Unnecessary Antibiotic Administration Research Articles

Retrospective cohort study comparing two versus three blood culture sets in people who inject drugs

Background The current standard of drawing two vs three blood culture sets lacks adequate guidance. Because people who inject drugs are at higher risk for bacteraemia and life-threatening infection, consideration of a third blood culture becomes more important. Aim To investigate the risks and benefits of obtaining two versus three blood culture sets. Methods Retrospective cohort study of adults who inject drugs at a multicentre catch-net hospital system from 2017–2022. Findings 998 people who inject drugs and 2278 blood culture sets were analysed. There were 1618 episodes with two blood culture sets and 660 episodes with three. A potential benefit of adding a third blood culture was seen in 30 (4.5%) episodes. However, only 13 (2.0%) episodes showed pathogen-identifying benefit, as 17 (2.6%) involved known inadequately treated infections or the same pathogen in another culture. The number of blood culture sets needed to achieve diagnostic benefit was 51. There were more contaminants for three blood culture sets (65, 9.8%) than for two (114, 7.0%) (p < 0.00001). By adding a third blood culture, the risk of a contaminant increased by 39.7%; the number of blood culture sets needed to find a contaminant was 36. Of 122 episodes with only contaminants and available for analysis, 111 (91.0%) experienced at least one complication. 33 (27.0%) patients experienced either prolonged admission, readmission, or unnecessary antibiotic administration. Conclusions The benefits of possibly isolating a pathogen from a third blood culture set do not universally outweigh the risks for contaminant growth for people who inject drugs. A third blood culture should be considered in specific clinical scenarios (i.e. inadequately treated endocarditis and osteomyelitis).

A-239 Comparison Between Blood Culture and MeMed BV Test Results

Abstract Background The rate of cultures ordered for patients in which infection is suspected is approximately 40% on Emergency Department patients at Maimonides Medical Center and represents a significant financial burden for our institution. Most blood cultures in clinical practice do not grow organisms suggesting that suboptimal blood culture collection practices (e.g., suboptimal blood volume) or suboptimal selection of patients to culture (patients with low likelihood of bacteremia may be occurring. •BV is a new host-protein test based on TRAIL, TNF-related apoptosis inducing ligand protein, IP-10, interferon gamma -induced protein 10 and CRP, C- reactive protein that produces a score between 1–100 indicating the likelihood of a bacterial vs viral infection. It has been validated in multiple studies to have sensitivity and specificity of more than 90%.• In this study we compare blood culture and BV results. Methods BV test were taken at ED physician discretion from March 2022 to December 2022 • BV score 0–35 is viral, 35–65 is equivocal and 65–100 is bacterial. • BV test was measured using MeMed BV (MeMed, Israel) and MeMed Key (MeMed, Israel) from serum samples. • This sub analysis focuses on patients presenting at the ED for whom blood culture was ordered and there was a record of the result. Results • BV test was taken for 545 patients during their ED visit, of these, 389 had blood cultures drawn and results recorded. • There were 233 cases with BV score bacterial, 42 with BV score equivocal and 114 with BV score viral • Out of the BV score viral, there were 7 with positive findings, of which 5 were considered contaminants Conclusion There is a high agreement between viral BV results and negative cultures. Ongoing collection of this data in real time will help establish this finding further in order to provide guidance for our clinicians to reduce the financial burden of unwarranted cultures as well as the unnecessary administration of antibiotics.

Diagnostic Stewardship - The right test for the right patient with the right consequences

In 2023, the Society for Healthcare Epidemiology of America (SHEA) Task Force issued a practice recommendation on the integration of diagnostic stewardship into antibiotic stewardship (ABS) programs, which focuses on optimizing sample collection, processing, and reporting to ensure a correct test result on the one hand, and on the justifying indication to perform diagnostics on the other.Unnecessary microbiological or serological tests produce results that can then lead to unnecessary further tests for clarification or unnecessary antibiotic administration. A classic example is "routine" urine cultures before non-urological, surgical interventions, which often lead to the treatment of asymptomatic bacteriuria. Every microbiological diagnosis must therefore be preceded by a specific question, whereby screening examinations from epidemiological questions must be clearly distinguished from clinical requirements. A particular problem is the distinction between contamination, colonization and infection, especially when samples are taken from catheters or drains. These materials should always be evaluated with extreme caution and may only be accepted at all if the clinical question is clear and subject to this very reservation. This article summarizes the existing evidence on diagnostic stewardship interventions and recommendations on their implementation, extrapolating the international literature to the specifications of the German health care system.

Epidemiologic, clinical, and serum markers may improve discrimination between bacterial and viral etiologies of childhood pneumonia.

Discrimination of bacterial and viral etiologies of childhood community-acquired pneumonia (CAP) is often challenging. Unnecessary antibiotic administration exposes patients to undue risks and may engender antimicrobial resistance. This study aimed to develop a prediction model using epidemiological, clinical and laboratory data to differentiate between bacterial and viral CAP. Data from 155 children with confirmed bacterial or mixed bacterial and viral infection (N = 124) and viral infection (N = 31) were derived from a comprehensive assessment of causative pathogens [Partnerships for Enhanced Engagement in Research-Pneumonia in Pediatrics (PEER-PePPeS)] conducted in Indonesia. Epidemiologic, clinical and biomarker profiles (hematology and inflammatory markers) were compared between groups. The area under the receiver operating characteristic curve (AUROC) for varying biomarker levels was used to characterize performance and determine cut-off values for discrimination of bacterial and mixed CAP versus viral CAP. Diagnostic predictors of bacterial and mixed CAP were assessed by multivariate logistic regression. Diarrhea was more frequently reported in bacterial and mixed CAP, while viral infections more frequently occurred during Indonesia's rainy season. White blood cell counts (WBC), absolute neutrophil counts (ANC), neutrophil-lymphocyte ratio (NLR), C-reactive protein (CRP), and procalcitonin (PCT) were significantly higher in bacterial and mixed cases. After adjusting for covariates, the following were the most important predictors of bacterial or mixed CAP: rainy season (aOR 0.26; 95% CI 0.08-0.90; p = 0.033), CRP ≥5.70 mg/L (aOR 4.71; 95% CI 1.18-18.74; p = 0.028), and presence of fever (aOR 5.26; 95% CI 1.07-25.91; p = 0.041). The model assessed had a low R-squared (Nagelkerke R2 = 0.490) but good calibration (p = 0.610 for Hosmer Lemeshow test). The combination of CRP and fever had moderate predictive value with sensitivity and specificity of 62.28 and 65.52%, respectively. Combining clinical and laboratory profiles is potentially valuable for discriminating bacterial and mixed from viral pediatric CAP and may guide antibiotic use. Further studies with a larger sample size should be performed to validate this model.

Tailored Therapy Using Bismuth Add-on Standard Triple Therapy vs. Concomitant Therapy: A First-line Regimen for Helicobacter pylori Infection

Background/Aims: Compared with other regimens, concomitant therapy (CT) used as a first-line regimen for Helicobacter pylori (H. pylori) infection is associated with higher eradication rates. We compared the efficacy of tailored therapy (TT) using bismuth added to standard triple therapy (STT) with CT.Methods: This consecutive study performed between September 2020 and 2021 included 210 patients with H. pylori infection. Two participating gastroenterologists prescribed TT and CT. Multiplex PCR assays were performed before eradication therapy to identify the relevant point mutations and confirm clarithromycin resistance in the TT group (n=105). Patients who showed negative PCR results received 14-day STT and those with positive PCR results received a 14-day regimen of bismuth added to STT. The other group (n=105) received 10-day CT.Results: Based on per-protocol analysis, eradication rates in the TT and CT groups were 89.2% (91/102) and 81.6% (84/103), respectively. We observed no statistically significant intergroup differences in eradication rates (P=0.12). The frequency of estimated clarithromycin resistance confirmed using multiplex PCR assays was 32.4% (34/105), and the eradication rate associated with bismuth add-on STT was 76.5% (26/34) in patients with clarithromycin resistance.Conclusions: Considering the current and emerging trends in antibiotic resistance, a therapeutic strategy using TT (bismuth add-on STT) is recommended to minimize unnecessary administration of antibiotics.

1313. Clinical significance of Rickettsia rickettsii antibody testing among children in Eastern Long Island, New York

Abstract Background Rocky Mountain spotted fever (RMSF) is a tickborne illness caused by Rickettsia rickettsii (Rr). Diagnosis is challenging due to non-specific symptoms and reliance on convalescent antibodies (Ab) for definitive diagnosis. Early doxycycline administration reduces poor outcomes but is sometimes prescribed without clear exposure or suggestive symptoms. Confusion also arises from positive Ab testing in patients lacking RMSF symptoms. Our study aims to describe Rr Ab results and clinical impact in a low incidence region. Specific objectives were to describe signs and symptoms of children tested for RMSF, false-positive Ab rates, and unnecessary antibiotic administration. Methods Retrospective chart review of patients ≤ 21 years old tested for Rr Ab within the Stony Brook Medicine system from 2010-2020. Patients were identified by ICD-9/-10 RMSF diagnosis code and/or Ab test results. Charts without clinical notes were excluded. Data collected included demographics, symptoms, laboratory results, treatments, and outcomes. Patients were classified as RMSF confirmed, probable, suspected, unlikely, or negative based on symptoms and Ab results, per CDC definitions (Table). Results recorded in Qualtrics. Descriptive statistics were calculated. ‘Unlikely RMSF’ cases were considered false positive Ab and ‘proven’ or ‘probable’ cases were considered true positive Ab. Case definitions based on CDC Rocky Mountain spotted fever (RMSF) case surveillance definition Abbreviation: Rr - Rickettsia rickettsii Results 172 charts were included. Average age was 14 years. 56% were male. Of RMSF classic triad symptoms, 52% had fever, 41% rash, and 44% headache. Of RMSF case categories, 2 (1.2%) were confirmed, 3 (1.7%) probable, 10 (5.8%) suspected, 14 (8.1%) unlikely, and 143 (83%) negative. Both confirmed cases had fever, rash and headache. False positive and true positive Rr Ab rates were 8.9% (n=5) and 2.9% (n=5), respectively. 5 patients with false positive Ab received doxycycline within 14 days of Ab collection date. Conclusion Among children in a low-incidence region, Rr Ab were frequently obtained without signs of infection, including half without fever. The cause of false positive Rr Ab in patients lacking RMSF symptoms is unknown, but may be due to non-severe infection or cross-reactivity with other Rickettsia. Focused testing on those with suggestive symptoms may avoid unnecessary treatment and anxiety. Disclosures All Authors: No reported disclosures.

Some issues of safety of antimicrobial therapy in COVID-19 patients

Currently, there is a lack of evidence for empiric use of antimicrobial agents in most patients with COVID-19 in outpatient and hospital settings as the overall proportion of secondary bacterial infections in COVID-19 is quite low. This literature review summarizes data on changes in antimicrobial resistance over the course of COVID-19 pandemic, especially in nosocomial ESKAPE pathogens. The other significant consequences of excessive and unnecessary administration of antibiotics to COVID-19 patients including risk of Clostridioides difficile infection and adverse effects of antimicrobial agents are also discussed.

665. Clinical and Financial Impact of Next Generation Sequencing (NGS) in addition to Conventional Microbiology Testing in our Urban Referral Health Center

BackgroundClinical microbiology traditionally relies on culture methodology and serological testing, that have inherent limitations. Newer diagnostic techniques such as Next Generation Sequencing (NGS) have shown promise to improve microbial identification. In select scenarios, we send clinical specimens to reference laboratories for NGS testing in addition to current standard of care (SOC) diagnostics. We wanted to determine how this diagnostic approach has impacted patient care. We also wanted to review the financial burden through cost-benefit analysis for these ‘send-out’ tests.MethodsWe performed a retrospective chart review of all cases over a 3-year period in which NGS was submitted. Data, including demographics, comorbidities, antimicrobial use, and diagnosis (by SOC and NGS) were gathered. We delineated how often there was concordance or discordance between SOC and NGS. We also obtained information on financial cost (direct and indirect) and turnaround time (TAT) for NGS results. ResultsA total of 33 clinical specimens from 25 patients were sent for NGS. The majority of specimens comprised joint tissue/fluid, organ tissue and CSF.Concordance occurred between SOC and NGS testing in 75.8% (25/33) of samples; of those, 88% excluded infection. NGS identified a pathogen in 20% (5/25) patients in which concomitant SOC testing was negative. A subsequent change in antimicrobial management occurred in 16% (4/25) of patients. The mean TAT was 14 days and average cost per specimen was &821.52 (range: &573-&1590).Table 1. Pathogens identified by NGS with negative traditional microbiological test results Figure 1. Distribution of specimen site (in %) sent for NGS ConclusionNGS can provide additional diagnostic sensitivity in infectious diseases, which at our institution identified a new pathogen in 20% and a resultant treatment change in 16% of our patients. This testing may also allow physicians to reaffirm the absence of an infection diagnosis. A larger NGS testing population may reveal more significant benefits. While the attributable cost of NGS was substantial, it should be measured against the costs of administration of unnecessary antibiotics, inaccurate diagnosis, and adverse patient outcomes that may result from SOC testing alone. Considering its financial cost and extended TAT, in-house NGS testing may be warranted to facilitate a higher volume of testing.Disclosures All Authors: No reported disclosures

Reducing Blood Culture and Antibiotic Usage in Neonates: Using Quality Improvement Science to Guide Implementation of a Neonatal Early-Onset Sepsis Calculator.

A maternal diagnosis of chorioamnionitis, based on maternal peripartum fever of 100.4°F alone, is commonly used as an indication for blood work and antibiotic treatment in newborns. New strategies such as the Kaiser Permanente early-onset sepsis (EOS) calculator have proven effective in identifying high-risk newborns and reducing unnecessary antibiotic administration. Retrospective data from October 2017 to September 2018 from 297 well-appearing newborns ≥35 weeks' gestational age (GA) with maternal chorioamnionitis showed that 93.6% had blood work and 90.2% were treated with antibiotics. This was despite no culture-positive cases of sepsis. Our aim was to reduce by 50% blood work evaluation and antibiotic treatment within a 6-month period. Using plan-do-study-act (PDSA) cycles, we adopted the Kaiser Permanente EOS calculator. We collected longitudinal data to track the outcomes after its implementation. In 423 newborns with maternal chorioamnionitis triaged with the EOS calculator from October 2018 to July 2020, the rates of blood culture and antibiotic treatment decreased from 93.6% to 26.7% and 90.2% to 12.3% (P < .0001). In the larger population of 6426 newborns ≥35 weeks' GA, the rate of blood culture and antibiotic treatment decreased from 12.8% to 5.8% and 9.9% to 2.5% (P < .0001). The EOS calculator substantially and safely decreases blood work and antibiotic administration in asymptomatic newborns with maternal chorioamnionitis. Our findings provide further evidence for the effectiveness and safety of the EOS calculator.Video abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Emergency Department Observes 83% Reduction in Blood Culture Contamination with Initial Specimen Diversion Technology Adoption

Background Blood culture attempts to reduce unfavorable outcomes for patients with bloodstream infections by guiding antibiotic therapy. False positive blood culture results are frequent (a 3% contamination rate is considered standard) and associated with unnecessary broad-spectrum antibiotic usage, extended hospital stays and elevated clinical costs. Diversion of the initial portion of a blood sample (which can host deep skin flora associated with venipuncture-dislodged skin fragments) is proposed to address an avenue for contamination unaddressed by conventional blood culture protocol. Methods Blood culture sets were obtained from adult patients during an 18-month observation period in a 32-bed emergency department in California for a non-randomized prospective controlled cohort study. Blood cultures were obtained using either conventional methods (venipuncture and intravenous catheter start) or with initial specimen diversion technology (in tandem with venipuncture and intravenous catheter start). Blood culture bottle tops were disinfected with alcohol pads and patient skin was prepared with a 30-second chlorhexidine gluconate solution scrub. Samples were considered contaminated if skin flora were present in either the aerobic or anaerobic bottle of a single blood culture set. Results Conventional methods were utilized to collect 3,170 blood cultures, from which 77 (2.43%) were contaminated, while initial specimen diversion technology was utilized to collect 2,168 blood cultures, from which 9 (0.42%) were contaminated. Conclusions Use of initial specimen diversion technology was associated with an 83% lower rate of blood culture contamination compared to conventional methods, sustained for 18 months. Lower rates of blood culture contamination translate to reduced administration of unnecessary antibiotics (diagnostic stewardship and antimicrobial stewardship), reduced patient length of stay, and reduced clinical expenditures.

Utility of Hematological Scoring System in Diagnosis of Neonatal Sepsis

Background: Neonatal septicemia is defined as a clinical syndrome characterized by systemic signs and symptoms caused by a bacterial infection and gives positive blood culture in the first month of life. It is associated with high morbidity and mortality, but early diagnosis and treatment significantly improve the outcomes. The present study brings out a quick and cost- effective Hematological Scoring System that enables early diagnosis of neonatal sepsis&#x0D; Method: This study was conducted in the Department of Pathology of Sree Gokulam Medical College and Research Foundation, Venjaramoodu, Thiruvananthapuram over 1 year. Eighty neonates with clinical suspicion of sepsis were studied with respect to their peripheral smear findings, blood culture and C-reactive protein levels.&#x0D; Result: Among the eighty cases, twelve neonates were culture positive. Male gender and late- onset of sepsis were the significant risk parameters. Escherichia coli and Staphylococcus aureus were the most common isolated organisms. Of the different parameters studied I:T ratio and Absolute neutrophil count showed the highest specificity and immature neutrophil count had the highest sensitivity. Forty-one percent of neonates had a high Hematological Scoring System score. The specificity of Hematological Scoring System with a score &gt; 5 was 92%&#x0D; Conclusion: Hematological Scoring System is a cost-effective, rapid and easy to perform screening test that can be used to rule out sepsis thus avoiding unnecessary administration of antibiotics to unaffected babies. It should be adopted as a routine screening procedure by minimally qualified rural doctors with minimal resources to ensure appropriate action immediately for children with high index of suspicion of sepsis.

Crowdsourced Photographs as an Effective Method for Large-Scale Passive Tick Surveillance.

As tick vector ranges expand and the number of tickborne disease cases rise, physicians, veterinarians, and the public are faced with diagnostic, treatment, and prevention challenges. Traditional methods of active surveillance (e.g., flagging) can be time-consuming, spatially limited, and costly, while passive surveillance can broadly monitor tick distributions and infection rates. However, laboratory testing can require service fees in addition to mailing and processing time, which can put a tick-bite victim outside the window of potential prophylactic options or under unnecessary antibiotic administration. We performed a retrospective analysis of a national photograph-based crowdsourced tick surveillance system to determine the accuracy of identifying ticks by photograph when compared to those same ticks identified by microscopy and molecular methods at a tick testing laboratory. Ticks identified by photograph were correct to species with an overall accuracy of 96.7% (CI: 0.9522, 0.9781; P < 0.001), while identification accuracy for Ixodes scapularis Say (Ixodida: Ixodidae), Amblyomma americanum Linnaeus (Ixodida: Ixodidae), and Dermacentor variabilis Say (Ixodida: Ixodidae), three ticks of medical importance, was 98.2% (Cohen's kappa [κ] = 0.9575; 95% CI: 0.9698, 0.9897), 98.8% (κ = 0.9466, 95% CI: 0.9776, 0.9941), and 98.8% (κ = 0.9515, 95% CI: 0.9776, 0.9941), respectively. Fitted generalized linear models revealed that tick species and stage were the most significant predictive factors that contributed to correct photograph-based tick identifications. Neither engorgement, season, nor location of submission affected identification ability. These results provide strong support for the utility of photograph-based tick surveillance as a tool for risk assessment and monitoring among commonly encountered ticks of medical concern.

The Rationality of Antibiotic Use on Patients of Typhoid Fever

Typhoid fever is an infectious disease caused by Salmonella typhi bacteria. The administration of antibiotics in typhoid fever is needed as a causative therapy to eradicate the bacteria based on the principles of rational therapy to avoid antibiotic resistance. However, there are still a considerable amount of cases of unnecessary antibiotic administration. This study aims to examine the rationality of antibiotic use on patients of typhoid fever. This research is a non-intervention study with descriptive analytic methods. Data were retrieved retrospectively by identifying the medical records of patients treated in the X Hospital Salatiga from January to August 2016 with a purposive sampling method based on the inclusion and exclusion criteria of 67 cases. The data was analyzed by using Gyssen criteria based on the standard of typhoid fever service of WHO 2011. The result showed that the percentage of female typhoid fever patients was higher than the male with the most prolonged 3-day hospitality. The most commonly used antibiotics are ceftriaxone, ciprofloxacin, and cefixime with the result of the rationality analysis of category 0 (55.22 %), category IIIA (1.49%), category IIIB ( 8.96% ), category IVA (17.91%), and category IVC (4.48%). It can be concluded that the rationality of antibiotics used in patients with typhoid fever at X Hospital Salatiga based on Gyssen criteria showed a good result.

Successful Chest Radiograph Reduction by Using Quality Improvement Methodology for Children With Asthma

To measure the effect of implementing quality improvement (QI) methodology on the rate of chest radiograph (CXR) ordering for pediatric patients with acute asthma exacerbations.A total of 6680 pediatric patients age ≥2 years seen in the emergency department (ED) of a tertiary care children’s hospital for acute asthma were included in the study.Children ≥2 years old were retrospectively identified by chart review from May 2013 to April 2017. Included subjects had a primary International Classification of Diseases, Ninth Revision or 10th Revision billing code for asthma. An asthma clinical practice guideline (CPG) for CXR ordering in the ED was implemented in May 2014. Thus, the data from May 2013 to April 2014 were included as a 1-year baseline before intervention. Additional QI methods included removal of CXR as a default component of the electronic medical record asthma order set (July 2015), public reminder placement (January 2016), and targeted resident education (February 2016). The primary measure was CXRs ordered as a percentage of total acute asthma encounters, with a preintervention goal of <20%.A total of 1539 CXRs were ordered during 6680 patient encounters. Hospital-wide implementation of an asthma CPG was associated with a decrease in CXR use in acute asthma visits, from 29.3% to 23.0%. Implementation of targeted QI measures was associated with a further reduction in CXR use to 16.0%, which was sustained for 14 months (from February 2016 to April 2017). CXR use decreased from 21.3% to 12.5% in the subset of patients discharged from the hospital from the ED and from 53.5% to 31.1% among patients ultimately admitted to the hospital.Investigators in this study describe sustained reduction in CXR ordering in pediatric patients with acute asthma exacerbations after implementation of a CPG, later followed by QI interventions targeted at the electronic medical record system and at provider education.Old habits die hard. Previous studies have established that routine use of CXR in the evaluation of children with acute asthma exacerbations, the most frequent cause of childhood hospitalization in the United States, is of low diagnostic yield and is associated with significant risk, including unnecessary antibiotic administration. Despite evidence demonstrating low utility of CXR in this setting, implementation of “best” practice into clinical routine is challenging and can take years before change occurs. This study demonstrates how QI methodology can help break old habits, improve clinical care through patient-centered outcome measures, and most importantly, assist clinicians working in busy medical settings. It is impossible for any of us to stay current with the rapidly evolving world of medical knowledge. That is why dedicated use of QI methodology and commitment to changing culture can be so valuable.

1528. Rates of Peripheral Blood Culture Contamination in an Urban Children’s Hospital

BackgroundPositive peripheral blood culture results are essential in guiding antimicrobial therapy in patients with bacteremia. However, false-positive results may frequently pose diagnostic issues in interpreting the test. These results can lead to increased costs and patient harm through the administration of unnecessary antibiotics and prolongation of hospital stay. The maximum acceptable contamination rate for peripheral blood cultures as suggested by the College of American Pathologists is 3%.MethodsWe initiated a longitudinal quality improvement project to monitor peripheral blood contamination rates at our children’s hospital in Brooklyn, NY. We reviewed positive blood culture results on a monthly basis and assessed whether they represented true infections vs. contamination based on review of patient charts. Residents and nurses in the pediatric emergency department (ED), neonatal intensive care unit (NICU), pediatric intensive care unit (PICU), inpatient unit, and newborn nursery were educated on proper skin sterilization techniques using video demonstration; the importance of avoiding palpating the venipuncture site after sterilization and the importance of cleaning the port on the blood culture bottle were reinforced.ResultsThe pediatric ED and the PICU had the highest contamination rates in 2018 at 4.38% and 3.82%, respectively. The newborn nursery had the lowest contamination rate, at 0%. The NICU and pediatric inpatient units had contamination rates that met the goal as well, at 1.25% and 0.72%, respectively.ConclusionThe departments in need of targeted interventions are the pediatric ED and the PICU, both of which had contamination rates greater than the 3% goal rate set for our project. Future interventions currently being considered include re-education of nursing and resident staff as well as the creation of equipment bundles to facilitate adequate skin preparation prior to venipuncture. Disclosures All authors: No reported disclosures.

1098. Perioperative Antibiotic Stewardship for Interventional Radiology Cases Improves Antibiotic Decision-Making

BackgroundAppropriate periprocedural antibiotic prophylaxis is critical to optimize in order to reduce excessive antibiotics exposure for patients and to minimize the risk for procedure-related infection. Wrong antibiotic or excess antibiotics increase the risk for development of antimicrobial resistance, Clostridium difficile infection, adverse side effects. Incorrect or missed antibiotic can put the patient at risk for an infection.MethodsInterventions included education of vascular and interventional radiology (IR) consult RN and physicians regarding updated institutional antimicrobial prophylaxis guidelines for vascular and IR procedures, creation of a consulting template that incorporated ongoing antibiotics. Review of recent cultures was incorporated into workflow and consult evaluation. Handoff between the IR RN and IR attendings was expanded to include a review of antimicrobials.ResultsAll IR cases were reviewed for antibiotic administration for 3 months pre- and post-intervention. In the pre-intervention timeframe, 23 of 290 procedures (7.9%) were associated with inappropriate antibiotic administration, further delineated as 6 cases where no antibiotics were given, 7 cases of inappropriate antibiotics administered, and 10 cases where extraneous antibiotics were administered. Of the 39 total procedures where antibiotics were indicated, 17 (43.6%) were associated with antibiotic errors. In the post-intervention period, only 9 of 309 total procedures (10.3%) were associated with inappropriate antibiotic administration: missed antibiotics in 3 cases, inappropriate antibiotics in 4 cases, and unnecessary antibiotics in 2 cases. Of the 32 cases where antibiotics were indicated, only 7 (21.9%) were associated with antibiotic errors.ConclusionIncorporating current antibiotics and review of culture data in a preoperative review and template for patients who need a surgical procedure helps guide appropriate antibiotic decision-making and greatly decreases administration of unnecessary antibiotics.Disclosures All authors: No reported disclosures.

Standardized Ventriculostomy Protocol without an Occlusive Dressing: Results of an Observational Study in Patients with Aneurysmal Subarachnoid Hemorrhage

Catheter-related infections are a potentially life-threatening complication of having an external ventricular drain (EVD). Patients with aneurysmal subarachnoid hemorrhage (aSAH) are at increased risk of infection associated with prolonged ventricular drainage, with a reported mean infection rate of 6%. We report the EVD-associated infection rate among patients with aSAH managed with a unique standardized treatment protocol without an occlusive EVD dressing. Patients with aSAH admitted from August 2015 through August 2017 were retrospectively analyzed for EVD placement. Cerebrospinal fluid (CSF) samples were obtained twice weekly for culture and routine studies. EVD-associated infection was defined as growth of CSF cultures. During the 2-year study period, 122 patients presented with an aSAH, with 91 (74.6%) having EVD placement. In patients with EVDs, the mean age was 57.9 years (68% women); 88% of aSAHs were Fisher grade III or IV. Mean duration of EVD was 14 days, and 13% of patients required EVD replacement. Endovascular coiling and surgical clipping were performed in 34 (37%) and 53 (58%) patients with EVD, respectively. A total of 347 CSF studies were performed with no EVD-associated infections. There were 3 CSF samples with false-positive Gram stain results but no growth on concurrent or multiple repeat cultures. Using a standardized protocol for placement and management of EVDs in patients with aSAH is associated with low risk of CSF infection. Our study demonstrates that occlusive EVD dressings are not necessary and that routine CSF sampling in patients with EVD may lead to false-positive findings and unnecessary antibiotic administration.

Clinical and radiographic factors associated with appendectomy in pediatric patients with abdominal pain and equivocal imaging findings for appendicitis.

Background and Hypothesis &#x0D; Acute appendicitis is a common surgical emergency in children. The diagnosis requires physicians to rely on clinical, radiographic and laboratory factors. The nonoperative management of appendicitis is becoming more frequent. This requires an accurate diagnosis prior to initiating therapy to prevent unnecessary antibiotic administration for abdominal pain unrelated to appendicitis. We hypothesize clinical and radiographic factors are associated with appendicitis in patients with abdominal pain and inconclusive imaging studies. &#x0D; Methods &#x0D; The DORIS (Dig Our RIS) interactive data-mining tool was utilized to identify patients&lt;18 years of age presenting to the emergency department in 2016 with abdominal pain who obtained abdominal imaging suggestive of early acute appendicitis. Relevant clinical and radiographic information was obtained from the medical record for univariate analysis looking for associations with appendectomy. &#x0D; Results &#x0D; One hundred patients were identified with 21 excluded due to imaging for other reasons or with clear non-appendicitis etiologies for pain (e.g. trauma cases, ovarian cyst). Seventy-nine patients were included with 49 (62%) undergoing surgery and 30 who were observed and/or discharged from the ED. Important differences between surgical and nonsurgical patients included: white blood cell count (13.81±0.68 vs. 10.29±0.90, p=0.002), neutrophil percentage (78.31±1.90 vs. 67.78±2.65, p=0.002), appendiceal diameter on CT scan (9.37±0.53 vs. 7.58±0.30, p=0.013). &#x0D; Conclusion and Potential Impact &#x0D; In a group of patients with concern for appendicitis and imaging suggestive of early acute appendicitis, distinct clinical and radiographic characteristics are associated with appendicitis. Within a paradigm of nonoperative management of appendicitis, accurate diagnosis will prevent the overutilization of antibiotics.

LIPOID PNEUMONIA, AN UNEXPECTED DIAGNOSIS IN A HEALTHY MIDDLE-AGED PATIENT

SESSION TITLE: Medical Student/Resident Occupational and Environmental Lung Diseases SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Lipoid pneumonia is a rare pneumonitis most often caused by aspiration of over-the-counter oil regimens such as nasal spray or mineral oil. The disease typically occurs in patients who are elderly or who have disorders that affect swallowing such as achalasia or reflux. CASE PRESENTATION: A 56-year-old woman presented to her regular doctor with complaint of left chest pain with deep breaths without coughing or fever. A Chest x-ray was performed, revealing bibasilar airspace disease in her right middle and left lower lobes. She was prescribed levofloxacin for 14 days. Her next x-ray showed no change to the infiltrates present. A Chest CT scan was obtained and confirmed dense left lower and right middle lobe consolidations without cavitation or malignant appearing pulmonary lesions. She was prescribed a second round of the same antibiotic in addition to prednisone. She was seen again in one month with improved symptoms, but she continued to show infiltrates on imaging. A CBC, ESR/CRP, Histoplasma, Legionella, Mycoplasma, and Blastomyces antibodies had all returned negative. She was then scheduled for CT guided biopsy of the left infiltrate. The sample ultimately showed lipid-laden “foamy” macrophages with some alveolar hyperplasia consistent with lipoid pneumonia. Further questioning revealed that she had been using mineral oil for several years before quitting but never noticed difficulty with swallowing and had no history of reflux, achalasia, or any neuromuscular disease. DISCUSSION: This patient’s history points to an exogenous source for her lipoid infiltration. Clinically, exogenous lipoid pneumonia can present in many ways, including severe shortness of breath with chest pain or asymptomatic. Our patient had both these presentations during her course. The current recommendations are to remove the potential causative agent and provide supportive care. Antibiotics and steroids have not been consistently shown to be effective in treatment. Our patient failed to see improvement with two long antibiotic courses and a steroid burst but symptoms gradually subsided after she had stopped ingesting oil. Lipoid pneumonia can lead to unnecessary administration of antibiotics and steroids as it did in our patient. It is also important to note also that our patient contracted this disease despite having none of the typical risk factors. CONCLUSIONS: This case highlights why it is important to consider this diagnosis of lipoid pneumonia in patients with a history of ingesting oil substances even in the absence of typical risk factors. Reference #1: Kuroyama M et al. Exogenous lipoid pneumonia caused by repeated sesame oil pulling: a report of two cases. BMC Pulm Med. 2015 Oct 30;15:135 Reference #2: Prasad KT et al. An Unusual Cause of Organizing Pneumonia: Hydrocarbon Pneumonitis. J Clin Diagn Res. 2017 Jun;11(6):OD03-OD04 Reference #3: Tavare AN et al. Exogenous Lipoid Pneumonia Mimicking Multifocal Bronchogenic Carcinoma. J Thorac Oncol. 2015 Dec;10(12):1809-10 DISCLOSURES: No relevant relationships by Clifford Hecht, source=Web Response

Effect of the neonatal early onset sepsis calculator on pharmacy‐prepared empirical antibiotics

AbstractBackgroundThe Kaiser Permanente early onset sepsis (EOS) calculator was introduced in 2016 for infants who were born at ≥35 weeks gestation or more (≥35GA) at a principal referral and specialist hospital for women and newborns in Western Australia to reduce unnecessary antibiotic administration in healthy neonates.AimThe aim of this study was to determine the effect of the EOS calculator on antibiotic orders aseptically prepared by the pharmacy.MethodsThe study retrospectively compared pharmacy data over two periods, before (2015) and after (2016) implementation.ResultsAfter implementation, the number of gentamicin prefilled syringes (PFS) distributed decreased by 41.6% (1466 doses). In addition, the number of ≥35GA neonates receiving benzylpenicillin PFS decreased by 33.9% (222 neonates), and the overall rate (number of neonates receiving a benzylpenicillin PFS/occupied bed days) decreased from 2.24% to 1.48% (p &lt; 0.0001).ConclusionThe introduction of the EOS calculator has reduced the empirical antibiotic use in ≥35GA neonates at the King Edward Memorial Hospital.