Unnecessary Antibiotic Exposure Research Articles

230. Impact of 10-day versus 5-day Duration Default on Length of Antibiotic Outpatient Prescriptions from the Emergency Department

BackgroundAntimicrobial stewardship programs (ASP) traditionally focus on inpatient care; however there is a growing effort to optimize antibiotic prescribing at transitions of care. Longer than necessary discharge prescriptions increase risk of antimicrobial resistance, C. difficile infection and adverse events. In order to minimize unnecessary antibiotic exposure, the health system updated the electronic medical record (EMR) outpatient antibiotic prescription default from 10 days to 5 days. The objective of this study was to assess the impact of a 10-day versus 5-day EMR antibiotic outpatient prescriptions default on length of therapy for patients discharged from the Emergency Department (ED).MethodsThis is a retrospective, single-system cohort study evaluating ED discharge prescriptions before and after transition from a default duration of 10 days to 5 days. Discharge prescriptions were collected and screened from December 2019 through January 2020 in the control group and March 2020 through April 2020 in the intervention group. Outpatient prescriptions were included for primary diagnoses of urinary tract infection (UTI), community-acquired pneumonia (CAP), skin and soft tissue infections (SSTI), diverticulitis, or dental infections. The primary outcome was the incidence of prescriptions written for a < 5 day duration.ResultsThe study included 3060 of 9651 (32%) prescriptions in the control group and 1610 of 4938 (33%) prescriptions in the intervention group. The mean age was 38 years old with 61% female. The most common primary diagnoses were SSTI (n=1633, 35%) and UTI (n=1633, 32%). The mean duration for discharge prescriptions was similar between groups (8.44 vs. 8.30 days). The incidence of outpatient antibiotic prescriptions for < 5 days was not significantly different between groups (10.72% vs 10.56%, p=0.996). There was an improvement in duration of therapy, with more prescriptions < 5 days for SSTI (2.96% vs. 7.64%, p=0.860) and dental infections (3.30% vs. 10.86%, p=0.808).ConclusionImplementation of a shorter default duration for antibiotic outpatient prescriptions from the ED did not significantly increase the incidence of prescriptions written for < 5 days. There was an improvement in duration for SSTI and dental infections after implementation.Disclosures All Authors: No reported disclosures

Antibiotic utilization variability among training services at an academic medical center: An observational study.

Evaluate the difference in antibiotic prescribing between various levels of resident training or attending types. Observational, retrospective study. Tertiary-care, academic medical center in Madison, Wisconsin. We measured antibiotic utilization from January 1, 2016, through December 31, 2018, in our general medicine (GM) and hospitalist services. The GM1 service is staffed by outpatient internal medicine physicians, the GM2 service is staffed by geriatricians and hospitalists, and the GM3 service is staffed by only hospitalists. The GMA service is led by junior resident physicians, and the GMB service is led by senior resident physicians. We measured utilization using days of therapy (DOT) per 1,000 patient days (PD). In a secondary analysis based on antibiotic spectrum, we used average DOT per 1,000 PD. Teaching services prescribed more antibiotics than nonteaching services (671.6 vs 575.2 DOT per 1,000 PD; P < .0001). Junior resident-led services used more antibiotics than senior resident-led services (740.9 vs 510.0 DOT per 1,000 PD; P < .0001). Overall, antibiotic prescribing was numerically similar between various attending physician backgrounds. A secondary analysis showed that GM services prescribed more broad-spectrum, anti-MRSA, and anti-pseudomonal antibiotics than the hospitalist services. GM junior resident-led services prescribed more broad-spectrum, anti-MRSA, and antipseudomonal therapy compared to their senior counterparts. Antibiotics were prescribed at a significantly higher rate in services associated with trainees than those without. Services led by a junior resident physician prescribed antibiotics at a significantly higher rate than services led by a senior resident. Interventions to reduce unnecessary antibiotic exposure should be targeted toward resident physicians, especially junior trainees.

Antibiotic Timing in Pediatric Septic Shock.

National guidelines advocate for the administration of antibiotics within 1 hour to children with septic shock, although there is variance in the pediatric evidence-based literature supporting this benchmark. Our objective for this study was to describe the association of target time to antibiotic administration (TTAA) with outcomes of children treated for suspected septic shock in a pediatric emergency department. Septic shock is suspected when signs of perfusion and/or hypotension are present. The primary outcome was mortality. Secondary outcomes included PICU admission, hospital and PICU length of stay, and organ dysfunction resolution by hospital day 2. We conducted a retrospective study of children <18 years of age admitted from the pediatric emergency department and treated for suspected septic shock between February 1, 2007, and December 31, 2015. Associations between TTAA and outcomes were evaluated by using multivariable linear and logistic regression models obtained from stepwise selection. Of 1377 patients, 47% were boys with a median age of 4.0 (interquartile range 1.4-11.6) years, 1.5% (20) died, 90% were compliant with TTAA goals, 40% required PICU admission, 38% had ≥2 unique complex chronic conditions, 71% received antibiotics in ≤2 hours, and 30% had a culture-positive bacterial etiology. There were no significant associations between TTAA and outcomes. We found no association with TTAA and any clinical outcomes, adding to the growing body of literature questioning the timing benchmark of antibiotic administration. Although the importance of antibiotics is not in question, elucidating the target TTAA may improve resource use and decrease inappropriate or unnecessary antibiotic exposure.

Lack of utility of tracheal aspirates in the management of suspected pneumonia in intubated neonates.

To evaluate the utility of tracheal aspirates in suspected pneumonia in intubated neonates and to measure the burden of antibiotic use associated with a positive tracheal aspirate culture. Retrospective cohort study between January 2016 and December 2017. A level IV neonatal intensive care unit (NICU). Intubated patients with a tracheal aspirate culture. Data on temporally associated clinical measures of illness, laboratory and radiographic testing, and clinical demographic information were analyzed. Positive tracheal aspirate cultures were associated with lower birth weight and a normal immature to total neutrophil ratio (I/T ratio). Positive tracheal aspirates were not significantly associated with clinical, laboratory, or radiographic markers used in clinical practice to screen for infection. Despite the lack of positive clinical associations, a positive tracheal aspirate culture was associated with increased risk of prolonged antibiotic exposure. These findings suggest that positive tracheal aspirates do not always represent clinical infection and may result in unnecessary antibiotic exposure.

Management of newborns at increased risk for early-onset sepsis in perinatology department

Introduction Assessing newborn infants at risk for early-onset sepsis (EOS) is a common clinical task conducted by pediatricians. A change in the internal protocol for managing neonates at risk was implemented in 2016. Unlike the previous protocol, which determined laboratory testing in asymptomatic newborns in the presence of one risk factor (RF) for sepsis; the new protocol advocates the screening in the presence of at least two RF. The purpose of this study was to characterize newborns at increased risk for EOS before and after the implementation of a diagnostic/treatment protocol. Methods Retrospective analysis of asymptomatic newborns with RF to EOS who had laboratory testing performed at perinatology department in a central hospital in north of Portugal before and after the protocol was reviewed (2016), in the years 2015 and 2017, respectively. Patients were divided in two groups: preprotocol (2015) and postprotocol (2017), according to the date of admission. Results A total of 361 newborns were enrolled, 296 (82%) pre-protocol and 65 (18%) post-protocol. There was a significant raise in the number of preterm newborns (9.5 versus 30.8%, pre- and post-protocol, respectively; p < .001), with similar other sociodemographic characteristics. There were 36 positive laboratory screenings at 12 h of life and 8.6% were transferred to the neonatology department, without differences between the groups (p = .250 and p = .488). All presented a favorable outcome, without differences in the number of readmissions in the first month of life (p = .204). Discussion The modification of the approach protocol has led to a significant decline in the laboratory testing performed, minimizing newborn pain, unnecessary antibiotic exposure and costs, without increased risk of readmission for sepsis.

Reduction of Inappropriate Antibiotic Use and Improved Outcomes by Implementation of an Algorithm-Based Clinical Guideline for Nonpurulent Skin and Soft Tissue Infections

Clinicians currently do not reliably adhere to antibiotic treatment guidelines, resulting in unnecessary patient exposure to broad-spectrum antimicrobials. Our objective is to determine whether a treatment intervention for the management of nonpurulent skin and soft tissue infections increases clinician adherence and improves patient outcomes. Between January 1 and December 31, 2017, patients presenting to 2 emergency departments (EDs) and who had received a diagnosis of a nonpurulent skin and soft tissue infection were enrolled and assigned to a pre- or postintervention cohort with a treatment intervention implemented on June 1. Primary outcomes were percentage of ED providers following the guidelines and percentage of patients admitted to the hospital. Secondary outcomes were patient self-reported treatment failure and hospital readmission. There were 1,360 patients, 665 in the preintervention and 695 in the postintervention cohorts. After algorithm implementation, guideline adherence increased (43.0% versus 55.1%; P<.001) and number of patients admitted to the hospital declined (36.5% versus 12.0%; P<.001). In addition, patients reported fewer treatment failures (26.8% versus 16.5%; P=.02) and fewer readmissions (22.3% versus 12.7%; P=.013). After multivariate adjustment, guideline adherence increased by 22% (adjusted relative risk [RR] 1.22; 95% confidence interval [CI] 1.10 to 1.37), whereas hospital admissions were reduced by 26% (adjusted RR 0.74; 95% CI 0.64 to 0.87). In addition, the risks of treatment failure and readmission were reduced by 46% (adjusted RR 0.64; 95% CI 0.43 to 0.97) and 45% (adjusted RR 0.55; 95% CI 0.34 to 0.87), respectively. Among patients with a nonpurulent skin and soft tissue infection, implementing an easy-to-follow treatment algorithm can reduce unnecessary antibiotic exposure by increasing clinician guideline adherence while reducing patient treatment failure rates.

A behavioural approach to specifying interventions: what insights can be gained for the reporting and implementation of interventions to reduce antibiotic use in hospitals?

BackgroundReducing unnecessary antibiotic exposure is a key strategy in reducing the development and selection of antibiotic-resistant bacteria. Hospital antimicrobial stewardship (AMS) interventions are inherently complex, often requiring multiple healthcare professionals to change multiple behaviours at multiple timepoints along the care pathway. Inaction can arise when roles and responsibilities are unclear. A behavioural perspective can offer insights to maximize the chances of successful implementation.ObjectivesTo apply a behavioural framework [the Target Action Context Timing Actors (TACTA) framework] to existing evidence about hospital AMS interventions to specify which key behavioural aspects of interventions are detailed.MethodsRandomized controlled trials (RCTs) and interrupted time series (ITS) studies with a focus on reducing unnecessary exposure to antibiotics were identified from the most recent Cochrane review of interventions to improve hospital AMS. The TACTA framework was applied to published intervention reports to assess the extent to which key details were reported about what behaviour should be performed, who is responsible for doing it and when, where, how often and with whom it should be performed.ResultsThe included studies (n = 45; 31 RCTs and 14 ITS studies with 49 outcome measures) reported what should be done, where and to whom. However, key details were missing about who should act (45%) and when (22%). Specification of who should act was missing in 79% of 15 interventions to reduce duration of treatment in continuing-care wards.ConclusionsThe lack of precise specification within AMS interventions limits the generalizability and reproducibility of evidence, hampering efforts to implement AMS interventions in practice.

Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey.

Sending blood cultures in children at low risk of bacteremia can contribute to a cascade of unnecessary antibiotic exposure, adverse effects, and increased costs. We aimed to describe practice variation, clinician beliefs, and attitudes about blood culture testing in critically ill children. Cross-sectional electronic survey. Fifteen PICUs enrolled in the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children collaborative, an investigation of blood culture use in critically ill children in the United States. PICU clinicians (bedside nurses, resident physicians, fellow physicians, nurse practitioners, physician assistants, and attending physicians). None. Survey items explored typical blood culture practices, attitudes and beliefs about cultures, and potential barriers to changing culture use in a PICU setting. Fifteen of 15 sites participated, with 347 total responses, 15-45 responses per site, and an overall median response rate of 57%. We summarized median proportions and interquartile ranges of respondents who reported certain practices or beliefs: 86% (73-91%) report that cultures are ordered reflexively; 71% (61-77%) do not examine patients before ordering cultures; 90% (86-94%) obtain cultures for any new fever in PICU patients; 33% (19-61%) do not obtain peripheral cultures when an indwelling catheter is in place; and 64% (36-81%) sample multiple (vs single) lumens of central venous catheters for new fever. When asked about barriers to reducing unnecessary cultures, 80% (73-90%) noted fear of missing sepsis. Certain practices (culture source and indication) varied by clinician type. Obtaining surveillance cultures and routinely culturing all possible sources (each lumen of indwelling catheters and peripheral specimens) are positively correlated with baseline blood culture rates. There is variation in blood culture practices in the PICU. Fear and reflexive habits are common drivers of cultures. These practices may contribute to over-testing for bacteremia. Further investigation of how to optimize blood culture use is warranted.

Improvement in adherence to antibiotic duration of therapy recommendations for uncomplicated cystitis: a quasi-experimental study.

Acute uncomplicated cystitis is one of the most common diagnoses for which antibiotic treatment is prescribed in the outpatient setting. Despite the availability of national guidelines, there remains a wide pattern in prescriber choices for therapy. Recent data portray a picture of consistently longer durations than recommended prescribed in outpatient settings. The objective was to evaluate the effect of a system-based intervention on adherence to guideline-recommended durations of therapy for uncomplicated cystitis in the outpatient setting. This quasi-experimental study included women aged 18-64 years who were seen at five family medicine clinics at an academic medical centre and were prescribed targeted antibiotics for uncomplicated cystitis (nitrofurantoin monohydrate/macrocrystals 100 mg, trimethoprim-sulfamethoxazole 160/800 mg or ciprofloxacin 250 mg). The intervention involved revising or adding pre-filled, but modifiable, default prescribing instructions in the electronic health record (EHR) for the targeted antibiotics. We evaluated adherence to guideline-recommended duration of therapy as well as days of therapy (DOT) before and after the intervention. A total of 787 pre-intervention and 862 post-intervention cases were included. Adherence to recommended duration of therapy increased from 29.4% to 76.3% (P < 0.01). The average DOT decreased by 23% from 6.6 to 5.1 (P < 0.01). A stewardship intervention consisting of revising/adding default prescribing instructions to targeted antimicrobials in an EHR was associated with increased adherence to recommended durations of therapy for uncomplicated cystitis and reduction of unnecessary antibiotic exposure. More studies are needed to confirm effectiveness across multiple medical record platforms.

149. Short vs. Long Course of Antibiotics for Uncomplicated Gram-Negative Bacteremia

BackgroundBloodstream infections (BSI) continue to be a major cause of morbidity and mortality in the United States; thus, the correct choice of antibiotics for an appropriate duration is imperative. However, there are limited recommendations on adequate duration of treatment of bacteremia caused by Gram-negative organisms. Therefore, treating an infection for an adequate duration to prevent complications while preventing adverse effects from unnecessary antibiotic exposure remains a balancing act. This study aims to compare clinical outcomes between patients treated with a short (7–10 days) vs. long (11–20 days) course of antibiotics for uncomplicated gram-negative bacteremia.MethodsThis single-center retrospective cohort study evaluated adult patients admitted between January 2007 to October 2018 with a blood culture positive for gram-negative bacteria. Data came from the University of Kentucky Microbiological Laboratory and Center for Clinical and Translational Science (CCTS) Data Bank. Patients included must have received appropriate antibiotics for at least 7 days. Appropriate antibiotics were defined as those to which the organism is susceptible with day one of therapy as the first day of appropriate antibiotic therapy. Patients were excluded if they were treated with aminoglycoside monotherapy, had polymicrobial bacteremia, or if treated for longer than 20 days of therapy.ResultsA total of 466 patients were identified (208 in the short-course group and 258 in the long course group). Gender and ethnicity were similar across both groups. The patients in the long course group had more ICU admissions compared with the short-course group (52.7% vs. 43.3%, P = 0.0426), tended to be older (57 ± 16.7 vs. 53 ± 15.9 years, P = 0.0119), had a higher Charlson Comorbidity Index (5.7 ± 3.6 vs. 4.6 ± 3.6, P = 0.0009) and remained admitted to the hospital longer (23.2 ± 25.6 vs. 15.8 ± 17.5 days, P = 0.0002). However, patients treated with a long course had no difference in 30-day mortality compared with the short-course group (3.9% vs. 3.4%, P = 0.7701).ConclusionPatients with an uncomplicated gram-negative BSI treated with a short course (7–10 days) of antibiotics do not appear to have a significant difference in 30-day mortality compared with those patients treated with a long course (11–20 days).Disclosures All authors: No reported disclosures.

Mycoplasma genitalium: A Review.

Mycoplasma genitalium is a fastidious organism of the class Mollicutes, the smallest prokaryote capable of independent replication. First isolated in 1981, much is still unknown regarding its natural history in untreated infection. It is recognized as a sexually transmitted pathogen causing acute and chronic non-gonococcal urethritis (NGU) in men, with a growing body of evidence to suggest it also causes cervicitis and pelvic inflammatory disease in women. Its role in several other clinical syndromes is uncertain. The majority of people infected remain asymptomatic and clear infection without developing disease; asymptomatic screening is therefore not recommended. Prevalence rates are higher in patients attending sexual health clinics and in men with NGU. Limited availability of diagnostics has encouraged syndromic management, resulting in widespread antimicrobial resistance and given that few antimicrobial classes have activity against M. genitalium, there is significant concern regarding the emergence of untreatable strains. There is a need for wider availability of testing, which should include detection of macrolide resistance mediating mutations. Expertise in interpretation of microbiological results with clinical correlation ensures targeted treatment avoiding unnecessary antibiotic exposure. Public health surveillance nationally and internationally is vital in monitoring and responding to changing epidemiology trends. In this review, we summarize current knowledge of M. genitalium, including epidemiology, clinical and microbiological data, and discuss treatment challenges in the era of rising multidrug resistance.

Reduction of Unnecessary Antibiotic Exposure in Newborns and Minimization of Mother-Newborn Separations

Reduction of Unnecessary Antibiotic Exposure in Newborns and Minimization of Mother-Newborn Separations

New Approaches to the Evaluation and Management of Well-Appearing Term and Late Preterm Neonates at Risk for Early-Onset Sepsis

We examine established guidelines for evaluating infants at risk for early-onset sepsis (EOS), as well as newer risk-based assessment strategies that may safely reduce unnecessary antibiotic exposure for well-appearing newborns. We highlight a new multivariate risk assessment tool (Neonatal Early-Onset Sepsis Calculator) that can reduce empirical antibiotic therapy, laboratory testing, maternal-infant separation, and healthcare costs, without increasing adverse events. In the era of intrapartum antimicrobial prophylaxis for group B Streptococcus (GBS), the incidence of EOS among term and late preterm infants has decreased substantially. Established guidelines recommend laboratory evaluation and empirical antibiotics for all infants exposed to maternal chorioamnionitis, regardless of the infant’s clinical condition. Since the publication of these guidelines, newer evidence suggests that well-appearing infants can safely be managed with close clinical observation alone. The Neonatal Early-Onset Sepsis Calculator is a useful tool that quantifies an individual newborn’s EOS risk based on perinatal risk factors and clinical examination and has been shown to decrease laboratory evaluations and antibiotic use.

Antibiotic Prescription Practice for Pediatric Urinary Tract Infection in a Tertiary Center.

Prescribing antibiotics for suspected urinary tract infection (UTI) is common practice and may lead to unnecessary antibiotic exposure. We aimed to review UTI diagnosis and management in the emergency department and to identify targets for antimicrobial stewardship. Single-center, retrospective cohort study of children aged 12 weeks to younger than 18 years discharged from the emergency department with a diagnosis of UTI between October and December 2016. Children with genitourinary malformations were excluded. Clinical information, urine collection method, laboratory findings, and urine culture results were gathered. The sensitivity and specificity of nitrite and leukocyte esterase for UTI diagnosis were calculated. The relationship between urinalysis characteristics and confirmed UTI was examined using logistic regression. A total of 183 children with a median (interquartile range) age of 4.2 (1.1-7.5) years were included; 82.5% were female. Almost all children were discharged home on antibiotics (n = 180, 98%) for a median (interquartile range) duration of 7 (7-10) days. A total of 85 patients (46.4%) received antibiotics despite negative urine cultures leading to 525 unnecessary antibiotic days. The presence of nitrites was the strongest predictor of UTI (odds ratio = 20.22, P < 0.001) and was highly specific. Current practice in managing suspected pediatric UTIs in our ED resulted in significant and unnecessary antibiotic exposure. We identified targets to reduce unnecessary antibiotic exposure including improving the diagnostic accuracy of UTIs, a process to discontinue antibiotics for negative cultures and standardizing antimicrobial duration.

A REVIEW OF ANTIBIOTIC USED IN SUSPECTED EARLY-ONSET NEONATAL SEPSIS FROM MALAYSIAN PERSPECTIVE: WHICH ONES TO CHOOSE AND HOW LONG TO GIVE?

Objective: Suspected early-onset sepsis is a common diagnosis among neonates which warrants admission to the neonatal intensive care unit. Prolonged empiric antibiotic is the biggest concern and treatment duration is still controversial. Antimicrobial stewardship (AMS) program promotes early antibiotic de-escalation to reduce unnecessary antibiotic exposure and its implementation in the intensive care setting seems to be feasible. The primary objective of this review was to compare the existing guidelines and review the literature regarding choice and duration of empiric antibiotic in managing suspected early-onset neonatal sepsis.Methods: Two Malaysian Ministry of Health guidelines were compared with guidelines from America (n=1), Australia (n=1), and United Kingdom (n=2). The literature search was conducted from January to June 2017 through open access journal and databases available at the author’s institution library (EBSCOHost, Ovid and Science Direct).Results: All guidelines recommended similar antibiotics range and suggested to review treatment at 36– 72 h post antibiotic exposure. A total of 113 abstracts and full articles were identified, and only 11 full-text articles published in English were related to the subject of interest. All studies show differences either in study design, choice of antibiotics, treatment duration or outcome measures; thus, a meta-analysis was not possible to be conducted.Conclusion: From this review, we found the potential to performed early empiric antibiotic de-escalation especially in clinically well-appearance neonates, and it is best to customize our guidelines based on local evidence which justify the need for more local research in this area.

A REVIEW OF ANTIBIOTIC USED IN SUSPECTED EARLY-ONSET NEONATAL SEPSIS FROM MALAYSIAN PERSPECTIVE: WHICH ONES TO CHOOSE AND HOW LONG TO GIVE?

Objective: Suspected early-onset sepsis is a common diagnosis among neonates which warrants admission to the neonatal intensive care unit. Prolonged empiric antibiotic is the biggest concern and treatment duration is still controversial. Antimicrobial stewardship (AMS) program promotes early antibiotic de-escalation to reduce unnecessary antibiotic exposure and its implementation in the intensive care setting seems to be feasible. The primary objective of this review was to compare the existing guidelines and review the literature regarding choice and duration of empiric antibiotic in managing suspected early-onset neonatal sepsis.Methods: Two Malaysian Ministry of Health guidelines were compared with guidelines from America (n=1), Australia (n=1), and United Kingdom (n=2). The literature search was conducted from January to June 2017 through open access journal and databases available at the author’s institution library (EBSCOHost, Ovid and Science Direct).Results: All guidelines recommended similar antibiotics range and suggested to review treatment at 36– 72 h post antibiotic exposure. A total of 113 abstracts and full articles were identified, and only 11 full-text articles published in English were related to the subject of interest. All studies show differences either in study design, choice of antibiotics, treatment duration or outcome measures; thus, a meta-analysis was not possible to be conducted.Conclusion: From this review, we found the potential to performed early empiric antibiotic de-escalation especially in clinically well-appearance neonates, and it is best to customize our guidelines based on local evidence which justify the need for more local research in this area.

858. Preoperative “Dirty” Urinalysis Leads to Antibiotic Use Without Benefit

BackgroundPyuria is often used as a surrogate for bacteriuria and may trigger antibiotic use even in the setting of negative cultures. The impact of preoperative pyuria on empirical antibiotic use and on postoperative outcomes has not been evaluated in large multisite studies. Thus, we investigated rates and outcomes associated with treated versus untreated preoperative pyuria in a national cohort of surgical patients.MethodsAll patients who underwent standardized Surgical Quality review after cardiac, orthopedic implant, or vascular surgery within the national VA health care system from October 1, 2008 to September 30, 2013 and had a urinalysis performed in the 30 days before surgery were eligible. Rates of preoperative pyuria (≥5 WBCs and/or positive leukocyte esterase) and antibiotics were measured. Adjusted rates of 30-day postoperative surgical (SSI) and urinary tract (UTI) infections were determined by a trained nurse reviewer using CDC definitions and compared between pyuria patients who did or did not receive antibiotics before surgery.ResultsAmong 17,749 preoperative urinalyses, 755 were culture-positive and 16,994 were culture-negative. Among culture negative patients, 1,812/16,994 (10.7%) had urinalyses diagnostic of pyuria. Antibiotics were prescribed to 574 (32%) of pyuria-positive, culture-negative patients. After adjusting for diabetes, smoking, age, and ASA score, the rate of post-op SSI was similar among antibiotic-treated pyuria patients (13/574, 2.3%) compared with those not treated (21/1,238, 1.7%), aOR 1.33, 95% (0.66–2.69, P = 0.41). Post-op UTI was also not reduced among pyuria treated (17/351, 4.8%) vs. untreated (39/893, 4.4%), aOR 1.09, 95% (0.60–1.96, P = 0.76).ConclusionIn this large national study cohort, almost 1/3 of pyuria-positive preoperative patients received antibiotics despite negative cultures. Antibiotic treatment was not associated with clinical benefits, including no reduction in post-operative SSI or UTI. There is an opportunity for diagnostic stewardship to reduce preoperative urinalysis testing and unnecessary antibiotic exposure.Disclosures K. Itani, Pfizer: Grant Investigator, Research grant. Sanofi: Grant Investigator, Research grant. K. Gupta, Iterum Therapeutics: Consultant, Consulting fee. Paratek Pharmaceutical: Consultant, Consulting fee. Tetraphase: Consultant, Consulting fee.

A Quality Improvement Initiative: Reducing Blood Culture Contamination in a Children's Hospital.

Blood culture contamination is a safety and quality concern in children's hospitals; it leads to increased unnecessary testing, admissions, antibiotic exposure, and cost. The standard benchmark for blood culture contamination is 3%. Our aim with the quality improvement project was to reduce the contamination rate at our children's hospital from a mean of 2.85% to <1.5% in 2 years. After initial unit-specific efforts, we formed a multidisciplinary team, created a process map and a cause-and-effect analysis, sent out surveys to nurses, and created observation sheets used to identify problem areas and record the most common deviations during the collection process. We also standardized the blood culture collection protocol and reemphasized nurse education in person and with online modules. During our project, we noted that nurses were collecting 1 to 3 mL of blood on all children regardless of weight. We developed optimal weight-based blood volumes and, after educating ordering providers, we updated our electronic medical record to reflect appropriate volumes in the order. Despite a steady increase in the number of blood cultures collected at our children's hospital, we were able to decrease the average contamination rate from 2.85% to 1.54%, saving the hospital an estimated average of $49 998 per month. By standardizing blood culture collection methods, optimizing blood volume, creating checklists, and reinforcing nurse education, we were able to develop a best practice for pediatric blood culture collection and reduce blood culture contamination to a sustainable low rate at our children's hospital.

Can biomarkers improve the rational use of antibiotics?

We aim to review recent literature about the use of biomarkers to guide the initiation and duration of antibiotic treatments for suspected bacterial infections. Several good quality meta-analyses show that procalcitonin can be safely used to guide antibiotic-related decisions, especially for respiratory infections, thereby decreasing unnecessary antibiotic exposure. Furthermore, the use of CRP-based algorithms to guide antibiotic initiation in primary care patients with acute respiratory infections is associated with a reduction in antibiotic use without an increase in adverse events. Regarding neutrophil CD64 and serum amyloid A, more good-quality evidence is needed to assess their utility as biomarkers to tailor antibiotic use. Finally, transcriptomics, metabolomics and proteomics are promising tools for the development of tests to differentiate specific host responses to viral, bacterial and noninfectious stimuli, but such tests still need further validation. Evidence shows that the use of biomarkers, procalcitonin and CRP, can safely reduce unnecessary antibiotic prescriptions in certain infectious syndromes. The clinical utility of host-based strategies such as transcriptomics, metabolomics and proteomics for the diagnosis of infectious diseases has yet to be evaluated, as well as considerations such as costs, technical complexity and result turnaround time.

Avoiding Unnecessary Antibiotic Exposure in Premature Infants

Avoiding Unnecessary Antibiotic Exposure in Premature Infants