Unnecessary Antibiotic Treatment Research Articles

Elevated Cerebrospinal Fluid CXCL13 Is a Helpful Marker for the Early Diagnosis of Neuroborreliosis in Children.

Lyme neuroborreliosis (LNB) is an early systemic manifestation of Lyme disease in children, but standard diagnostic measures have constraints that limit early LNB diagnosis. Elevated cerebrospinal fluid (CSF) concentrations of the chemokine CXCL13 are considered a useful marker for early LNB diagnosis in adults, however, few studies have evaluated their diagnostic value in children. In this retrospective analysis, stored CSF samples of 232 hospitalized pediatric patients tested for LNB with standard serological methods were re-analyzed for CXCL13. CXCL13 levels were compared in children classified as definite, possible or no LNB patients according to European Federation of Neurological Societies guidelines. Specificity and sensitivity of CSF CXCL13 were determined for the diagnosis of early LNB, using previously published cutoff levels for pediatric patients. CSF CXCL13 levels differed significantly between 25 patients with definite LNB (all >7.8 pg/mL; range: 37.9->500 pg/mL) and 174 patients without LNB [160 (92%) <7.8 pg/mL; 13 (7%) with a range of 7.8-59.3 pg/mL; 1 (1%) with >500 pg/mL and Ureaplasma parvum CNS infection]. Using a cutoff of 55 pg/mL, CSF CXCL13 resulted in a specificity of 98.9% (95% CI: 97.4-100) and sensitivity of 92.0% (95% CI: 81.4-100). This study confirms the high sensitivity and specificity of CSF CXCL13 for the diagnosis of pediatric LNB using a cutoff value of 55 pg/mL. The use of CSF CXCL13 as an additional diagnostic measure in children with suspected LNB could improve diagnostic specificity and thereby reduce unnecessary antibiotic treatment, especially in the early phases of the disease.

P-1686. Appropriateness of Antibiotic Prescribing in Urgent Care Centers in Chicago, 2019-2022

Abstract Background Urgent care centers (UCC) face unique challenges such as high patient volume and turnover, contributing to increased overall antibiotic prescriptions and inappropriate prescribing. The Chicago Department of Public Health (CDPH) obtained the IQVIA Longitudinal Prescription and Medical Claims dataset to evaluate antibiotic prescribing trends between 2019-2022 in Chicago UCC, including appropriateness. Methods We analyzed IQVIA data from 2019-2022, restricted to encounters with Chicago UCC providers. Claims data were linked to prescription data using a unique patient identifier. Using previously published methodology, antibiotic appropriateness was assessed by assigning ICD-10 codes to three tiers: tier 1 conditions, for which antibiotics are almost always indicated; tier 2, antibiotics may be indicated; and tier 3, antibiotics are almost never indicated. Results There were 24,776 antibiotic prescriptions with matched diagnosis codes attributed to Chicago UCC providers between 2019-2022, representing 19,809 unique patients. Tier 3 conditions accounted for 44.6% of prescriptions, followed by tier 2 (37.0%) and tier 1 (18.4%) conditions . The most common tier 3 diagnosis codes were respiratory infections (43.2%), including viral upper respiratory infections (40.4%), bronchitis/bronchiolitis (11.9%), and other respiratory conditions (37.7%). Inappropriate prescribing was lowest in 2019 and highest in 2021, with 40.1% and 48.3% of prescriptions matched to a tier 3 condition, respectively. The three most frequently prescribed antibiotics following an encounter for a tier 3 condition were azithromycin (25.2%), amoxicillin (12.3%), and amoxicillin/clavulanate (11.4%). Nurse practitioners (29.1%) were the most frequent tier 3 prescribers followed by family medicine (25.4%) and internal medicine (24.0%) physicians. Conclusion Nearly half of antibiotics prescribed in Chicago UCC from 2019-2022 were associated with a condition where antibiotics are almost never indicated, and this trend increased during the COVID-19 pandemic. Antibiotic stewardship efforts should target unnecessary antibiotic treatment for respiratory infections, and stewardship education should prioritize nurse practitioners, and family medicine and internal medicine physicians. Disclosures All Authors: No reported disclosures

416. Impact of clinical diagnostic stewardship of respiratory cultures across a multicenter PICU collaborative

Abstract Background Respiratory culture practices for critically ill patients with artificial airways vary across and within institutions. Over-testing contributes to unnecessary antibiotic treatment. This study aimed to evaluate the efficacy and safety of implementing clinical decision support to standardize indications of respiratory cultures across a multicenter PICU collaborative. Monthly Respiratory Culture Rate per 100 Ventilator-Days Before and After Implementing Diagnostic Stewardship Programs The monthly respiratory culture rate is shown for 15 pediatric intensive care units participating in BrighT STAR Respiratory, a multicenter diagnostic stewardship quality improvement collaborative, 24 months before and 18 months after implementing diagnostic stewardship programs. The mean monthly average rate over time was estimated using a smoothing spline. Methods 15 U.S. PICUs participated in the BrighT STAR Respiratory Collaborative, a prospective multicenter quality improvement program (QI) from 2019-2023. Each hospital executed local QI programs to improve respiratory culture practices, facilitated by the larger collaborative. The primary outcome was the monthly rate of respiratory cultures per 100 ventilator-days. Process and safety measures included the proportion of cultures repeated within 3 days, bronchoalveolar lavage (BAL) cultures per 100 ventilator-days, and ventilator-associated events (VAE) per 100 ventilator-days among 3 centers conducting this surveillance. We analyzed rates 24 months pre- and 18 months post-intervention using a Poisson generalized linear mixed model with random intercept for sites, robust variance estimates and adjustment for seasonality. Site leads surveyed local faculty for patient safety concerns. Results Across 15 PICUs, the monthly average respiratory culture rate was 7.80 per 100 ventilator-days pre-implementation and 6.55 per 100 ventilator-days post-implementation, a 16% rate ratio (RR) reduction (95% confidence interval (CI) 0.78-0.90, P&amp;lt; 0.001). Cultures repeated within 3 days declined 22% from 13% to 10% (95%CI 0.68-0.89, P&amp;lt; 0.001). The BAL culture rate did not change from 0.67 to 0.72 (RR 1.07, 95% 0.85-1.34, P=0.57). The VAE rate did not change from 0.21 to 0.25 (RR 1.17, 95%CI 0.87-1.58, P=0.28). Among 2,525 inquiries to attendings about safety concerns, 2348 replied (93%); 2 concerns were reported (0.08%) regarding perceived delay to cultures with no resulting patient harm. Conclusion Standardizing respiratory culture ordering practices may be an effective diagnostic stewardship approach for pediatric patients with artificial airways. We plan to assess impact on clinical outcomes and antibiotic use and to assess facilitators and barriers to implementation. Disclosures Aaron Milstone, MD, MHS, Merck: Grant/Research Support

The Impact of Rapid Molecular Diagnostics for Influenza on Antibiotic Stewardship in the Emergency Department—An Observational Retrospective Study

Objective: The clinical diagnosis of respiratory tract infections (RTIs) may result in unnecessary antibiotic treatment due to clinical exams’ low sensitivity and specificity to differentiate viral from bacterial infections and costly diagnostic work-ups. Unnecessary antibiotic consumption drives antibiotic resistance. We explored whether a rapid influenza-specific polymerase chain reaction (PCR) assay reduced antibiotic use in an emergency room before the COVID-19 pandemic. Methods: We conducted an observational retrospective study of patients with RTI symptoms treated in the ER of the University Hospital Basel from September 2014 to June 2015. We evaluated the impact of rapid diagnostic results, such as an influenza-specific PCR, blood sample results, and radiological imaging, on antibiotic prescription rates. Patient-related confounding factors were included since a patient’s clinical condition affects doctors’ clinical decision-making. Results: We included 607 patients with RTIs, tested with PCR for influenza A or B. Logistic regression showed that the odds ratio (OR) of being treated with antibiotics was significantly reduced by more than two-thirds in patients with a positive influenza PCR result (OR = 0.37; 95% CI, 0.22–0.59; p &lt; 0.001). Increasing C-reactive protein (CRP) levels by tenfold (OR = 5.14; 95% CI, 3.34–8.12; p &lt; 0.001) or suspected chest infection on a radiograph (OR = 5.81; 95% CI, 3.23–10.89; p &lt; 0.001) increased the OR of antibiotic treatment by fivefold. The highest OR for antibiotic prescription was due to increased procalcitonin level by tenfold (OR = 10.13; 95% CI, 4.79–23.4; p &lt; 0.001). Conclusions: Our study provides real-world evidence from a pre-COVID-19 ER setting of diagnostic tools used for RTI evaluation and their impact on antibiotic prescriptions. Rapid influenza-specific PCR results may affect the prescription rate of antibiotics but should be seen as part of a comprehensive diagnostic approach to guide clinical decision-making.

A quantitative PCR to detect non-toxigenic Clostridioides difficile.

Clostridioides difficile species lacking toxin genes (non-toxigenic C. difficile or NTCD) may confer protection against CDI. However, current diagnostic tests detect either toxin proteins or toxin genes and cannot detect NTCD. This study developed a molecular testing method that uniquely identified NTCD and assessed its prevalence in a clinical cohort. A quantitative PCR (qPCR) assay was developed and validated using reference strains. Analytic sensitivity was determined using DNA from reference NTCD strains, and qPCR efficiency was assessed using the slope of the standard curves of DNA dilutions. A random selection of 95 clinical stool samples, tested using the GDH enzyme and toxin enzyme immunoassay (EIA), was used to evaluate the prevalence of NTCD in hospitalized patients tested for CDI. The KB-1/KB-2 primers and probe designed were specific for NTCD strains and did not amplify with toxigenic C. difficile or other related strains. The NTCD qPCR assay analytical sensitivity was linear between 3 × 101 and 3 × 106 gDNA (R2 = 0.999; P < 0.0001). No NTCD was found in 25 GDH-EIA -/- samples compared to 5 of 25 (20%) GDH-EIA +/- samples and 2 of 23 (8.7%) GDH-EIA +/+ samples. Of samples detected with NTCD, median NTCD DNA was 33,039 (IQR: 22.449-45.688) in GDH-EIA +/- samples and 370 [IQR: 159-583] in GDH-EIA +/+ samples. The new qPCR NTCD assay identified NTCD colonization in 7% of hospitalized patients tested for CDI. This NTCD assay may have important implications for diagnostic and antimicrobial stewardship as colonization with NTCD strains may offer protection against CDI.IMPORTANCECurrent diagnostic strategies do not detect non-toxigenic Clostridioides difficile (NTCD) strains, which may provide protection against C. difficile infection (CDI). Detecting these strains is critical as it underscores the importance of avoiding unnecessary antibiotic treatment in patients colonized with NTCD. To better guide clinical decisions and enhance the understanding of NTCD epidemiology, molecular assays that specifically target non-coding regions unique to NTCD strains are needed. In this study, we developed and validated a qPCR assay capable of uniquely identifying NTCD strains. This innovative assay holds significant potential for applications in public health, infection control, diagnostic, and therapeutic strategies related to CDI.

Antibiotic Overuse in Pediatric Patients Hospitalized with RSV, COVID-19, and Influenza

Abstract Background Children hospitalized with viral respiratory tract infections (RTIs) are often treated with antibiotics due to concern for bacterial co-infection, although most do not have concurrent bacterial infections. This practice leads to unnecessary antibiotic treatment, which can lead to development of resistant bacteria and adverse events. The extent of antibiotic overuse in hospitalized children with community-onset viral RTI has not been well-quantified in recent years and may have worsened during the COVID-19 pandemic. The objectives of this study were to quantify and compare the extent of antibiotic overtreatment and to determine predictors of antibiotic use post-COVID-19 pandemic in children hospitalized with RSV, COVID-19, and influenza. Methods We performed a single center retrospective study evaluating percentages of antibiotic use and bacterial co-infection among children and adolescents aged &amp;lt;19 years old, hospitalized with respiratory syncytial virus (RSV), influenza, or SARS-CoV-2 between April 2020 and May 2023. Bacterial infection was defined as growth of bacteria from any specimen source, including blood, urine, pleural fluid, cerebrospinal fluid, and respiratory secretions, excluding common contaminants like coagulase-negative Staphylococci. Predictors of antibiotic treatment were determined using multivariable logistic regression. Results During the study period 1,718 patients were included (1022 with RSV, 188 with influenza, 535 with COVID-19). RSV patients were younger and more likely to be in the ICU than influenza or COVID-19 patients. The overall proportion of patients with culture-confirmed bacterial co-infection was low at 8% and did not differ greatly by virus type (8% for influenza, 6.9% for RSV, 10.3% for COVID-19, p=0.03). The proportion of children receiving antibiotics was higher for influenza than for other viruses (60.6% for influenza, 41.2% for RSV, and 48.6% for COVID-19, p &amp;lt; 0.001). Among patients with the lowest severity of illness (with normal inflammatory markers [PCT &amp;lt;0.5 ug/mL or CRP &amp;lt;50 mg/L] and not admitted to the ICU), 7.3% had a culture-confirmed bacterial infection while 48.1% received antibiotics. Independent predictors for receiving antibiotics were elevated inflammatory markers (C-reactive protein or procalcitonin), having &amp;gt;3 comorbidities, mechanical ventilation, and influenza diagnosis. Conclusion In children hospitalized with community-onset viral RTIs, antibiotic treatment is substantially higher than the burden of culture-confirmed bacterial infection, suggesting antibiotic overuse. Antibiotic use was greater for patients with influenza than for those with RSV or COVID-19. Antibiotic overuse was estimated to occur in over 40% of patients with low severity of illness. Stewardship programs can use this data to design interventions to promote more judicious antibiotic use. Figure 1. Rates of bacterial co-infection and antibiotic utilization among patients hospitalized with influenza, RSV, and COVID. Blue, percentage of patients who had a culture-confirmed bacterial infection; orange, percentage of patients who received any antibiotics; green, percentage of patients who received &amp;gt;3 days of antibiotics.

Factors associated with antibiotic use in children hospitalized for acute viral gastroenteritis and the relation to rotavirus vaccination

ABSTRACT Evidence on unnecessary antibiotic use in children with acute viral gastroenteritis (AGE) is scarce. We characterized the extent and correlates of antibiotic use among children hospitalized with viral AGE. A single-center study enrolled children aged 0–59 months hospitalized for AGE between 2008 and 2015 in Israel. Information was collected on laboratory tests, diagnoses, antibiotic treatment, and rotavirus vaccination. Stool samples were tested for rotavirus antigen, GII-norovirus, and stool cultures were performed for bacterial enteropathogens. Data from 2240 children were analyzed. Rotavirus vaccine was given to 79% of eligible children. Rotavirus test was performed on 1419 (63.3%) children. Before the introduction of universal rotavirus vaccination (2008–2010), rotavirus positivity in stool samples was 37.0%, which declined to 17.3% during the universal vaccination years (2011–2015). Overall, 1395 participants had viral AGE. Of those, 253 (18.1% [95% CI 16.1–20.2]) had unnecessary antibiotic treatment, mostly penicillin 46.6%, ceftriaxone 34.0% and azithromycin 21.7%. A multivariable analysis showed an inverse association between rotavirus vaccination and unnecessary antibiotic treatment (odds ratio = 0.53 [95% CI 0.31–0.91]), while positive associations were found with performing chest-X-ray test (3.00 [1.73–5.23]), blood (3.29 [95% CI 1.85–5.86]) and urine cultures (7.12 [3.77–13.43]), levels of C-reactive protein (1.02 [1.01–1.02]) and leukocytes (1.05 [1.01–1.09]). The results were consistent in an analysis of children with laboratory-confirmed rotavirus or norovirus AGE, or after excluding children with CRP > 50 mg/L. In conclusion, antibiotic prescription was common among hospitalized children with viral AGE, which was inversely related to rotavirus vaccination, possibly due to less severe illness in the vaccinated children.

Impact and Safety of Diagnostic Stewardship to Improve Urine Culture Testing Among Patients with Indwelling Urinary Catheters

Background: Indiscriminate urine culturing of patients with indwelling urinary catheters may lead to overdiagnosis of urinary tract infections, resulting in unnecessary antibiotic treatment and inaccurate reporting of catheter-associated urinary tract infections (CAUTIs) as a hospital quality metric. We evaluated the impact of a computerized diagnostic stewardship intervention to improve urine culture testing among patients with indwelling urinary catheters. Methods: We performed a single-center retrospective observational study at Rush University Medical Center from April 2018 – July 2023. In February 2021, we implemented a computerized clinical decision support tool to promote adherence to our internal urine culture guidelines for patients with indwelling urinary catheters. Providers were required to select one guideline criteria: 1) neutropenia, 2) kidney transplant, 3) recent urologic procedure, 4) urinary tract obstruction; or if none of the criteria were met, then an infectious diseases consultation was required for approval. We compared facility-wide CAUTI rate per 10,000 catheter days and standardized infection ratio (SIR) during baseline and intervention periods using ecologic models, controlling for time and for monthly Covid-19 hospitalizations. In the intervention period, we evaluated how providers responded to the intervention. Potential harm was defined as collection of a urine culture within 7 days of the intervention that resulted in a change in clinical management. Results: In unadjusted models, CAUTI rate decreased from 12.5 to 7.6 per 10,000 catheter days (p=0.04) and SIR decreased from 0.77 to 0.49 (p=0.09) during baseline vs intervention periods. In adjusted models, the CAUTI rate decreased from 6.9 to 5.5 per 10,000 catheter days (p=0.60) (Figure 1) and SIR decreased from 0.41 to 0.35 (p=0.65) during baseline vs intervention periods. Urine catheter standard utilization ratio (SUR) did not change (p=0.36). There were 598 patient encounters with ≥1 intervention. Selecting the first intervention for each encounter, 284 (47.5%) urine cultures met our guidelines for testing and 314 (52.5%) were averted (Figure 2). Of these, only 3 ( &lt; 1 %) had a urine culture collected in the subsequent 7 days that resulted in change in clinical management. Conclusion: We observed a trend of decreased CAUTIs over time, but effect of our diagnostic stewardship intervention was difficult to assess due to healthcare disruption caused by Covid-19. Adverse outcomes were rare among patients who had a urine culture averted. A computerized clinical decision support tool may be safe and effective as part of a multimodal program to reduce unnecessary urine cultures in patients with indwelling urinary catheters.

Diagnostic Performance of Plasma SP-D, KL-6, and CC16 in Acutely Hospitalised Patients Suspected of Having Community-Acquired Pneumonia-A Diagnostic Accuracy Study.

Community-acquired pneumonia is a common cause of acute hospitalisation. Identifying patients with community-acquired pneumonia among patients suspected of having the disease can be a challenge, which causes unnecessary antibiotic treatment. We investigated whether the circulatory pulmonary injury markers surfactant protein D (SP-D), Krebs von den Lungen-6 (KL-6), and Club cell protein 16 (CC16) could help identify patients with community-acquired pneumonia upon acute admission. In this multi-centre diagnostic accuracy study, SP-D, KL-6, and CC16 were quantified in plasma samples from acutely hospitalised patients with provisional diagnoses of community-acquired pneumonia. The area under the receiver operator characteristics curve (AUC) was calculated for each marker against the following outcomes: patients' final diagnoses regarding community-acquired pneumonia assigned by an expert panel, and pneumonic findings on chest CTs. Plasma samples from 339 patients were analysed. The prevalence of community-acquired pneumonia was 63%. AUCs for each marker against both final diagnoses and chest CT diagnoses ranged between 0.50 and 0.56. Thus, SP-D, KL-6, and CC16 demonstrated poor diagnostic performance for community-acquired pneumonia in acutely hospitalised patients. Our findings indicate that the markers cannot readily assist physicians in confirming or ruling out community-acquired pneumonia.

Follow-up of patients with urinary tract infections discharged from the emergency department: a mixed methods study.

To evaluate the quality of culture follow-up after emergency department (ED) discharge in patients with urinary tract infections (UTIs). This convergent mixed methods study included an observational cohort study and a qualitative interview study in UTI patients discharged from the ED of a Dutch university hospital. The primary outcomes of the observational study were the proportion of patients requiring adjustment of antibiotic therapy after culture review, and the proportion of patients in whom these adjustments were made. Logistic regression identified factors associated with these outcomes. Interviews assessed patient experiences and transcripts were analysed using inductive thematic content analysis. Integration of the results informed recommendations for high-quality follow-up. Out of 455 patients, 285 (63%) required culture-based treatment adjustments. In most patients, no adjustments were made (239/285, 84%). De-escalation was most frequently omitted (98%), followed by discontinuation of antibiotics (92%). A mean of 7.1 (SD 3.8) antibiotic days per patient could have been avoided in 103 patients. Patients with diabetes were less likely to require adjustments (aOR 0.50, 95%-CI 0.29-0.85). Patients with moderate or severe renal impairment (aOR 4.1, 95%-CI 1.45-11.33; aOR 4.2, 95%-CI 1.50-11.94) or recurrent UTIs (aOR 5.0, 95%-CI 2.27-11.18) were more likely to have received necessary adjustments. Twelve interviews also revealed varying degrees of follow-up. Three themes were identified: 'information and communication', 'coordination and accessibility of care' and 'individual needs and preferences'. Recommendations for high-quality follow-up advocate a person centred approach. This study highlights the importance of urine culture follow-up after ED discharge, mainly to reduce unnecessary antibiotic treatment, promote de-escalation and improve patient experience.

Utility of dipstick urinalysis in the diagnosis of urinary tract infections among outpatients in Mwanza and Dar es Salaam regions in Tanzania

Abstract Background Globally, urinary tract infections (UTIs) are the leading cause of hospital visits, especially among women. In many developing countries, especially in lower health facilities, the dipstick urinalysis is the most commonly requested test, as urine culture is not routinely performed. The dipstick test can potentially reduce the number of patients who could be treated with empirical antibiotics and reduce the burden of antibiotic resistance. The current study determined the utility of dipstick urinalysis in diagnosing UTIs using urine culture as a gold standard method. Methods A cross-sectional study was conducted between July and November 2021. The study involved 1327 outpatients attending lower health centres in Mwanza (n = 678) and Dar es Salaam (n = 649) regions. The samples were subjected to dipstick urinalysis (nitrite and leucocytes) and quantitative bacterial culture. Results Of all 1326 patient samples, 808(60.9%) and 48(3.6%) were positive for urinary leucocyte and nitrite, respectively, while significant urine culture was found in 364(27.4%). leucocyte test correctly diagnosed UTI in 283 (77.75%) and nitrite test in 36 (9.89%). The leucocytes and nitrites, in combination, exhibited a sensitivity of 79.40% and NPV of 85.24% but a lower specificity of 44.96% and a lower PPV of 35.29%. Urinary leucocyte test had a higher discrimination ability to detect urinary tract infection than urinary nitrite test (AUC = 0.073, 95% CI 0.043–0.103, p &lt; 0.001); likewise, combined results of urinary nitrite and leucocytes tests had higher discrimination ability to detect UTI than nitrite only (AUC = − 0.079, 95% CI − 0.107–0.050, p &lt; 0.001). Conclusions In settings where culture is available, dipstick urinalysis can be a helpful screening method for reducing unnecessary urine cultures and related expenses because of its higher negative predictive value. In most low-resource settings where patients' diagnosis solely depends on clinical diagnosis and culture is not easily available, urine dipstick can decrease the risk of overuse of antibiotics. However, the combined (leucocytes and nitrites) dipstick urinalysis has a rather low positive predictive value, with approximately one-third of cases giving positive test results being truly UTI, subjecting over 65% of cases to unnecessary antibiotic treatment.

Parent and Clinician Views on Not Using Antibiotics for Mild Community-Acquired Pneumonia.

Preschool-aged children with mild community-acquired pneumonia (CAP) routinely receive antibiotics even though most infections are viral. We sought to identify barriers to the implementation of a "no antibiotic" strategy for mild CAP in young children. Qualitative study using semistructured interviews conducted in a large pediatric hospital in the United States from January 2021 to July 2021. Parents of young children diagnosed with mild CAP in the previous 3 years and clinicians practicing in outpatient settings (pediatric emergency department, community emergency department, general pediatrics offices) were included. Interviews were conducted with 38 respondents (18 parents, 20 clinicians). No parent heard of the no antibiotic strategy, and parents varied in their support for the approach. Degree of support related to their desire to avoid unnecessary medications, trust in clinicians, the emotional difficulty of caring for a sick child, desire for relief of suffering, willingness to accept the risk of unnecessary antibiotics, and judgment about the child's illness severity. Eleven (55%) clinicians were familiar with guidelines specifying a no antibiotic strategy. They identified challenges in not using antibiotics, including diagnostic uncertainty, consequences of undertreatment, parental expectations, follow-up concerns, and acceptance of the risks of unnecessary antibiotic treatment of many children if it means avoiding adverse outcomes for some children. Although both parents and clinicians expressed broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges. Interventions will need to consider the emotional, social, and logistical aspects of managing pneumonia, in addition to developing techniques to improve diagnosis.

Improving Pediatric Clostridioides difficile Testing Practices: Implementation of a 2-Tier Diagnostic Pathway

Introduction: Clostridioides difficile (C. difficile) is a significant concern for children, especially for those who are hospitalized or who have underlying medical conditions. Diagnosis of C. difficile infection (CDI) in these patients can be challenging due to asymptomatic colonization. Inappropriate testing and non-adherence to laboratory testing guidelines can result in increased false-positive rates precipitating unnecessary isolation precautions and antibiotic treatment for these patients. &#x0D; &#x0D; Methods: This retrospective cohort study aimed to evaluate the effectiveness of a new diagnostic pathway for C. difficile testing that was implemented in two pediatric hospitals. The study design collected data for two years, one year before and one year after pathway implementation. The study highlighted the importance of appropriate testing and the need for interventions to improve testing practices in pediatric patients. A 2-tier testing algorithm was implemented, consisting of polymerase chain reaction (PCR) for the presence or absence of the toxin B gene and an enzyme immunoassay for toxin A/B production. The best practice advisory was used to determine when C. difficile testing should not be performed. The chi-square test and Fisher's Exact Test analyzed the data using SPSS version 29.&#x0D; &#x0D; Results: The study found a significant association between the implementation of the C. difficile testing pathway and the test positivity rates for both inpatient and emergency department (ED) patients at both hospitals. Out of 159,434 Hospital A inpatients, 71 had positive C. difficile test results, and out of 11,109 Hospital B inpatients, nine had positive test results. Similarly, out of 121,951 Hospital A ED patients, eight had positive test results, and out of 67,999 Hospital B ED patients, 16 had positive test results. The study found a statistically significant association between the pre and post pathway implementation years for both hospitals (p&lt;0.001 for Hospital B inpatient and ED, p=0.033 for Hospital A inpatient, and p=0.004 for Hospital A ED).&#x0D; &#x0D; Conclusion: Adherence to laboratory testing guidelines, appropriate testing based on factors such as the patient's age, underlying health conditions, recent antibiotic use, and the presence of other infections or illnesses can reduce unnecessary testing and false-positive rates. False-positive results can occur in pediatric patients due to the high rate of asymptomatic colonization, making it essential to use a combination of clinical symptoms, history, and appropriate diagnostic testing to minimize the risk of misdiagnosis.

Amoxicillin-induced aseptic meningitis: clinical features, diagnosis and management

ObjectivesThe clinical features of aseptic meningitis associated with amoxicillin are unknown. The main objective of this study was to investigate the clinical characteristics of amoxicillin-induced aseptic meningitis (AIAM) and provide a reference for clinical diagnosis and treatment.MethodsAIAM-related studies were collected by searching the relevant databases from inception to October 31, 2022.ResultsAIAM usually occurred 3 h to 7 days after amoxicillin administration in 13 males and 9 females. Twenty-one patients (95.5%) had recurrent AIAM with a total of 62 episodes. Fever (19 cases, 86.4%) and headache (18 cases, 81.8%) were the most common symptoms. Typical cerebrospinal fluid (CSF) findings were leukocytosis (100%) with lymphocytic predominance (14 cases, 63.6%), elevated protein (20 cases, 90.1%), normal glucose (21 cases, 95.5%) and negative culture (21 cases, 100%). Brain magnetic resonance imaging showed mild meningeal enhancement in one patient. The symptoms resolved mainly within 1–4 days after drug discontinuation in all patients.ConclusionClinical attention should be given to the adverse effects of AIAM. The medication history of patients with suspected meningitis should be investigated to avoid unnecessary examination and antibiotic treatment.

A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria

Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events. To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB. This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022. Participation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion. Overall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration. Of the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00). This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.

Diagnosis of Epstein-Barr and cytomegalovirus infections using decision trees: an effective way to avoid antibiotic overuse in paediatric tonsillopharyngitis

BackgroundThe incidence of tonsillopharyngitis is especially prevalent in children. Despite the fact that viruses cause the majority of infections, antibiotics are frequently used as a treatment, contrary to international guidelines. This is not only an inappropriate method of treatment for viral infections, but it also significantly contributes to the emergence of antibiotic-resistant strains. In this study, EBV and CMV-related tonsillopharyngitis were distinguished from other pathogens by using machine learning techniques to construct a classification tree based on clinical characteristics.Materials and methodsIn 2016 and 2017, we assessed information regarding 242 children with tonsillopharyngitis. Patients were categorized according to whether acute cytomegalovirus or Epstein-Barr virus infections were confirmed (n = 91) or not (n = 151). Based on symptoms and blood test parameters, we constructed decision trees to discriminate the two groups. The classification efficiency of the model was characterized by its sensitivity, specificity, positive predictive value, and negative predictive value. Fisher’s exact and Welch’s tests were used to perform univariable statistical analyses.ResultsThe best decision tree distinguished EBV/CMV infection from non-EBV/CMV group with 83.33% positive predictive value, 88.90% sensitivity and 90.30% specificity. GPT (U/l) was found to be the most discriminatory variable (p < 0.0001). Using the model, unnecessary antibiotic treatment could be reduced by 66.66% (p = 0.0002).DiscussionOur classification model can be used as a diagnostic decision support tool to distinguish EBC/CMV infection from non EBV/CMV tonsillopharyngitis, thereby significantly reducing the overuse of antibiotics. It is hoped that the model may become a tool worth considering in routine clinical practice and may be developed to differentiate between viral and bacterial infections.

Expression of TRAIL, IP-10, and CRP in children with suspected COVID-19 and real-life impact of a computational signature on clinical decision-making: a prospective cohort study

PurposeWe evaluated the host-response marker score “BV” and its components TRAIL, IP-10, and CRP in SARS-CoV-2 positive children, and estimated the potential impact on clinical decision-making.MethodsWe prospectively analyzed levels of TRAIL, IP-10, CRP, and the BV score, in children with suspected COVID-19. Classification of infectious etiology was performed by an expert panel. We used a 5-point-questionnaire to evaluate the intention to treat with antibiotics before and after receiving test results.ResultsWe screened 111 children, of whom 6 (5.4%) were positive for SARS-CoV-2. A total of 53 children were included for the exploratory analysis. Median age was 3.1 years (interquartile range [IQR] 1.3–4.3), and 54.7% (n = 29) were girls. A viral and a bacterial biomarker pattern was found in 27/53 (50.9%) and 15/53 (28.3%), respectively. BV scores differed between COVID-19, children with other viral infections, and children with bacterial infections (medians 29.5 vs. 9 vs. 66; p = 0.0006). Similarly, median TRAIL levels were different (65.5 vs. 110 vs. 78; p = 0.037). We found no differences in IP-10 levels (555 vs. 504 vs. 285; p = 0.22). We found a concordance between physicians’ “unlikely intention to treat” children with a viral test result in most cases (n = 19/24, 79.2%). When physicians expressed a “likely intention to treat” (n = 15), BV test revealed 5 bacterial, viral, and equivocal scores each. Antibiotics were withheld in three cases (20%). Overall, 27/42 (64%) of pediatricians appraised the BV test positively, and considered it helpful in clinical practice.ConclusionHost-response based categorization of infectious diseases might help to overcome diagnostic uncertainty, support clinical decision-making and reduce unnecessary antibiotic treatment.

Quantifying the Implementation and Cost of a Multisite Antibiotic Stewardship Intervention for Asymptomatic Bacteriuria.

The intensity of an antibiotic stewardship intervention to achieve clinical impact is not known. We conducted a multisite dissemination project of an intervention to reduce treatment of asymptomatic bacteriuria (ASB) and studied: (1) the association between implementation metrics and clinical outcomes and (2) the cost of implementation. A central site facilitated a multimodality intervention to decrease unnecessary urine cultures and antibiotic treatment in patients with ASB at 4 Veterans Affairs medical centers. The intervention consisted of a decision support aid algorithm and interactive teaching cases that provided in the moment audit and feedback on how to manage ASB. Implementation outcomes included minutes spent in intervention delivery, number of healthcare professionals reached, and number of sessions delivered. Clinical outcomes included days of antibiotic therapy (DOT), length of antibiotic therapy (LOT), and number of urine cultures ordered per 1000 bed days. Personnel reported weekly time logs. Minutes spent in intervention delivery were inversely correlated with two clinical outcomes, DOT (R -0.3, P = .04) and LOT (R -0.3, P = .02). Number of healthcare professionals reached and number of sessions delivered were not correlated with clinical outcomes of DOT (R -0.003, P = .98, R = -0.059, P = .69) or LOT (R +0.073, P = .62, R -0.102, P = .49). Physician champions spent an average of 3.8% of effort on the intervention. The implementation cost was USD 22,299/year per site on average. The amount of time local teams spent in delivery of an antibiotic stewardship intervention was correlated with the desired decrease in antibiotic use. Implementing this successful antibiotic stewardship intervention required minimal time.

Evaluation of Sysmex-UF 5000-BF Module for Sterile Body Fluids. An Alternative for Conventional Methods?

Infections of cerebrospinal fluid (CSF), peritoneal and pleural fluids often result in severe morbidity and mortality. Cytometric analysis, cell count, and cell differentiation is supportive in rapid clinical decision. The aim of this study is to evaluate the performance of Sysmex UF-5000 (Sysmex Co., Kobe, Japan) in body fluid (BF) mode for white blood cells and bacterial counting and compare the results with manual microscopy, gram staining, and culture as reference method. A total of 634 body fluid samples (433 CSF, 100 pleural, and 101 peritoneal fluid) submitted to our clinical microbiology laboratory between December 2018 and January 2020 were enrolled in the study. Specimens were analyzed for white blood cell (WBC) counts with Sysmex UF-5000-BF mode. The results were grouped into five categories and compared with the conventional methods as reference method. The relationship between culture results and Sysmex UF5000-BF bacterial load and WBC count were evaluated for the detection of infection. The categorical agreement of UF 5000-BF mode was very strong for CSF (correlation coefficient: 0.70, p < 0.05) and good agreement was found for pleural and peritoneal samples (correlation coefficient: 0.63, p < 0.05). Sensitivity was 100% and specificity was 64% in pleural samples. For ascites sensitivity and specificity were found as 94.1% and 77.4%, and for CAPD samples as 100% and 81,2% respectively. Bacterial and WBC count with flow cytometry was higher among culture positive samples (p < 0.05). The same significant difference was detected between the UF 5000-BF bacterial counts and the samples in which bacteria were detected in the gram preperation (p < 0.05). WBC count by UF-5000-BF was also higher among culture positive compared to culture negative samples (p < 0.05). Our results demonstrated that the flow cytometric method, Sysmex UF-5000 body fluid (BF) mode, can be an alternative particularly in CSF samples. Detection of 100% sensitivity in peritoneal and pleural samples can prevent unnecessary antibiotic treatment and possible resistance development. Besides, automated bacterial counting can be used for rapid prediction of a positive body fluid culture.

1592. SHEA Featured Oral Abstract: Reducing Unnecessary Antibiotic Treatment for Asymptomatic Bacteriuria: A Statewide Collaborative Quality Initiative

Abstract Background Up to one-third of hospitalized patients treated for urinary tract infection (UTI) have asymptomatic bacteriuria (ASB). Both diagnostic (avoiding inappropriate urine cultures) and antibiotic stewardship (reducing unnecessary antibiotic use in asymptomatic patients) have been proposed to reduce unnecessary antibiotic use for ASB. However, it's unclear which method is most effective. Methods The Michigan Hospital Medicine Safety Consortium aimed to improve antibiotic use and outcomes of hospitalized patients with a positive urine culture between 7/1/2017—3/31/2020 (see Table 1 for patient characteristics) by benchmarking performance across 46 Michigan hospitals, sharing best practices, and implementing pay-for-performance metrics related to unnecessary treatment of ASB (see Figure 1). Using logistic regression models controlling for hospital clustering, we assessed change over time in percentage of hospitalized patients treated for UTI who had ASB (i.e., had no documented signs or symptoms of UTI) and hospital characteristics associated with baseline or change in unnecessary antibiotic prescribing. We then estimated the percentage of avoided ASB treatment attributable to diagnostic (decrease in urine cultures ordered on asymptomatic patients) vs. antibiotic stewardship (decrease duration or avoidance of antibiotic treatment). Results Across 46 hospitals, there were 15,493 patients with a positive urine culture. Of 13,805 patients treated for a UTI, 23.2% (3,197) had ASB. The percentage of patients treated for UTI who had ASB declined over time from 29.0% (95% CI: 26.1%, 32.0%) to 16.9% (95% CI: 14.2%, 20.1%; aOR 0.94 per quarter, 95% CI: 0.92-0.96; Figure 1) with hospitals not belonging to a larger healthcare system having the largest decrease over time (Table 2). Neither the proportion of patients with ASB who were treated with antibiotics (P=0.07) nor the duration of therapy for ASB changed over time (P=0.09); thus, nearly all avoided antibiotic therapy for ASB appeared due to diagnostic stewardship. Conclusions Across 46 hospitals, there was a decrease over time in unnecessary treatment for ASB with independent hospitals improving most. Diagnostic stewardship appeared responsible for nearly all improvement. Disclosures Payal K. Patel, MD, MPH, Qiagen: Honoraria.