively. By class, carbapenems reflected the most geographic variability. Conclusions: In a large, diverse cohort of US hospitals, adult inpatients received antibiotics at a rate similar to, but higher than, previously published estimates. In adjusted models, lower antibiotic use was frequently associated with facilities likely to have robust antibiotic stewardship programs—those with teaching status and larger bed size. Further research to understand other reasons for regional differences in antibiotic use such as different rates of resistance is needed.Funding: This work was supported by Funding: from the Agency for Healthcare Research and Quality (AHRQ) (R01-HS026205 to A.D.H.).Disclosures: None

Standardized Antimicrobial Administration Ratio (SAAR) Clinical Outcomes Assessment in a Large Community Healthcare System

Background: Research on the association between the standardized antimicrobial administration ratio (SAAR) and clinical outcomes is lacking. Objective: We compared SAAR and patient outcomes in 97 acute-care facilities affiliated with a large healthcare system. Methods: Facilities were classified using the broad-spectrum hospital-onset (BSHO) SAAR for medical, surgical, and medical-surgical wards as low, moderate, or high antimicrobial use: low use SAAR, &lt;0.8; moderate use SAAR, 0.95–1.05; and high-use SAAR, &gt;1.2. Data were included from patients aged ≥18 years who were discharged between the first quarter of 2018 and the second quarter of 2019, had nonmissing matching criteria, BMI between 10 and 90, and at least 1 BSHO medication administered in a medical, surgical, or medical-surgical ward. Patients were matched for gender, age group, BMI category, year and quarter of discharge, ICU stay, and diagnosis-related group (DRG). Eligible drugs included all routes for cefepime, ceftazidime, doripenem, imipenem/cilastatin, meropenem, and piperacillin/tazobactam and IV only for amikacin, aztreonam, gentamicin, and tobramycin. Outcomes were evaluated in a pairwise manner using t tests or χ2 tests. Results: Each of the 3 study groups consisted of 6,327 patients, 51% of whom were men; average age, 63 years; 70% of whom were obese or overweight, and 19% of whom had an ICU stay. The most common DRG code was infectious and parasitic diseases (57%) followed by digestive system (9%), respiratory system (7%), and kidney and urinary tract (6%). High antibiotic use was associated with longer length of stay and a higher estimated cost per visit. Low antibiotic use was associated with higher rate of mortality and a lower rate of readmissions compared to moderate use. The low-usage group did not exhibit a statistically significant difference in mortality, readmissions, or rate of C. difficile compared to the high-usage group. Conclusions: The optimal antibiotic utilization group varied among outcomes. Further evaluation of outcomes is needed for the SAAR to understand the ranges and the relationship between the measure and clinical outcomes.Funding: NoneDisclosures: None

Trends, seasonality and the association between outpatient antibiotic use and antimicrobial resistance among urinary bacteria in the Netherlands.

To determine trends, seasonality and the association between community antibiotic use and antimicrobial resistance (AMR) in Escherichia coli and Klebsiella pneumoniae in urinary tract infections. We analysed Dutch national databases from January 2008 to December 2016 regarding antibiotic use and AMR for nitrofurantoin, trimethoprim, fosfomycin and ciprofloxacin. Antibiotic use was expressed as DDD/1000 inhabitant-days (DID) and AMR was expressed as the percentage of resistance from total tested isolates. Temporal trends and seasonality were analysed with autoregressive integrated moving average (ARIMA) models. Each antibiotic use-resistance combination was cross-correlated with a linear regression of the ARIMA residuals. The trends of DID increased for ciprofloxacin, fosfomycin and nitrofurantoin, but decreased for trimethoprim. Similar trends were found in E. coli and K. pneumoniae resistance to the same antibiotics, except for K. pneumoniae resistance to ciprofloxacin, which decreased. Resistance levels peaked in winter/spring, whereas antibiotic use peaked in summer/autumn. In univariate analysis, the strongest and most significant cross-correlations were approximately 0.20, and had a time delay of 3-6 months between changes in antibiotic use and changes in resistance. In multivariate analysis, significant effects of nitrofurantoin use and ciprofloxacin use on resistance to these antibiotics were found in E. coli and K. pneumoniae, respectively. There was a significant association of nitrofurantoin use with trimethoprim resistance in K. pneumoniae after adjusting for trimethoprim use. We found a relatively low use of antibiotics and resistance levels over a 9 year period. Although the correlations were weak, variations in antibiotic use for these four antibiotics were associated with subsequent variations in AMR in urinary pathogens.

Effect of different antibiotic use strategies on infection in neonates with premature rupture of membranes and high-risk factors for neonatal infection

To study the effect of different antibiotic use strategies on infection in neonates with premature rupture of membranes and the high-risk factors for neonatal infection. A retrospective analysis was performed for the clinical data of 223 neonates with premature rupture of membranes. According to the antibiotic use strategies, they were classified into two groups: study group (n=95) and control group (n=128). The neonates in the study group were given antibiotics based on risk assessment and infection screening, and those in the control group were given antibiotics based on risk assessment alone after admission. General status and prognosis were compared between the two groups. According to the presence or absence of infection, the neonates were classified into two groups: infection group (n=32) and non-infection group (n=191). The clinical data were compared between the two groups. A logistic regression model was used to investigate the high-risk factors for infection in neonates with premature rupture of membranes. Compared with the control group, the study group had a significantly longer time of premature rupture of membranes, a significantly higher rate of cesarean section, and a significantly lower antibiotic use rate at admission and a significantly lower total antibiotic use rate (P<0.05). The study group also had a significantly higher incidence rate of infection and a significantly lower incidence rate of sepsis (P<0.05). There were no significant differences in the incidence rates of other complications between the two groups (P>0.05). Compared with the non-infection group, the infection group had a significantly lower gestational age, a significantly longer time of premature rupture of membranes, a significantly higher rate of cesarean section, and significantly higher levels of C-reactive protein (CRP) and procalcitonin on admission and during reexamination (P<0.05), with fever as the most common symptom. The logistic regression analysis showed that preterm birth and cesarean section were high-risk factors for infection in neonates with premature rupture of membranes (P<0.05). Strict adherence to the indications for antibiotic use in neonates with premature rupture of membranes does not increase the incidence rate of complications. Neonates with premature rupture of membranes, especially preterm infants and infants delivered by cesarean section, should be closely observed for the change in disease conditions, and infection indices including CRP should be reexamined in case of fever and antibiotics should be used to prevent serious infection.